Barriers and facilitators of seeking help for mental health challenges among adolescents across 13 countries: A qualitative investigation

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Nadhira, Shoshanna L. Fine This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6823046/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Adolescence is a period of developmental transition marked by a high prevalence of mental health challenges. The emergence of these challenges underscores the importance of encouraging help-seeking behaviors among adolescents to mitigate negative psychological outcomes. Gaining a deeper understanding of the lived experiences of adolescents can inform intervention development and increase access to care. Methods This study draws on qualitative information collected from 71 focus group discussions across 13 countries with male and female adolescents aged 12–19 years old. Focus group discussions were transcribed verbatim and translated into English, with transcripts coded and analyzed for emergent themes. Focused data analysis centered on themes related to help-seeking strategies for mental health challenges as well as related barriers and facilitators. Results Participants emphasized the critical role of informal support systems, including friends and family, in helping adolescents cope with mental health challenges. Additionally, participants highlighted the importance of accessing professional support through school or community mental health services. Significant barriers to help-seeking were described, including mental health stigma, restrictive gender norms, limited service availability, poor quality or unaffordable services, low mental health literacy, and unsupportive interpersonal relationships. Participants emphasized the role of digital technologies, school and community environments, and trustworthy relationships as facilitators of seeking help. Conclusions While many adolescents are aware of the importance of seeking help for mental health challenges, there is a need for country-level interventions to increase mental health literacy and reduce mental health stigma in order to ensure optimal access to care. Psychology Epidemiology Adolescents Youth Mental health Help-seeking behaviors Qualitative research Introduction Adolescence (ages 10-19) is a period of developmental transition characterized by hormonal changes, physical maturation, experimentation, self-exploration, and a growing desire for deeper social connections with peers [1]. It is also a period marked by a high prevalence of mental health challenges when compared to other age groups [2]. Studies suggest that up to 20% of adolescents worldwide experience mental health challenges, including elevated rates of depression, anxiety, eating disorders, substance abuse, self-harm, and suicidal behaviors [2,3]. Further, there is recent evidence that these challenges have been exacerbated by the COVID-19 pandemic due to the detrimental impacts of prolonged social isolation, disconnection from school, economic instability, uncertainties around vaccines, and bereavement [4–6]. The emergence of mental health challenges during adolescence, as well as troubling recent trends in the context of the pandemic, underscores the importance of encouraging help-seeking behaviors among adolescents to mitigate negative short- and long-term psychological outcomes. The World Health Organization defines help-seeking behaviors as, “any action or activity carried out by an adolescent who perceives herself/himself as needing personal, psychological, affective assistance or health or social services with the purpose of meeting this need in a positive way” [7]. This can include both formal (e.g., healthcare professionals, teachers, religious leaders) and informal (e.g., family, friends) sources of support [7,8]. The use and impact of these forms of help-seeking have been found to vary depending on a wide range of sociodemographic characteristics including an adolescent’s age, gender, race/ethnicity, urbanicity, and socioeconomic status [9,10]. In the context of the pandemic, studies have also documented a greater reliance on the internet as the means of accessing both formal and informal support [11–13]. Despite the high burden of mental health challenges in adolescence, studies have found that the majority of adolescents are reluctant to seek help for these challenges [14,15]. Further, research suggests that those with the most severe symptoms are often the least likely to pursue outside support [15,16]. In understanding the most prominent barriers to help-seeking among adolescents, one recent systematic review identified mental health stigma, negative family beliefs regarding mental health services, poor mental health literacy, and perceived self-sufficiency as key impediments to seeking help [15]. Conversely greater mental health literacy, prior positive experiences with mental health services, and trusting relationships with adults were identified as key facilitators of help-seeking [15]. These findings align with another recent review which highlighted the need to reduce stigma, improve mental health literacy, support self-help strategies, reduce structural barriers, and recognize young people’s autonomy in order to improve help-seeking behaviors [10]. It is important to note that existing evidence on mental health help-seeking among adolescents has largely been drawn from high-income countries: for example, only 5 out of 90 included studies in the