A Cross-Country Comparative Study on Mental Health Literacy Among Youth Using A Reusable Learning Object in Saudi Arabia and Malaysia: A Quasi-Experimental Study

A Cross-Country Comparative Study on Mental Health Literacy Among Youth Using A Reusable Learning Object in Saudi Arabia and Malaysia: A Quasi-Experimental Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Cross-Country Comparative Study on Mental Health Literacy Among Youth Using A Reusable Learning Object in Saudi Arabia and Malaysia: A Quasi-Experimental Study Nasriah Zakaria, Nik Daliana Nik Farid, Haslina Muhamad, Nurul Fazmidar Mohd Noor, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8151634/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Mental health disorders such as depression, anxiety, and stress are significant public health concerns, affecting 10–20% of adolescents globally. In Malaysia and Saudi Arabia, youth mental health issues are growing, yet Mental Health Literacy (MHL) remains low. MHL encompasses recognizing mental disorders, seeking appropriate help, and understanding treatment options. E-learning tools, particularly Reusable Learning Objects (RLO), offer a promising solution to provide evidence-based education. However, studies on their effectiveness in different cultural settings are limited. This study employed the protocol of a cross-country comparison study aimed at evaluating the effectiveness of RLO in promoting MHL among youth in Saudi Arabia and Malaysia. Methods A quasi-experimental design was employed among youth aged 16–24 years in Riyadh, Saudi Arabia, and Klang Valley, Malaysia. RLO was developed using the ASPIRE methodology, and a validated English and Arabic MHL questionnaire was used in the study. Participants were assigned to intervention and control groups. The intervention group engaged with RLOs, while the control group completed the questionnaire without RLO exposure. Data were collected at baseline and post-intervention. Tests of normality (Kolmogorov–Smirnov and Shapiro–Wilk) indicated non-normal data distribution; thus, non-parametric analyses were conducted. Wilcoxon signed-rank tests compared baseline and post-intervention scores within groups, while Mann–Whitney U tests compared post-intervention change scores between countries. Results Wilcoxon signed-rank analyses revealed significant improvements in MHL among participants in Saudi Arabia and Malaysia. In Saudi Arabia, improvements were observed across all domains, including a reduction in erroneous beliefs (p = .021). Mann–Whitney U tests showed that Malaysian participants achieved greater gains in mental health disorder knowledge (p < .001) and overall MHL (p = .002) compared to Saudi Arabian participants, with small-to-medium effect sizes. In Malaysia, large gains were found in mental health disorder knowledge, help seeking/first aid skill, self-help strategies, and total MHL (p < .001), whereas changes in erroneous beliefs were not significant. Conclusions Findings from this study provided insights into how e-learning tools like RLO can support youth mental health literacy in different cultural contexts. The results will contribute to shaping future e-promotion strategies and policies aimed so that both nations have high level of mental health literacy. Trial registration: Not applicable. Mental health literacy Reusable Learning Objects Youth Digital health education Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Mental health problems, including depression, anxiety, and stress, affect millions of youth worldwide. Studies estimate that 10–20% of children and youth experience mental health issues, which can significantly impact their academic performance, social relationships, and overall well-being [ 1 ]. Despite the growing awareness of mental health concerns, a review conducted by Furnham and Swami [ 2 ] revealed that mental health literacy (MHL) remains low, particularly in developing countries, limiting youth's ability to recognize symptoms and seek appropriate help. In Malaysia, the prevalence of youth mental health issues has reached a concerning level, with increasing cases of stress, anxiety, and depression among youth [ 3 ]. The rise of digital technology provides an opportunity to introduce innovative learning methods that enhance MHL by making mental health education more accessible and engaging. Meanwhile, in Saudi Arabia, mental health issues among youth remain underreported and under-addressed due to cultural stigma and limited access to mental health education. Research has shown that youth in Saudi Arabia with lower educational attainment are at a higher risk of experiencing disruptive behaviour disorders, mood disorders, and substance use disorders, further emphasizing the need for early intervention [ 4 ]. MHL among Malaysian youth is shaped by various factors, including sociodemographic influences and cultural considerations. Research has shown that higher MHL levels are associated with being female, older, a non-smoker, and not experiencing loneliness, highlighting the need for targeted policies and programs to address mental health issues among youth [ 5 ]. Additionally, expert perspectives from fields such as psychiatry, psychology, and social work emphasize key MHL components, including the ability to recognize mental disorders, seek information, develop positive attitudes, and understand self-treatment and professional help. These findings underscore the importance of culturally relevant MHL initiatives tailored to the Malaysian context to improve mental health awareness and help-seeking behaviours among young people [ 6 ]. This study employed a cross-country comparison design to assess the effectiveness of Reusable Learning Object (RLO) in improving MHL across two settings. By assessing youth’s engagement with RLO-based mental health education, this research will contribute to a better understanding of digital interventions in MHL promotion. Research objectives: To compare the baseline and post intervention MHL scores within each setting (Saudi Arabia and Malaysia). To examine interactions between country and intervention effects. Methods Study Design This research employs a quasi-experimental, with a baseline and post-test evaluation of effectiveness of Reusable Learning Object (RLO) for mental health literacy (MHL) among youth. A cross-country comparison approach is used to compare findings between Riyadh, Saudi Arabia, and Klang Valley, Malaysia. The study involved an intervention group using RLO-based learning and a control group who will answer baseline assessment only. ASPIRE Framework for RLO Development Reusable Learning Objects (RLOs) represent an innovative approach to education by offering digital resources that can be leveraged repeatedly, scaled, and distributed from a central online location to enhance teaching and learning. They come in different sizes, scopes, and levels of detail, ranging from brief instructional segments to a collection of resources designed to create a more comprehensive educational experience. The ASPIRE framework [ 7 , 8 ], a structured methodology for developing high-quality e-learning resources, provides a foundation for RLO development. ASPIRE consists of Aim, Storyboarding, Population, Implementation, Release, and Evaluation, ensuring that Reusable Learning Objects (RLOs) are pedagogically robust, interactive, and adaptable to diverse educational settings. The ASPIRE framework (Fig. 1 ) is systematically applied in the creation and implementation of RLOs in this study: Aim: The development process begins with defining the learning objectives and ensuring that the content aligns with mental health literacy goals. This phase establishes clear educational targets for the RLOs to enhance student understanding of mental health concepts. Storyboarding: This phase allows educators, mental health experts, and e-learning specialists to collaboratively sketch and annotate the structure of the RLOs. The visual representation of content ensures clarity in instructional design before development begins. Population: The content framework developed during the storyboarding stage is populated with detailed specifications for multimedia elements, activities, and assessments. A peer review process is conducted at this stage to validate content accuracy and pedagogical soundness. Implementation: This phase involves the technical development of RLOs, focusing on assembling and refining the content to ensure clarity, accessibility and effective knowledge delivery. Release: The finalized RLOs undergo a secondary peer review before being made accessible to learners. This ensures that the digital content meets quality standards for usability and effectiveness. Evaluation: The effectiveness of RLOs on mental health literacy is measured through data collection and analysis, providing insights into resource effectiveness and areas for refinement. Theoretical Underpinnings: Mental Health Literacy Model The development of RLO content is guided by Jorm’s Mental Health Literacy Model [ 9 ] and Campos [ 10 ], which defines MHL as: The ability to recognize specific mental disorders. Help-seeking/first aid options and available resources. Understanding of self-help strategies for mental well-being. Awareness of risk factors and causes of mental health conditions. Reduction of mental health stigma through education and awareness. Campos [ 10 ] constructed a short version questionnaire for adult (SVa)in 2022 and validated the questionnaire across the European and Asian countries. In addition, a follow-up validation for the Arabic version was performed by Zakaria et al in 2025 [ 11 ]. Campos et al [ 10 ] Mental Health Literacy dimensions and the 16 items that are used in this study Factor name Items Dimension 1: Knowledge on Mental Health Disorders (MHD) 1. Mental disorders affect people’s thoughts 2. A person with schizophrenia may see and hear things that nobody else sees and hears 3. One of the symptoms of depression is the loss of interest or pleasure in most things 4. Highly stressful situations may cause mental disorders 5. Changes in brain function may lead to the onset of mental disorder 6. The symptoms’ length is one of the important criteria for the diagnosis of a mental disorder Dimension 2: Erroneous Beliefs 7. Only adults have mental disorders 8. Mental disorders don’t affect people’s feelings 9. Mental disorders don’t affect people’s behavior/actions Dimension 3: Help Seeking and First aid skill 10. If I had a mental disorder, I would seek for a psychologist’s help 11. If someone close to me had a mental disorder, I would encourage her/him to see a psychiatrist 12. If I had a mental disorder, I would seek for a psychiatrist’s help. Dimension 4: Self Help Strategies 13. Sleeping well contributes to a good mental health 14. A balanced diet contributes to a good mental health 15. Physical exercise contributes to a good mental health 16. Doing something enjoyable contributes to a good mental health By using this questionnaire along with the RLO intervention, this study can measure the mental health literacy level. Implementation of RLOs in the Study The intervention involved embedding in a Reusable Learning Object (RLO) into the mental health education resources for the intervention group. The RLO is accessible through an online platform, offering self-paced and interactive digital content focused on key aspects of mental health literacy. Bilingual RLO in Saudi Arabia: https://acord.my/xerte/play.php?template_id=138#page1 RLO in English used in Malaysia: https://acord.my/xerte/play.php?template_id=151#page1 The mental health literacy questionnaire short version for adults by Campos et al [ 10 ] is used as a key instrument to assess changes in MHL among youth following educational intervention using RLOs [ 10 ]. The first page of RLO begins with a baseline questionnaire as shown in Fig. 2 to assess youth's baseline MHL before engaging with