above-mentioned systematic review were conducted in low- and middle-income countries (LMICs) [15]. This is a significant gap in evidence as additional barriers may be present in LMICs due to inadequate funding, poor service accessibility, and limited mental health specialists in low-resource settings [17]. Further, research in this area has primarily been quantitative and while informative, there is a need for qualitative research to gain a deeper understanding of the lived experiences of adolescents [11]. Finally, research on adolescents’ help-seeking behaviors in the context of the pandemic remains sparse [6,18]. Knowledge of the primary methods, barriers, and facilitators of help-seeking among adolescents is imperative as this can inform intervention development, increase access to care, and prevent the intensification of mental health challenges [14]. In response to these needs, the present study seeks to gain an in-depth understanding of mental health help-seeking behaviors among adolescents drawn from 13 countries. Conducted during the height of the COVID-19 pandemic, findings illustrate both challenges and opportunities for supporting mental health among adolescents across a diverse range of low-, middle-, and high-income country contexts. Methods Data Collection The current study draws on qualitative information that was collected as part of the United Nations Children’s Fund (UNICEF) 2021 State of the World’s Children Report. The methods from the primary study have been described in detail previously [19]. To summarize, 13 countries participated (Table 1), with partner organizations in each country conducting a minimum of four focus group discussions (FGDs) with adolescents. The FGDs were divided based on sex and age group such that there were at least two younger (ages 12-15) and two older (ages 16-19) FGDs held separately with boys and girls in each country. In total, 71 FGDs were conducted across the included countries. Depending on the COVID-19 regulations in each country, FGDs were either conducted online or in-person. All FGDs were conducted between February and June 2021 and were between 60 and 90 minutes each. The FGDs were conducted using the local languages. The country partner organizations were responsible for recording the FGDs, transcribing them verbatim, and then translating the transcripts into English when necessary. Table 1. Adolescent mental health focus group discussions (FGDs) Country Setting FGDs Data Collection Belgium Francophone 4 In-person Flemish 2 In-person Chile Santiago 6 Online China Shanghai 6 In-person Democratic Republic of the Congo Kinshasa 4 In-person Egypt Asyut 6 In-person Indonesia Yogyakarta 4 In-person Jamaica Kingston 9 Online Jordan Amman 4 In-person Kenya Nairobi 4 In-person Malawi Blantyre 4 In-person Sweden Stockholm 10 In-person Switzerland Lausanne 4 Online United States New Orleans 4 Online [Insert Table 1 about here.] Data Analysis The primary data analysis was conducted using the English transcripts. These transcripts were coded using an inductive thematic approach [20]. Following a process of open coding, initial codes were compared, grouped, refined, and organized into a codebook. The codes were also checked for consistency across countries. Finally, these codes were applied across the full qualitative dataset by two data analysts. Coded data specifically related to help-seeking behaviors were subsequently reanalyzed by the authors of the current study. ATLAS.ti version 9.1 and MAXQDA 2022 were used to facilitate the data analysis process. Ethical Approval Each country partner organization obtained ethical approval locally prior to the study’s commencement. In accordance with ethical principles, county partner organizations worked together with schools or community organizations to obtain consent from adolescents’ caregivers and assent from adolescents prior to data collection. Adolescents older than the legal age could give consent for themselves. Results Our findings are presented in three main themes: help-seeking strategies, barriers to help-seeking, and facilitators to help-seeking. Theme 1: Help-Seeking Strategies Informal support . Across participating countries, the majority of adolescents discussed relying on close support networks for help dealing with social, emotional, and behavioral problems. Most commonly, this included connecting with trusted friends. Participants reflected on the ways in which their friends provided them with relief, comfort, encouragement, understanding, and solidarity when faced with mental health challenges. Many also mentioned turning to their friends for help thinking through different problem-solving strategies. Once you have removed something from your heart and spoken about it you feel free... you feel relieved not like before when you felt your heart was heavy carrying something. At least when I tell my friend, they will carry something for me. – Older girl, Kenya Beyond their friends, many adolescents also mentioned seeking support from their families: most frequently parents, but also siblings, grandparents, and other relatives. For adolescents with close relationships with their families, a common refrain was the idea that their families knew them best and were therefore most able to offer support, safety, and trust. I grew up with [my parents], they know everything about me, so I think the people that I can trust the most are my parents. – Younger girl, Switzerland I like to take refuge in my grandmother…I feel very safe