the RLO. Figure 3 outlines the introduction of the RLO, outlines the key learning outcomes and emphasizes the importance of enhancing mental health literacy (MHL) among youth. Figure 4 an example of the learning content designed to educate learners to neuroendocrine systems in relation to Mental Health disorders. Figure 5 shows some parts of the RLO content aimed to educate common mental health erroneous thoughts and how to encourage a more accurate understanding of mental health issues. Study Setting The study was conducted around schools and colleges located in Riyadh, Saudi Arabia, and Klang Valley, Malaysia. The locations were conveniently selected based on their willingness to participate and demographic similarities that align with the study objectives. The selected settings have an existing structure for implementing e-learning initiatives, ensuring the feasibility of RLO-based interventions. Study Participants Participants composed of youth aged 16–24 years old who are enrolled in the selected educational institutions are eligible to participate. The inclusion criteria for participation are: (1) access to the internet and basic digital literacy, (2) the ability to read and comprehend Arabic or English (for Saudi Arabia participants) and English (for Malaysian participants), and (3) obtaining parental or guardian consent when needed. Youth who do not meet the inclusion criteria or decline participation will be excluded from the study. Sample Size The sample size calculation was determined with reference to prior similar studies. Utilizing a power of 0.80 and an anticipated effect size of 0.5, as per Cohen [ 12 ], a minimum of 64 participants per group was required. To account for potential attrition or dropout (20%), the sample size was increased to approximately 80 participants per group. This results in a total of 160 participants across both the intervention and control groups as determined by the study design. The sample size calculation was conducted using the TTestIndPower function from the statsmodels library in Python, adhering to standard statistical guidelines [ 13 ]. Sampling Method Purposive sampling method was used to select educational institutions that align with the study's demographic and feasibility criteria. Within each selected education setting, cluster sampling was applied to assign youth to either the intervention group (receiving RLO-based learning) or the control group (receiving traditional mental health education through printed brochures and classroom discussions). This sampling approach ensures balanced representation across different socioeconomic and educational backgrounds. Data Collection Data collection took place in three phases: baseline assessment (pre-test), intervention, and post-intervention assessment (post-test). The study procedure was structured to ensure consistency in data gathering across both intervention and control groups. The enrolment process began with visits to identify the available groups to participate in the study. During these sessions, prospective participants received an overview of the study’s objectives and procedures. The importance of confidentiality and voluntary participation was emphasized. Upon agreement to participate, youth completed the baseline screening questions to assess eligibility and establish initial mental health literacy levels. Quasi-Experimental Study Conditions Participants were assigned to one of two groups based on a non-randomized allocation approach. Youth from one education setting formed the intervention group, receiving RLO-based learning, while youth from different settings formed the control group, to answer only the baseline questions. Intervention Condition Youth allocated to the intervention group first completed a baseline screening, which includes eligibility criteria, sociodemographic information, and the Mental Health Literacy (MHL) Questionnaire to assess their initial MHL level. Upon completion of the baseline survey, they were given immediate access to the developed Reusable Learning Object (RLO) on mental health literacy. Participants were instructed to engage with the RLO modules and actively interact with the embedded activities. After completing the review of RLO, the investigator requested participants to answer the MHL Questionnaire for post-intervention assessment. Control Condition Participants assigned to the control group first completed the baseline screening questions, which include eligibility criteria, sociodemographic information, and the Mental Health Literacy (MHL) questionnaire to assess their current mental health literacy. Following the baseline assessment, they were not given access to the RLO. After the survey is completed, all participants in the control group were given access to the developed RLO to ensure equitable learning opportunities. Results Data collection period took place from January 2025 to May 2025 across schools and universities in these two cities. Our research team managed to collect data from schools and universities with the average age of 21 years old in both setting. Table 1 Sociodemographic characteristics of the Saudi Arabia – Intervention group Sociodemographic Variables n Valid % Gender Female 61 74.4 Male 21 25.6 Mean age (SD) 21.39 (3.46) Educational Institution College/University 72 87.8 School 10 12.2 Table 2 Sociodemographic characteristics of the Malaysia – Intervention group Sociodemographic Variables n Valid % Gender Female 81 74.3 Male 28 25.7 Mean age (SD) 20.73 (0.97) Educational Institution College/University 109 100.0 Analysis for the Intervention Group in Saudi Arabia group Table 3 Reliability analysis of mental health literacy dimensions among participants in Saudi Arabia. Dimension No of items Cronbach’s α MHD Knowledge 6 .841 Erroneous Beliefs 3 .718 Help Seeking/First Aid 3 .822 Self-Help Strategies 4 .923 The reliability coefficients for each dimension are presented in Table 3 . Reliability analyses were conducted to assess the internal consistency of the mental health literacy (MHL) dimensions. The MHD Knowledge dimension (6 items) demonstrated good reliability, Cronbach’s α = .84. The Erroneous Beliefs dimension (3 items) showed acceptable reliability, α = .72. The Help seeking/First aid dimension (3 items) indicated good reliability, α = .82. Finally, the Self-Help Strategies dimension (4 items) exhibited excellent reliability, α = .92. Overall, these results suggest that the MHL instrument demonstrated acceptable to excellent internal consistency across all dimensions. Table 4 Wilcoxon signed-rank test results comparing baseline and post-intervention mental health literacy dimensions among participants in Saudi Arabia. Dimension N Negative Ranks (Declined) Positive Ranks (Improved) Ties Z p-value MHD Knowledge 82 11 61 10 -5.584 < .001 Erroneous Beliefs/stereotypes 82 18 12 52 -2.301 .021 Help-Seeking & First aid 82 8 29 45 -3.308 < .001 Self-Help Strategies 82 10 27 45 -2.997 .003 Total MHL 82 19 56 7 -3.749 < .001 Results of the Wilcoxon signed-rank test are shown in Table 4 . Tests of normality (Kolmogorov-Smirnov and Shapiro-Wilk) showed that all baseline test variables significantly deviated from a normal distribution (all p < .001). Therefore, the non-parametric Wilcoxon signed-rank test was employed. Results indicated that the intervention produced significant improvements in mental health disorder knowledge (MHD), Z = -5.58, p < .001, Help seeking/First aid skills, Z = -3.31, p < .001, self-help strategies, Z = -3.00, p = .003, and total mental health literacy, Z = -3.75, p < .001. In addition, erroneous beliefs decreased significantly, Z = -2.30, p = .021, suggesting a reduction in misconceptions in Saudi Arabia settings. Analysis of the Intervention Group in Malaysia setting Table 5 Reliability analysis of mental health literacy dimensions among Malaysian participants. Dimension No of items Cronbach’s α MHD Knowledge 6 .847 Erroneous Beliefs 3 .878 Help seeking/First aid 3 .806 Self-Help Strategies 4 .803 Reliability analyses were conducted to examine the internal consistency of the mental health literacy (MHL) dimensions. The MHD Knowledge dimension (6 items) demonstrated good reliability, Cronbach’s α = .85. The Erroneous Beliefs dimension (3 items) showed high reliability, α = .88. The Help seeking/First aid dimension (3 items) had good reliability, α = .81, while the Self-Help Strategies dimension (4 items) also demonstrated good reliability, α = .80. Overall, the findings indicate that the MHL instrument demonstrates good to excellent internal consistency across all dimensions. Table 6 Wilcoxon signed-rank test results comparing baseline and post- intervention mental health literacy dimensions among Malaysian participants. Dimension N Negative Ranks (Declined) Positive Ranks (Improved) Ties Z p-value MHD Knowledge 107 8 65 34 -5.82 < .001 Erroneous Beliefs/stereotypes 109 16 32 61 -0.96 .335 Help-Seeking /First aid Skills 109 3 61 45 -6.45 < .001 Self-Help Strategies 109 4 44 61 -5.16 < .001 Total MHL 107 11 78 18 -5.95 < .001 Prior to hypothesis testing, the assumption of normality was assessed using both the Kolmogorov–Smirnov and Shapiro–Wilk tests. Results indicated that all variables significantly deviated from normality ( p < .001 for all), suggesting that the data were non-normally distributed. Therefore, the non-parametric Wilcoxon signed-rank test was used to evaluate baseline and post-intervention differences. The analysis revealed significant improvements across most dimensions of mental health literacy. Participants showed higher mental health disorder knowledge following the intervention ( Z = -5.82, p < .001, r = .56), greater Help seeking/First aid skills ( Z = -6.45, p < .001, r = .62), enhanced self-help strategies ( Z = -5.16, p < .001, r = .50), and overall improvement in total mental health literacy ( Z = -5.95, p < .001, r = .57). Each of these effects was large in magnitude. In contrast, there was no significant change in erroneous beliefs ( Z = -0.96, p = .335, r = .09). Analysis for the Cross-country comparison A series of Mann–Whitney U tests were conducted to examine differences in change scores between youth in Saudi Arabia and Malaysia across mental health literacy outcomes. Results showed that Malaysian participants reported significantly greater improvements in mental health problem knowledge ( U = 12,742, Z = − 4.78, p < .001, r = .24), representing a small-to-medium effect size. Similarly, Malaysian participants demonstrated significantly greater overall mental health literacy gains compared to Saudi Arabia participants ( U = 14,432, Z = − 3.10, p = .002, r = .16). In contrast, there were no significant differences between the two countries for First aid knowledge ( U = 16,717, Z = − 1.14, p = .253, r = .06), self-help strategies ( U = 16,986, Z = − 0.90, p = .369, r = .05), or erroneous beliefs ( U = 17,711, Z = − 0.19, p = .853, r = .01). After applying a Bonferroni correction for multiple comparisons (α = .05/5 = .01), the results for mental health disorder knowledge and total mental health literacy remained statistically significant, confirming that these effects were robust. Together, these findings suggest that while both groups benefited from the intervention, participants in Malaysia setting experienced larger gains in mental health disorder knowledge and overall mental health literacy. Table 7 Mann–Whitney U test results comparing post-intervention changes in mental health literacy outcomes between Saudi Arabia and Malaysia. Outcome Variable Malaysia N Saudi N Mean Rank (MY) Mean Rank (SA) U Z p (2-tailed) r Interpretation Δ MHD Knowledge 216 164 213.51 160.20 12,742 –4.78 Saudi (small–medium effect) Δ Help seeking/ First Aid 218 164 186.18 198.57 16,717 –1.14 .253 .06 No significant difference Δ Self-Help Strategies 218 164 195.58 186.07 16,986 –0.90 .369 .05 No significant difference Δ Erroneous Beliefs 218 164 190.74 192.51 17,711 –0.19 .853 .01 No significant difference Δ Total MHL 216 164 205.69 170.50 14,432 –3.10 .002 .16 Malaysia > Saudi (small effect) A series of Mann–Whitney U tests were conducted to examine differences in change scores between Saudi Arabia and Malaysia across mental health literacy outcomes. Results showed that Malaysian participants reported significantly greater improvements in mental health problem knowledge ( U = 12,742, Z = − 4.78, p < .001, r = .24), representing a small-to-medium effect size. Similarly, Malaysian participants demonstrated significantly greater overall mental health literacy gains compared to Saudi Arabian participants ( U = 14,432, Z = − 3.10, p = .002, r = .16). In contrast, there were no significant differences between the two countries for First aid knowledge ( U = 16,717, Z = − 1.14, p = .253, r = .06), self-help strategies ( U = 16,986, Z = − 0.90, p = .369, r = .05), or erroneous beliefs ( U = 17,711, Z = − 0.19, p = .853, r = .01). After applying a Bonferroni correction for multiple comparisons (α = .05/5 = .01), the results for mental health disorder knowledge and total mental health literacy remained statistically significant, confirming that these effects were robust. Discussion This study aims to evaluate the effectiveness of Reusable Learning Object (RLO) in enhancing mental health literacy (MHL) among youth in Saudi Arabia and Malaysia. The integration of RLOs as an e-learning intervention represents a shift from traditional mental health promotion toward a more interactive and engaging approach. By comparing the outcomes between an intervention group utilizing RLOs and a control group that do not receive information via RLO, this study seeks to provide empirical evidence regarding the effectiveness of this RLO to increase the mental health literacy among youth. Both dataset in Saudi Arabia and Malaysia were subject to reliability testing (Table 3 and Table 5 ) and both analyses indicated the instrument used [ 10 ] proved to be reliable. To answer Research Objective one which is to compare the baseline and post intervention MHL scores within each setting, analysis was performed within each intervention group. For Saudi Arabia youth participants, the intervention showed significant improvements in most dimensions of mental health literacy (Table 4 ). Gains were particularly evident in mental health disorder knowledge, help seeking/first aid skills, self-help strategies, and overall MHL, with moderate-to-large effect sizes. These findings align with recent reviews confirming that structured and interactive psychoeducational approaches can meaningfully enhance literacy and knowledge when implemented in diverse cultural contexts [ 14 , 15 ] For the Malaysia setting, the analysis (Table 6 ) shows the intervention significantly improved participants’ mental health problem knowledge, help-seeking/first aid skills, self-help strategies, and overall MHL, with large effect sizes. These findings indicate that the intervention was successful in enhancing both conceptual understanding and practical skills related to mental health. However, no significant reduction was observed in erroneous beliefs, suggesting that misconceptions about mental health may be more resistant to change. The significant improvements across knowledge-based and skills-related dimensions in Malaysia setting highlight the effectiveness of structured psychoeducation in raising mental health awareness, which is consistent with prior research demonstrating that educational and skills-based interventions can substantially enhance MHL [ 16 ]. In particular, the large effects observed in the help seeking/first aid and overall MHL in the Malaysia setting highlight the practical benefits of providing participants with actionable strategies that can be applied in everyday contexts [ 17 ].The lack of change in erroneous beliefs aligns with evidence that stigma and misconceptions are more deeply rooted and less responsive to short-term interventions. Meta-analytic reviews have shown that while knowledge can be improved through education, attitudes and stigma require more sustained, multifaceted approaches [ 18 , 19 ]. Cultural norms and stereotypes often reinforce such beliefs, making them more resistant to modification through brief psychoeducation alone. A notable outcome was the reduction in erroneous beliefs (Table 4 ) following the intervention in the Saudi setting. This effect contrasts with findings compared to Malaysian participants, where misconceptions remained unchanged, suggesting a higher receptivity among Saudi Arabia participants to corrective educational content. Such results are consistent with contemporary evidence showing that well-designed interventions, particularly those that are interactive, contact-based, or digitally supported can reduce stigma and misconceptions, provided they move beyond a purely symptom-focused model [ 20 , 21 ]. These findings highlight the potential of personalized, and tailor made MHL e-promotion programs to deliver broad impact, not only by improving knowledge but also by challenging embedded misconceptions and stigma in a society. Recent large-scale and digital initiatives highlight that combining psychoeducation with stigma-reduction strategies can be especially effective in contexts where cultural beliefs shape mental health perceptions [ 22 ]. The interventions demonstrated overall effectiveness across both the Saudi Arabia and Malaysian groups, with participants showing significant gains in mental health problem knowledge, help seeking/first aid skills, and self-help strategies. These findings reinforce recent systematic reviews which conclude that structured psychoeducational and digital interventions can substantially improve MHL in diverse cultural settings [ 20 , 22 ]. Despite these shared improvements, a notable difference emerged in relation to erroneous beliefs/stereotypes. In the Saudi Arabia group, misconceptions declined significantly, suggesting that participants were receptive to corrective educational content. In contrast, the Malaysian group showed no significant change in this domain, reflecting the persistence of stigma-related attitudes despite knowledge gains. This divergence echoes recent literature indicating that while educational approaches reliably improve knowledge, their impact on stigma varies depending on cultural context and the inclusion of targeted stigma-reduction strategies [ 18 , 19 ]. The results highlight the need for culturally responsive program design. For Saudi Arabia participants, structured educational content alone was sufficient to reduce misconceptions, while Malaysian participants may require more integrated approaches that combine psychoeducation with stigma-focused elements such as contact-based learning, narratives, or digital storytelling. This aligns with emerging evidence that interventions using holistic and culturally grounded messaging are more likely to reduce stigma sustainably [ 21 ]. For Objective 2, which is to examine interactions between countries and intervention effects, we found interesting findings (Table 7 ). Findings indicated that while both groups demonstrated improvements, Malaysian participants showed significantly greater gains in knowledge of mental health disorders and overall mental health literacy. These results suggest that contextual and language factors may shape the extent to which interventions translate into measurable knowledge gains. Recent evidence demonstrates the effectiveness of structured mental health literacy interventions in enhancing knowledge and reducing stigma. Culturally responsive approaches that integrate local beliefs, practices, and educational norms consistently produce stronger outcomes, as they align more closely with participant experiences. The stronger effects observed in the Malaysian cohort may be attributable to previous mental health literacy initiatives and public health campaigns, which likely fostered a more receptive environment. Interestingly, no significant differences were observed in help seeking/first aid skills, self-help strategies, or erroneous beliefs. This aligns with recent findings suggesting that while brief interventions can improve recognition and knowledge, deeper changes in beliefs and self-help behaviours often require sustained, multi-component engagement [ 23 ]. Future research should therefore consider longer-term follow-up and integration of peer-led or digital components, which have been shown to enhance retention and application of skills [ 24 ]. The findings found in Research objective 2 demonstrates that mental health literacy interventions can be improved in diverse cultural contexts. The results also emphasize the necessity of adapting intervention strategies to specific cultural settings to achieve maximum effectiveness. The overall findings of this study contributed to the growing body of research on e-learning in mental health promotion. Given that mental health issues among youth are increasingly prevalent, particularly in post-pandemic contexts, equipping youth with adequate MHL is critical. Poor MHL is associated with increased stigma, reduced help-seeking/first aid skills, and a greater risk of untreated mental health conditions. By addressing these gaps through RLO-based learning, this study has the potential to inform future educational policies and mental health interventions. Theoretical and Conceptual Framework The ASPIRE framework used [ 7 , 8 ] in the development of RLOs ensures that these e-learning materials are pedagogically robust, linguistically adaptable, and interactive. The emphasis on active learning, multimedia engagement, and self-paced study aligns with contemporary educational best practices. Furthermore, the integration of Campos’s Mental Health Literacy Model [ 10 ] within the RLO ensures comprehensive coverage of essential MHL dimensions, such as recognizing mental health conditions, understanding risk factors, and identifying appropriate help-seeking strategies. Strengths and limitations A key strength of this study is its cross-country comparison approach, allowing for a comparison of MHL improvements between youth in Saudi Arabia and Malaysia. By assessing the transferability of RLOs across diverse educational and cultural settings [ 1 ], this research provided insights into the effectiveness of digital interventions in different contexts. Additionally, the quasi-experimental design allows for a structured evaluation of baseline and post-intervention MHL levels, ensuring methodological rigor. Despite its strengths, the study has several limitations. First, the non-randomized allocation of participants into intervention and control groups may introduce selection bias. While efforts were made to ensure baseline equivalence between groups, uncontrolled confounding variables may still influence outcomes. Second, the reliance on self-reported measures for MHL assessment may introduce response bias, as youth may overestimate or underestimate their knowledge and attitudes toward mental health. To mitigate this, a validated MHL instrument was used, and triangulation with qualitative feedback from participants will be considered for future research. Future research directions could include expanding the study to a broader age range of youth or implementing a longitudinal design to assess the long-term retention of MHL knowledge. Additionally, exploring the integration of RLOs with blended learning models, combining digital and face-to-face instruction could provide further insights into optimizing mental health education for youth. Conclusion This study demonstrated that Reusable Learning Object (RLO) significantly improved mental health literacy (MHL) among youth in Saudi Arabia and Malaysia. Participants showed gains in knowledge of mental health disorders, help seeking and first aid skills, and self-help strategies, confirming the potential of interactive e-learning as a scalable and culturally adaptable e-promotion tool. The cross-country comparison revealed meaningful differences in youth knowledge, skills and strategies towards mental health, underscoring the need for localized content to address stigma and misconceptions effectively. These findings highlight the promise of integrating RLO-based mental health education into existing curricula to promote awareness and early help-seeking among young people. Future research should explore long-term retention, integration with blended learning approaches, and user experience and usability studies that can further enhance engagement and impact. Declarations Ethical approval and consent to participate Ethical approval for this study has been obtained from the relevant Ethics Committees in Saudi Arabia and Malaysia, including the Institutional Review Board in Saudi Arabia [IRB24-066] and Universiti Malaya (UM) [UM. TNC2.UMREC_4075]. Additionally, approvals have been obtained from the respective educational authorities overseeing the selected institutions in both countries to ensure compliance with local research regulations. Consent for publication Not applicable. Availability of data and materials The Reusable Learning Objects (RLOs) used in this study are available online: Saudi Arabia: https://acord.my/xerte/play.php?template_id=138#page1 Malaysia: https://acord.my/xerte/play.php?template_id=151#page1 Data supporting the findings of this study are available from the corresponding author upon reasonable request. Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding This research was fully funded by AlMaarefa University. Authors’ contribution NZ, NDNF, ST, NF and HM contributed to the study of conception and design. Material preparation, data collection, and analysis were performed by NZ, NDNF, NF and HM. RLO modifications and translation were handled by NZ, NDNF, DM. Data collection was conducted by NZ, AM, AB in Saudi Arabia while NF, NDNF, HM and EA collected data in Malaysia. The first draft of the manuscript was written by NZ, NDNF, EAR, HM, NFMN and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements The researchers from the College of Applied Sciences, AlMaarefa University would like to thank AlMaarefa University for the financial support under the Internal Grant scheme. The researchers also acknowledge Alfred Tan from Institute of Biological Sciences University Malaya, for his contribution in building the first version of the RLO. References The transferability of Open Reusable Learning. Objects (RLOs) to nursing clinical skills education in the Saudi context: a mixed method study [Internet]. Nottingham: University of Nottingham; [cited 2024 Apr 28]. Available from: https://eprints.nottingham.ac.uk/id/eprint/63650 Furnham A, Swami V. Mental Health Literacy: A review of what it is and why it matters. Int Perspect Psychol. 2018;7(4):240–57. https://doi.org/10.1037/ipp0000094 . 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The effect of digital mental health literacy interventions on mental health outcomes: A systematic review and meta-analysis. J Med Internet Res. 2024;26(1):e51268. https://doi.org/10.2196/51268 . Shalaby RAH, Agyapong VIO. Peer support in mental health: Literature review. Int J Mental Health Syst. 2020;14:69. https://doi.org/10.1186/s13033-020-00383-1 . Torok M, Han J, Werner-Seidler A. Digital interventions for youth mental health literacy: A systematic review. JMIR Mental Health. 2023;10:e41926. https://doi.org/10.2196/41926 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 02 Jan, 2026 Reviews received at journal 25 Dec, 2025 Reviews received at journal 19 Dec, 2025 Reviewers agreed at journal 15 Dec, 2025 Reviewers agreed at journal 13 Dec, 2025 Reviewers invited by journal 30 Nov, 2025 Editor invited by journal 21 Nov, 2025 Editor assigned by journal 20 Nov, 2025 Submission checks completed at journal 20 Nov, 2025 First submitted to journal 19 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8151634","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":553636169,"identity":"c322dd77-2bdc-486a-95b5-3ac9678a7544","order_by":0,"name":"Nasriah 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16:20:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":483393,"visible":true,"origin":"","legend":"\u003cp\u003eLearning Objectives Overview.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8151634/v1/ded109a95d489d1c70d90523.png"},{"id":97271736,"identity":"283dcc9a-97fd-474f-945e-adcb910b3160","added_by":"auto","created_at":"2025-12-02 15:03:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":231570,"visible":true,"origin":"","legend":"\u003cp\u003eIntroduction to the Neuroendocrine System.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8151634/v1/b85d079be4e908c09d78b2b1.png"},{"id":97271731,"identity":"d7b9c674-8cb9-45b9-b11b-a08801f611fa","added_by":"auto","created_at":"2025-12-02 15:03:45","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":201927,"visible":true,"origin":"","legend":"\u003cp\u003eAddressing Misconceptions and Enhancing Understanding.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8151634/v1/c0f2785d794e70e2c77f4c76.png"},{"id":97372712,"identity":"db7cef8d-7668-4835-b2e0-0402be1e7051","added_by":"auto","created_at":"2025-12-03 16:32:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2479496,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8151634/v1/9e169350-6df8-4203-b8e6-7bd8246f5f0a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Cross-Country Comparative Study on Mental Health Literacy Among Youth Using A Reusable Learning Object in Saudi Arabia and Malaysia: A Quasi-Experimental Study","fulltext":[{"header":"Background","content":"\u003cp\u003eMental health problems, including depression, anxiety, and stress, affect millions of youth worldwide. Studies estimate that 10\u0026ndash;20% of children and youth experience mental health issues, which can significantly impact their academic performance, social relationships, and overall well-being [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite the growing awareness of mental health concerns, a review conducted by Furnham and Swami [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] revealed that mental health literacy (MHL) remains low, particularly in developing countries, limiting youth's ability to recognize symptoms and seek appropriate help.\u003c/p\u003e\u003cp\u003eIn Malaysia, the prevalence of youth mental health issues has reached a concerning level, with increasing cases of stress, anxiety, and depression among youth [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The rise of digital technology provides an opportunity to introduce innovative learning methods that enhance MHL by making mental health education more accessible and engaging. Meanwhile, in Saudi Arabia, mental health issues among youth remain underreported and under-addressed due to cultural stigma and limited access to mental health education. Research has shown that youth in Saudi Arabia with lower educational attainment are at a higher risk of experiencing disruptive behaviour disorders, mood disorders, and substance use disorders, further emphasizing the need for early intervention [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMHL among Malaysian youth is shaped by various factors, including sociodemographic influences and cultural considerations. Research has shown that higher MHL levels are associated with being female, older, a non-smoker, and not experiencing loneliness, highlighting the need for targeted policies and programs to address mental health issues among youth [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additionally, expert perspectives from fields such as psychiatry, psychology, and social work emphasize key MHL components, including the ability to recognize mental disorders, seek information, develop positive attitudes, and understand self-treatment and professional help. These findings underscore the importance of culturally relevant MHL initiatives tailored to the Malaysian context to improve mental health awareness and help-seeking behaviours among young people [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study employed a cross-country comparison design to assess the effectiveness of Reusable Learning Object (RLO) in improving MHL across two settings. By assessing youth\u0026rsquo;s engagement with RLO-based mental health education, this research will contribute to a better understanding of digital interventions in MHL promotion.\u003c/p\u003e\u003cp\u003eResearch objectives:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo compare the baseline and post intervention MHL scores within each setting (Saudi Arabia and Malaysia).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo examine interactions between country and intervention effects.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis research employs a quasi-experimental, with a baseline and post-test evaluation of effectiveness of Reusable Learning Object (RLO) for mental health literacy (MHL) among youth. A cross-country comparison approach is used to compare findings between Riyadh, Saudi Arabia, and Klang Valley, Malaysia. The study involved an intervention group using RLO-based learning and a control group who will answer baseline assessment only.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eASPIRE Framework for RLO Development\u003c/h3\u003e\n\u003cp\u003eReusable Learning Objects (RLOs) represent an innovative approach to education by offering digital resources that can be leveraged repeatedly, scaled, and distributed from a central online location to enhance teaching and learning. They come in different sizes, scopes, and levels of detail, ranging from brief instructional segments to a collection of resources designed to create a more comprehensive educational experience.\u003c/p\u003e\u003cp\u003eThe ASPIRE framework [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], a structured methodology for developing high-quality e-learning resources, provides a foundation for RLO development. ASPIRE consists of Aim, Storyboarding, Population, Implementation, Release, and Evaluation, ensuring that Reusable Learning Objects (RLOs) are pedagogically robust, interactive, and adaptable to diverse educational settings. The ASPIRE framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) is systematically applied in the creation and implementation of RLOs in this study:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAim: The development process begins with defining the learning objectives and ensuring that the content aligns with mental health literacy goals. This phase establishes clear educational targets for the RLOs to enhance student understanding of mental health concepts.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStoryboarding: This phase allows educators, mental health experts, and e-learning specialists to collaboratively sketch and annotate the structure of the RLOs. The visual representation of content ensures clarity in instructional design before development begins.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePopulation: The content framework developed during the storyboarding stage is populated with detailed specifications for multimedia elements, activities, and assessments. A peer review process is conducted at this stage to validate content accuracy and pedagogical soundness.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eImplementation: This phase involves the technical development of RLOs, focusing on assembling and refining the content to ensure clarity, accessibility and effective knowledge delivery.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eRelease: The finalized RLOs undergo a secondary peer review before being made accessible to learners. This ensures that the digital content meets quality standards for usability and effectiveness.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEvaluation: The effectiveness of RLOs on mental health literacy is measured through data collection and analysis, providing insights into resource effectiveness and areas for refinement.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eTheoretical Underpinnings: Mental Health Literacy Model\u003c/h3\u003e\n\u003cp\u003eThe development of RLO content is guided by Jorm\u0026rsquo;s Mental Health Literacy Model [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and Campos [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which defines MHL as:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThe ability to recognize specific mental disorders.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHelp-seeking/first aid options and available resources.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eUnderstanding of self-help strategies for mental well-being.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAwareness of risk factors and causes of mental health conditions.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eReduction of mental health stigma through education and awareness.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eCampos [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] constructed a short version questionnaire for adult (SVa)in 2022 and validated the questionnaire across the European and Asian countries. In addition, a follow-up validation for the Arabic version was performed by Zakaria et al in 2025 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCampos et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Mental Health Literacy dimensions and the 16 items that are used in this study\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFactor name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension 1:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKnowledge on Mental Health Disorders (MHD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1. Mental disorders affect people\u0026rsquo;s thoughts\u003c/p\u003e\u003cp\u003e2. A person with schizophrenia may see and hear things that nobody else sees and hears\u003c/p\u003e\u003cp\u003e3. One of the symptoms of depression is the loss of interest or pleasure in most things\u003c/p\u003e\u003cp\u003e4. Highly stressful situations may cause mental disorders\u003c/p\u003e\u003cp\u003e5. Changes in brain function may lead to the onset of mental disorder\u003c/p\u003e\u003cp\u003e6. The symptoms\u0026rsquo; length is one of the important criteria for the diagnosis of a mental disorder\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension 2:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eErroneous Beliefs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7. Only adults have mental disorders\u003c/p\u003e\u003cp\u003e8. Mental disorders don\u0026rsquo;t affect people\u0026rsquo;s feelings\u003c/p\u003e\u003cp\u003e9. Mental disorders don\u0026rsquo;t affect people\u0026rsquo;s behavior/actions\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension 3:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHelp Seeking and First aid skill\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10. If I had a mental disorder, I would seek for a psychologist\u0026rsquo;s help\u003c/p\u003e\u003cp\u003e11. If someone close to me had a mental disorder, I would encourage her/him to see a psychiatrist\u003c/p\u003e\u003cp\u003e12. If I had a mental disorder, I would seek for a psychiatrist\u0026rsquo;s help.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension 4:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf Help Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13. Sleeping well contributes to a good mental health\u003c/p\u003e\u003cp\u003e14. A balanced diet contributes to a good mental health\u003c/p\u003e\u003cp\u003e15. Physical exercise contributes to a good mental health\u003c/p\u003e\u003cp\u003e16. Doing something enjoyable contributes to a good mental health\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBy using this questionnaire along with the RLO intervention, this study can measure the mental health literacy level.\u003c/p\u003e\n\u003ch3\u003eImplementation of RLOs in the Study\u003c/h3\u003e\n\u003cp\u003eThe intervention involved embedding in a Reusable Learning Object (RLO) into the mental health education resources for the intervention group. The RLO is accessible through an online platform, offering self-paced and interactive digital content focused on key aspects of mental health literacy.\u003c/p\u003e\u003cp\u003eBilingual RLO in Saudi Arabia: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://acord.my/xerte/play.php?template_id=138#page1\u003c/span\u003e\u003cspan address=\"https://acord.my/xerte/play.php?template_id=138#page1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eRLO in English used in Malaysia: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://acord.my/xerte/play.php?template_id=151#page1\u003c/span\u003e\u003cspan address=\"https://acord.my/xerte/play.php?template_id=151#page1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mental health literacy questionnaire short version for adults by Campos et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] is used as a key instrument to assess changes in MHL among youth following educational intervention using RLOs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The first page of RLO begins with a baseline questionnaire as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e to assess youth's baseline MHL before engaging with the RLO.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e outlines the introduction of the RLO, outlines the key learning outcomes and emphasizes the importance of enhancing mental health literacy (MHL) among youth.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e an example of the learning content designed to educate learners to neuroendocrine systems in relation to Mental Health disorders.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows some parts of the RLO content aimed to educate common mental health erroneous thoughts and how to encourage a more accurate understanding of mental health issues.\u003c/p\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThe study was conducted around schools and colleges located in Riyadh, Saudi Arabia, and Klang Valley, Malaysia. The locations were conveniently selected based on their willingness to participate and demographic similarities that align with the study objectives. The selected settings have an existing structure for implementing e-learning initiatives, ensuring the feasibility of RLO-based interventions.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStudy Participants\u003c/h2\u003e\u003cp\u003eParticipants composed of youth aged 16\u0026ndash;24 years old who are enrolled in the selected educational institutions are eligible to participate. The inclusion criteria for participation are: (1) access to the internet and basic digital literacy, (2) the ability to read and comprehend Arabic or English (for Saudi Arabia participants) and English (for Malaysian participants), and (3) obtaining parental or guardian consent when needed. Youth who do not meet the inclusion criteria or decline participation will be excluded from the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSample Size\u003c/h3\u003e\n\u003cp\u003eThe sample size calculation was determined with reference to prior similar studies. Utilizing a power of 0.80 and an anticipated effect size of 0.5, as per Cohen [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], a minimum of 64 participants per group was required. To account for potential attrition or dropout (20%), the sample size was increased to approximately 80 participants per group. This results in a total of 160 participants across both the intervention and control groups as determined by the study design. The sample size calculation was conducted using the TTestIndPower function from the statsmodels library in Python, adhering to standard statistical guidelines [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eSampling Method\u003c/h3\u003e\n\u003cp\u003ePurposive sampling method was used to select educational institutions that align with the study's demographic and feasibility criteria. Within each selected education setting, cluster sampling was applied to assign youth to either the intervention group (receiving RLO-based learning) or the control group (receiving traditional mental health education through printed brochures and classroom discussions). This sampling approach ensures balanced representation across different socioeconomic and educational backgrounds.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData Collection\u003c/h2\u003e\u003cp\u003eData collection took place in three phases: baseline assessment (pre-test), intervention, and post-intervention assessment (post-test). The study procedure was structured to ensure consistency in data gathering across both intervention and control groups. The enrolment process began with visits to identify the available groups to participate in the study. During these sessions, prospective participants received an overview of the study\u0026rsquo;s objectives and procedures. The importance of confidentiality and voluntary participation was emphasized. Upon agreement to participate, youth completed the baseline screening questions to assess eligibility and establish initial mental health literacy levels.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eQuasi-Experimental Study Conditions\u003c/h2\u003e\u003cp\u003eParticipants were assigned to one of two groups based on a non-randomized allocation approach. Youth from one education setting formed the intervention group, receiving RLO-based learning, while youth from different settings formed the control group, to answer only the baseline questions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eIntervention Condition\u003c/h2\u003e\u003cp\u003eYouth allocated to the intervention group first completed a baseline screening, which includes eligibility criteria, sociodemographic information, and the Mental Health Literacy (MHL) Questionnaire to assess their initial MHL level. Upon completion of the baseline survey, they were given immediate access to the developed Reusable Learning Object (RLO) on mental health literacy. Participants were instructed to engage with the RLO modules and actively interact with the embedded activities. After completing the review of RLO, the investigator requested participants to answer the MHL Questionnaire for post-intervention assessment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eControl Condition\u003c/h2\u003e\u003cp\u003eParticipants assigned to the control group first completed the baseline screening questions, which include eligibility criteria, sociodemographic information, and the Mental Health Literacy (MHL) questionnaire to assess their current mental health literacy. Following the baseline assessment, they were not given access to the RLO. After the survey is completed, all participants in the control group were given access to the developed RLO to ensure equitable learning opportunities.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eData collection period took place from January 2025 to May 2025 across schools and universities in these two cities. Our research team managed to collect data from schools and universities with the average age of 21 years old in both setting.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic characteristics of the Saudi Arabia \u0026ndash; Intervention group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSociodemographic Variables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eValid %\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean age (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(3.46)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducational Institution\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege/University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic characteristics of the Malaysia \u0026ndash; Intervention group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSociodemographic Variables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eValid %\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean age (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e(0.97)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducational Institution\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege/University\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis for the Intervention Group in Saudi Arabia group\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReliability analysis of mental health literacy dimensions among participants in Saudi Arabia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo of items\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCronbach\u0026rsquo;s α\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMHD Knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.841\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eErroneous Beliefs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.718\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHelp Seeking/First Aid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.822\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-Help Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.923\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe reliability coefficients for each dimension are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Reliability analyses were conducted to assess the internal consistency of the mental health literacy (MHL) dimensions. The MHD Knowledge dimension (6 items) demonstrated good reliability, Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.84. The Erroneous Beliefs dimension (3 items) showed acceptable reliability, α\u0026thinsp;=\u0026thinsp;.72. The Help seeking/First aid dimension (3 items) indicated good reliability, α\u0026thinsp;=\u0026thinsp;.82. Finally, the Self-Help Strategies dimension (4 items) exhibited excellent reliability, α\u0026thinsp;=\u0026thinsp;.92. Overall, these results suggest that the MHL instrument demonstrated acceptable to excellent internal consistency across all dimensions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eWilcoxon signed-rank test results comparing baseline and post-intervention mental health literacy dimensions among participants in Saudi Arabia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNegative Ranks (Declined)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePositive Ranks (Improved)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eZ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMHD Knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-5.584\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eErroneous Beliefs/stereotypes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-2.301\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHelp-Seeking \u0026amp; First aid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-3.308\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-Help Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-2.997\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal MHL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-3.749\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eResults of the Wilcoxon signed-rank test are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Tests of normality (Kolmogorov-Smirnov and Shapiro-Wilk) showed that all baseline test variables significantly deviated from a normal distribution (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Therefore, the non-parametric Wilcoxon signed-rank test was employed. Results indicated that the intervention produced significant improvements in mental health disorder knowledge (MHD), \u003cem\u003eZ\u003c/em\u003e = -5.58, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, Help seeking/First aid skills, \u003cem\u003eZ\u003c/em\u003e = -3.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, self-help strategies, \u003cem\u003eZ\u003c/em\u003e = -3.00, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003, and total mental health literacy, \u003cem\u003eZ\u003c/em\u003e = -3.75, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. In addition, erroneous beliefs decreased significantly, \u003cem\u003eZ\u003c/em\u003e = -2.30, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.021, suggesting a reduction in misconceptions in Saudi Arabia settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis of the Intervention Group in Malaysia setting\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReliability analysis of mental health literacy dimensions among Malaysian participants.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo of items\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCronbach\u0026rsquo;s α\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMHD Knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.847\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eErroneous Beliefs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.878\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHelp seeking/First aid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.806\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-Help Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.803\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eReliability analyses were conducted to examine the internal consistency of the mental health literacy (MHL) dimensions. The MHD Knowledge dimension (6 items) demonstrated good reliability, Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.85. The Erroneous Beliefs dimension (3 items) showed high reliability, α\u0026thinsp;=\u0026thinsp;.88. The Help seeking/First aid dimension (3 items) had good reliability, α\u0026thinsp;=\u0026thinsp;.81, while the Self-Help Strategies dimension (4 items) also demonstrated good reliability, α\u0026thinsp;=\u0026thinsp;.80. Overall, the findings indicate that the MHL instrument demonstrates good to excellent internal consistency across all dimensions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eWilcoxon signed-rank test results comparing baseline and post- intervention mental health literacy dimensions among Malaysian participants.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNegative Ranks (Declined)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePositive Ranks (Improved)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eZ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMHD Knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-5.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eErroneous Beliefs/stereotypes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.335\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHelp-Seeking /First aid Skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-6.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-Help Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-5.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal MHL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-5.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePrior to hypothesis testing, the assumption of normality was assessed using both the Kolmogorov\u0026ndash;Smirnov and Shapiro\u0026ndash;Wilk tests. Results indicated that all variables significantly deviated from normality (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001 for all), suggesting that the data were non-normally distributed. Therefore, the non-parametric Wilcoxon signed-rank test was used to evaluate baseline and post-intervention differences.\u003c/p\u003e\u003cp\u003eThe analysis revealed significant improvements across most dimensions of mental health literacy. Participants showed higher mental health disorder knowledge following the intervention (\u003cem\u003eZ\u003c/em\u003e = -5.82, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.56), greater Help seeking/First aid skills (\u003cem\u003eZ\u003c/em\u003e = -6.45, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.62), enhanced self-help strategies (\u003cem\u003eZ\u003c/em\u003e = -5.16, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.50), and overall improvement in total mental health literacy (\u003cem\u003eZ\u003c/em\u003e = -5.95, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.57). Each of these effects was large in magnitude. In contrast, there was no significant change in erroneous beliefs (\u003cem\u003eZ\u003c/em\u003e = -0.96, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.335, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.09).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eAnalysis for the Cross-country comparison\u003c/h2\u003e\u003cp\u003eA series of Mann\u0026ndash;Whitney U tests were conducted to examine differences in change scores between youth in Saudi Arabia and Malaysia across mental health literacy outcomes. Results showed that Malaysian participants reported significantly greater improvements in mental health problem knowledge (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12,742, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;4.78, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.24), representing a small-to-medium effect size. Similarly, Malaysian participants demonstrated significantly greater overall mental health literacy gains compared to Saudi Arabia participants (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14,432, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;3.10, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.16). In contrast, there were no significant differences between the two countries for First aid knowledge (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16,717, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;1.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.253, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.06), self-help strategies (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16,986, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.90, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.369, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.05), or erroneous beliefs (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17,711, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.19, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.853, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.01). After applying a Bonferroni correction for multiple comparisons (α\u0026thinsp;=\u0026thinsp;.05/5\u0026thinsp;=\u0026thinsp;.01), the results for mental health disorder knowledge and total mental health literacy remained statistically significant, confirming that these effects were robust. Together, these findings suggest that while both groups benefited from the intervention, participants in Malaysia setting experienced larger gains in mental health disorder knowledge and overall mental health literacy.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMann\u0026ndash;Whitney U test results comparing post-intervention changes in mental health literacy outcomes between Saudi Arabia and Malaysia.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome Variable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMalaysia \u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSaudi \u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean Rank (MY)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean Rank (SA)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eU\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e (2-tailed)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eΔ MHD Knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e213.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e160.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e12,742\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026ndash;4.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eMalaysia\u0026thinsp;\u0026gt;\u0026thinsp;Saudi (small\u0026ndash;medium effect)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eΔ Help seeking/ First Aid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e186.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e198.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e16,717\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026ndash;1.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.253\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNo significant difference\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eΔ Self-Help Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e195.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e186.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e16,986\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026ndash;0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.369\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNo significant difference\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eΔ Erroneous Beliefs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e218\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e190.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e192.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e17,711\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026ndash;0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.853\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eNo significant difference\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eΔ Total MHL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e205.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e170.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e14,432\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026ndash;3.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eMalaysia\u0026thinsp;\u0026gt;\u0026thinsp;Saudi (small effect)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA series of Mann\u0026ndash;Whitney U tests were conducted to examine differences in change scores between Saudi Arabia and Malaysia across mental health literacy outcomes. Results showed that Malaysian participants reported significantly greater improvements in mental health problem knowledge (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12,742, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;4.78, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.24), representing a small-to-medium effect size. Similarly, Malaysian participants demonstrated significantly greater overall mental health literacy gains compared to Saudi Arabian participants (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14,432, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;3.10, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.16). In contrast, there were no significant differences between the two countries for First aid knowledge (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16,717, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;1.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.253, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.06), self-help strategies (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16,986, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.90, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.369, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.05), or erroneous beliefs (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17,711, \u003cem\u003eZ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.19, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.853, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.01). After applying a Bonferroni correction for multiple comparisons (α\u0026thinsp;=\u0026thinsp;.05/5\u0026thinsp;=\u0026thinsp;.01), the results for mental health disorder knowledge and total mental health literacy remained statistically significant, confirming that these effects were robust.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aims to evaluate the effectiveness of Reusable Learning Object (RLO) in enhancing mental health literacy (MHL) among youth in Saudi Arabia and Malaysia. The integration of RLOs as an e-learning intervention represents a shift from traditional mental health promotion toward a more interactive and engaging approach. By comparing the outcomes between an intervention group utilizing RLOs and a control group that do not receive information via RLO, this study seeks to provide empirical evidence regarding the effectiveness of this RLO to increase the mental health literacy among youth.\u003c/p\u003e\u003cp\u003eBoth dataset in Saudi Arabia and Malaysia were subject to reliability testing (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) and both analyses indicated the instrument used [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] proved to be reliable. To answer Research Objective one which is to compare the baseline and post intervention MHL scores within each setting, analysis was performed within each intervention group. For Saudi Arabia youth participants, the intervention showed significant improvements in most dimensions of mental health literacy (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Gains were particularly evident in mental health disorder knowledge, help seeking/first aid skills, self-help strategies, and overall MHL, with moderate-to-large effect sizes. These findings align with recent reviews confirming that structured and interactive psychoeducational approaches can meaningfully enhance literacy and knowledge when implemented in diverse cultural contexts [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eFor the Malaysia setting, the analysis (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) shows the intervention significantly improved participants\u0026rsquo; mental health problem knowledge, help-seeking/first aid skills, self-help strategies, and overall MHL, with large effect sizes. These findings indicate that the intervention was successful in enhancing both conceptual understanding and practical skills related to mental health. However, no significant reduction was observed in erroneous beliefs, suggesting that misconceptions about mental health may be more resistant to change.\u003c/p\u003e\u003cp\u003eThe significant improvements across knowledge-based and skills-related dimensions in Malaysia setting highlight the effectiveness of structured psychoeducation in raising mental health awareness, which is consistent with prior research demonstrating that educational and skills-based interventions can substantially enhance MHL [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In particular, the large effects observed in the help seeking/first aid and overall MHL in the Malaysia setting highlight the practical benefits of providing participants with actionable strategies that can be applied in everyday contexts [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].The lack of change in erroneous beliefs aligns with evidence that stigma and misconceptions are more deeply rooted and less responsive to short-term interventions. Meta-analytic reviews have shown that while knowledge can be improved through education, attitudes and stigma require more sustained, multifaceted approaches [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Cultural norms and stereotypes often reinforce such beliefs, making them more resistant to modification through brief psychoeducation alone.\u003c/p\u003e\u003cp\u003eA notable outcome was the reduction in erroneous beliefs (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) following the intervention in the Saudi setting. This effect contrasts with findings compared to Malaysian participants, where misconceptions remained unchanged, suggesting a higher receptivity among Saudi Arabia participants to corrective educational content. Such results are consistent with contemporary evidence showing that well-designed interventions, particularly those that are interactive, contact-based, or digitally supported can reduce stigma and misconceptions, provided they move beyond a purely symptom-focused model [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings highlight the potential of personalized, and tailor made MHL e-promotion programs to deliver broad impact, not only by improving knowledge but also by challenging embedded misconceptions and stigma in a society. Recent large-scale and digital initiatives highlight that combining psychoeducation with stigma-reduction strategies can be especially effective in contexts where cultural beliefs shape mental health perceptions [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe interventions demonstrated overall effectiveness across both the Saudi Arabia and Malaysian groups, with participants showing significant gains in mental health problem knowledge, help seeking/first aid skills, and self-help strategies. These findings reinforce recent systematic reviews which conclude that structured psychoeducational and digital interventions can substantially improve MHL in diverse cultural settings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these shared improvements, a notable difference emerged in relation to erroneous beliefs/stereotypes. In the Saudi Arabia group, misconceptions declined significantly, suggesting that participants were receptive to corrective educational content. In contrast, the Malaysian group showed no significant change in this domain, reflecting the persistence of stigma-related attitudes despite knowledge gains. This divergence echoes recent literature indicating that while educational approaches reliably improve knowledge, their impact on stigma varies depending on cultural context and the inclusion of targeted stigma-reduction strategies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe results highlight the need for culturally responsive program design. For Saudi Arabia participants, structured educational content alone was sufficient to reduce misconceptions, while Malaysian participants may require more integrated approaches that combine psychoeducation with stigma-focused elements such as contact-based learning, narratives, or digital storytelling. This aligns with emerging evidence that interventions using holistic and culturally grounded messaging are more likely to reduce stigma sustainably [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFor Objective 2, which is to examine interactions between countries and intervention effects, we found interesting findings (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Findings indicated that while both groups demonstrated improvements, Malaysian participants showed significantly greater gains in knowledge of mental health disorders and overall mental health literacy. These results suggest that contextual and language factors may shape the extent to which interventions translate into measurable knowledge gains. Recent evidence demonstrates the effectiveness of structured mental health literacy interventions in enhancing knowledge and reducing stigma. Culturally responsive approaches that integrate local beliefs, practices, and educational norms consistently produce stronger outcomes, as they align more closely with participant experiences. The stronger effects observed in the Malaysian cohort may be attributable to previous mental health literacy initiatives and public health campaigns, which likely fostered a more receptive environment. Interestingly, no significant differences were observed in help seeking/first aid skills, self-help strategies, or erroneous beliefs. This aligns with recent findings suggesting that while brief interventions can improve recognition and knowledge, deeper changes in beliefs and self-help behaviours often require sustained, multi-component engagement [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Future research should therefore consider longer-term follow-up and integration of peer-led or digital components, which have been shown to enhance retention and application of skills [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe findings found in Research objective 2 demonstrates that mental health literacy interventions can be improved in diverse cultural contexts. The results also emphasize the necessity of adapting intervention strategies to specific cultural settings to achieve maximum effectiveness.\u003c/p\u003e\u003cp\u003eThe overall findings of this study contributed to the growing body of research on e-learning in mental health promotion. Given that mental health issues among youth are increasingly prevalent, particularly in post-pandemic contexts, equipping youth with adequate MHL is critical. Poor MHL is associated with increased stigma, reduced help-seeking/first aid skills, and a greater risk of untreated mental health conditions. By addressing these gaps through RLO-based learning, this study has the potential to inform future educational policies and mental health interventions.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eTheoretical and Conceptual Framework\u003c/h2\u003e\u003cp\u003eThe ASPIRE framework used [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] in the development of RLOs ensures that these e-learning materials are pedagogically robust, linguistically adaptable, and interactive. The emphasis on active learning, multimedia engagement, and self-paced study aligns with contemporary educational best practices. Furthermore, the integration of Campos\u0026rsquo;s Mental Health Literacy Model [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] within the RLO ensures comprehensive coverage of essential MHL dimensions, such as recognizing mental health conditions, understanding risk factors, and identifying appropriate help-seeking strategies.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eA key strength of this study is its cross-country comparison approach, allowing for a comparison of MHL improvements between youth in Saudi Arabia and Malaysia. By assessing the transferability of RLOs across diverse educational and cultural settings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], this research provided insights into the effectiveness of digital interventions in different contexts. Additionally, the quasi-experimental design allows for a structured evaluation of baseline and post-intervention MHL levels, ensuring methodological rigor.\u003c/p\u003e\u003cp\u003eDespite its strengths, the study has several limitations. First, the non-randomized allocation of participants into intervention and control groups may introduce selection bias. While efforts were made to ensure baseline equivalence between groups, uncontrolled confounding variables may still influence outcomes. Second, the reliance on self-reported measures for MHL assessment may introduce response bias, as youth may overestimate or underestimate their knowledge and attitudes toward mental health. To mitigate this, a validated MHL instrument was used, and triangulation with qualitative feedback from participants will be considered for future research.\u003c/p\u003e\u003cp\u003eFuture research directions could include expanding the study to a broader age range of youth or implementing a longitudinal design to assess the long-term retention of MHL knowledge. Additionally, exploring the integration of RLOs with blended learning models, combining digital and face-to-face instruction could provide further insights into optimizing mental health education for youth.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrated that Reusable Learning Object (RLO) significantly improved mental health literacy (MHL) among youth in Saudi Arabia and Malaysia. Participants showed gains in knowledge of mental health disorders, help seeking and first aid skills, and self-help strategies, confirming the potential of interactive e-learning as a scalable and culturally adaptable e-promotion tool. The cross-country comparison revealed meaningful differences in youth knowledge, skills and strategies towards mental health, underscoring the need for localized content to address stigma and misconceptions effectively.\u003c/p\u003e\u003cp\u003eThese findings highlight the promise of integrating RLO-based mental health education into existing curricula to promote awareness and early help-seeking among young people. Future research should explore long-term retention, integration with blended learning approaches, and user experience and usability studies that can further enhance engagement and impact.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study has been obtained from the relevant Ethics Committees in Saudi Arabia and Malaysia,\u0026nbsp;including the Institutional Review Board in Saudi Arabia [IRB24-066] and Universiti Malaya (UM) [UM. TNC2.UMREC_4075]. Additionally, approvals have been obtained from the respective educational authorities overseeing the selected institutions in both countries to ensure compliance with local research regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Reusable Learning Objects (RLOs) used in this study are available online:\u003c/p\u003e\n\u003cp\u003eSaudi Arabia: https://acord.my/xerte/play.php?template_id=138#page1\u003c/p\u003e\n\u003cp\u003eMalaysia: https://acord.my/xerte/play.php?template_id=151#page1\u003c/p\u003e\n\u003cp\u003eData supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was fully funded by AlMaarefa University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNZ, NDNF, ST, NF and HM contributed to the study of conception and design. Material preparation, data collection, and analysis were performed by NZ, NDNF, NF and HM. RLO modifications and translation were handled by NZ, NDNF, DM. Data collection was conducted by NZ, AM, AB in Saudi Arabia while NF, NDNF, HM and EA collected data in Malaysia. The first draft of the manuscript was written by NZ, NDNF, EAR, HM, NFMN and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researchers from the College of Applied Sciences, AlMaarefa University would like to thank AlMaarefa University for the financial support under the Internal Grant scheme. The researchers also acknowledge Alfred Tan from Institute of Biological Sciences University Malaya, for his contribution in building the first version of the RLO.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThe transferability of Open Reusable Learning. Objects (RLOs) to nursing clinical skills education in the Saudi context: a mixed method study [Internet]. Nottingham: University of Nottingham; [cited 2024 Apr 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://eprints.nottingham.ac.uk/id/eprint/63650\u003c/span\u003e\u003cspan address=\"https://eprints.nottingham.ac.uk/id/eprint/63650\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFurnham A, Swami V. Mental Health Literacy: A review of what it is and why it matters. 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JMIR Mental Health. 2023;10:e41926. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/41926\u003c/span\u003e\u003cspan address=\"10.2196/41926\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mental health literacy, Reusable Learning Objects, Youth, Digital health education","lastPublishedDoi":"10.21203/rs.3.rs-8151634/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8151634/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMental health disorders such as depression, anxiety, and stress are significant public health concerns, affecting 10\u0026ndash;20% of adolescents globally. In Malaysia and Saudi Arabia, youth mental health issues are growing, yet Mental Health Literacy (MHL) remains low. MHL encompasses recognizing mental disorders, seeking appropriate help, and understanding treatment options. E-learning tools, particularly Reusable Learning Objects (RLO), offer a promising solution to provide evidence-based education. However, studies on their effectiveness in different cultural settings are limited. This study employed the protocol of a cross-country comparison study aimed at evaluating the effectiveness of RLO in promoting MHL among youth in Saudi Arabia and Malaysia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA quasi-experimental design was employed among youth aged 16\u0026ndash;24 years in Riyadh, Saudi Arabia, and Klang Valley, Malaysia. RLO was developed using the ASPIRE methodology, and a validated English and Arabic MHL questionnaire was used in the study. Participants were assigned to intervention and control groups. The intervention group engaged with RLOs, while the control group completed the questionnaire without RLO exposure. Data were collected at baseline and post-intervention. Tests of normality (Kolmogorov\u0026ndash;Smirnov and Shapiro\u0026ndash;Wilk) indicated non-normal data distribution; thus, non-parametric analyses were conducted. Wilcoxon signed-rank tests compared baseline and post-intervention scores within groups, while Mann\u0026ndash;Whitney U tests compared post-intervention change scores between countries.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e Wilcoxon signed-rank analyses revealed significant improvements in MHL among participants in Saudi Arabia and Malaysia. In Saudi Arabia, improvements were observed across all domains, including a reduction in erroneous beliefs (p\u0026thinsp;=\u0026thinsp;.021). Mann\u0026ndash;Whitney U tests showed that Malaysian participants achieved greater gains in mental health disorder knowledge (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and overall MHL (p\u0026thinsp;=\u0026thinsp;.002) compared to Saudi Arabian participants, with small-to-medium effect sizes. In Malaysia, large gains were found in mental health disorder knowledge, help seeking/first aid skill, self-help strategies, and total MHL (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), whereas changes in erroneous beliefs were not significant.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eFindings from this study provided insights into how e-learning tools like RLO can support youth mental health literacy in different cultural contexts. The results will contribute to shaping future e-promotion strategies and policies aimed so that both nations have high level of mental health literacy.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"A Cross-Country Comparative Study on Mental Health Literacy Among Youth Using A Reusable Learning Object in Saudi Arabia and Malaysia: A Quasi-Experimental Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 15:03:40","doi":"10.21203/rs.3.rs-8151634/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-02T05:51:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-25T22:04:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-20T01:46:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248845637649089528562410097770160742578","date":"2025-12-15T23:34:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"271164230176316684431223004760090084727","date":"2025-12-14T01:20:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-01T03:10:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-21T08:13:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-20T05:40:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-20T05:34:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-19T06:23:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93387c3d-ea97-4650-8062-3d7e25f1f18a","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-01T05:38:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 15:03:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8151634","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8151634","identity":"rs-8151634","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}