with her. – Older girl, Chile. Notably, in determining the most appropriate individuals to turn to, several adolescents specified that they would seek help from their parents for more serious problems, when they felt that adult advice or intervention was necessary. It depends on the magnitude of the problem. If it is a small problem, you can discuss with a friend…But if you are struggling a lot, most young people go and inform their parents so that they can help them with wisdom. – Older boy, Malawi Despite the clear importance of their families, adolescents around the world often described greater comfort in seeking support from their friends. In reflecting upon this preference, participants discussed the feeling that peers their own age were better able to relate to them with regards to their experiences and feelings. Many also perceived an intergenerational divide with older family members when it came to the topic of adolescent mental health, with parents or grandparents seen as dismissive of their problems due to their “old fashioned” or “traditional” thinking. I as an individual can’t go to my parents about certain things...Even though our peers are young and inexperienced, they are the ones who we can talk to because they may understand and share the same feelings and thoughts as we. – Older boy, Jamaica I also don’t communicate with my family frequently, I just feel that we don't have common topics, their thinking is old-school… I usually tell my friends about everything. – Older girl, China Beyond friends and family, some adolescents also mentioned seeking support from their teachers, although this strategy arose far less commonly across countries. Formal support. While it was clear that most adolescents relied on informal sources of support for help dealing with mental health challenges, a number of participants did discuss seeking professional support through school or community mental health services. The specific services that arose most widely included school counselors, therapists, psychologists, psychiatrists, primary care doctors, peer support groups, hotlines, and substance use treatment programs. Notably, adolescents living in middle- and high-income country settings placed a greater emphasis on these formal sources of support than those living in low-income countries. Also, it was clear that many adolescents saw community mental health services as a last resort for the most serious problems: for example, severe anxiety or depression, traumatic stress, eating disorders, or suicidal behaviors. [My friend] went to the emergency room last month…for taking sleeping pills. Because she felt that life wasn’t worth living…. At that time, I kept telling her that she should go to see a psychiatrist, and then she did go, she went to the mental health prevention and control center in her community, and then she went to talk to the doctor. [Now she] sounds well, she has been taking medicine. – Older girl, China I think that psychologists, it’s really for grave problems, [like] when there is trauma. Because it is easier to confide in someone we don’t know about some traumas. – Older girl, Belgium Theme 2: Barriers to Help-Seeking Societal barriers. Across participating countries, adolescents reflected on the role of mental health stigma as a serious impediment to help-seeking behaviors. Adolescents described the ways in which people experiencing mental health problems were regarded as “crazy,” “abnormal,” “good for nothing,” “full of trouble,” or “untrustworthy.” A number of participants also discussed the taboo nature of discussing mental health problems – and several adolescents described deep-seated beliefs, particularly among older generations, that such problems were fake. As a result of such stigma, adolescents around the world worried that they would face judgment or ostracization from their friends or family for disclosing mental health problems. Many also feared being labeled as “crazy” for seeking formal mental health services. The mentality of most Jamaican parents is that depression is not a real thing...I have seen memes or some parodies...on the internet where the child goes to the parent and says, ‘Mommy I’m depressed,’ and her response is ‘Go depress the plates. Did you depress your books yet? You depress your uniform yet?’ – Older boy, Jamaica If you have psychological counselling [at school], sometimes the conversation may take a long time...If you go out for a long time, your teacher will wonder: Why did you have to go for so long? Where did you go? Why did you go to the mental room? Do you have a mental problem? – Older boy, China At the societal level, gender norms also arose consistently as a central deterrent of help-seeking among boys. Adolescents around the world described norms around masculinity which dictate that boys should be strong, invulnerable, and able to handle problems on their own. As a result, boys who chose to share their feelings were often viewed as soft, weak, or feminine – and many preferred to stay quiet about their mental health problems so as to avoid shame, humiliation, and disparagement. It’s harder for a boy to express his feelings because he is embarrassed about it, and he thinks that if he told other people about his problems, people would belittle him and mock him. – Older boy, Indonesia Community barriers. At the community level, adolescents across participating countries discussed the lack of available school and community mental health services. Even where services did exist, a number of adolescents mentioned financial barriers that impeded accessibility, including the cost of both transportation and the services themselves. When you see that you don’t have anything or at your home there is no food, you cannot ask for transport money from your parents so that you can go and share your problems with someone. So, it just makes you to say, ‘Ah I will just see how to deal with it alone.’ – Older boy, Malawi In addition to financial challenges, several participants highlighted concerns about the quality of mental health services that might deter adolescents from seeking help. Around the world, specific issues that arose included a lack of confidentiality, unskilled or unhelpful providers, antipathy towards adolescents, and a one-size-fits-all approach. Many don’t want the help that, for example, the school provides, because, the help that the school provides is not always the best. People who don’t like to talk are still forced to talk. And that maybe doesn’t help. – Younger girl, Sweden Interpersonal barriers. While friends and families emerged as the most important sources of support for adolescents, participants also reflected upon steep interpersonal barriers to seeking help. Those which arose most widely included fears that others would judge or ridicule them, would not take their problems seriously, would not understand or care, or would not be able to truly help. A number of adolescents also shared instances in which their feelings or experiences were invalidated, particularly by their parents, and how this decreased their willingness to seek help in the future. I find that it is difficult for [adolescents] to ask for help because of being criticized, judged...they prefer to keep quiet instead of expressing themselves to others. – Older girl, Chile You probably go to your parents and they're like, “What do you have to be depressed about? You're not paying bills…” They’re saying that you don't have any real problems. – Younger girl, Jamaica While adolescents commonly relied on their friends for support, many also discussed challenges with trust. Specifically, they worried that friends would expose their secrets, leading others to find out about their mental health problems. I don't like to confide in friends because they can expose your secrets, so I keep things to myself and this increases my suffering. – Older girl, Egypt Across participating countries, many adolescents also shared concerns that their parents or other family members would become angry or upset with them when they sought help. While this most commonly included verbal reactivity, adolescents in Egypt, Jordan, and Malawi also described physical aggression arising from help-seeking. If I’m in trouble or sad about something, I keep it to myself because I think my parents are going to get angry. – Younger boy, Chile She thinks that she will go to her family and tell them, but she is afraid that her family will beat her and they may humiliate her. – Younger girl, Jordan Individual barriers. At the individual level, adolescents across participating countries most commonly discussed barriers arising from difficulties discussing their feelings. Specifically, participants expressed limitations with articulating their emotional distress as well as feelings of awkwardness or discomfort related to seeking help for such distress. This was seen as a particular challenge for boys given additional barriers imposed by masculine gender norms, as mentioned previously. Our main difficulty is expressing how we feel...we know how we feel, you know, but we don’t know how to just come out and say it. – Older boy, Jamaica I choose to hide my emotions and deal with them on my own. I am not good at communicating my inner thoughts. – Older girl, China Numerous participants also mentioned feelings of shame or embarrassment that prevented adolescents from seeking help, clearly connected to pervasive mental health stigma in many communities. A lot of kids have...gone through something they don’t want they think is embarrassing. So, they don’t want to say nothing about it. – Older girl, United States Theme 3: Facilitators of Help-Seeking Societal and community facilitators. Despite the clear impediments to seeking support for mental health challenges, several factors arose widely as helping adolescents overcome these barriers. At the societal level, a number of adolescents discussed the ways in which digital technologies facilitated help-seeking by allowing for anonymity, continuous access, and connection to both formal and informal sources of support (e.g., helplines, chat groups, social media). At the community level, adolescents around the world highlighted the importance of school and community mental health services, previously mentioned barriers notwithstanding. As with digital technology-based supports, these types of services were seen as particularly appealing when they could ensure anonymity or confidentiality. Let’s say you don’t want your parents to know, or you need a somewhat more private space to talk other than the school, then you can seek help in the puskesmas [primary health care center]...I prefer to go to the puskesmas. I guess it’s because they don’t know us personally. – Older boy, Indonesia If you feel quite sad, it is good to go to the school counselor. Because it can be good with someone you do not know, who has a duty of confidentiality. – Younger boy, Sweden Interpersonal facilitators. Across participating countries, adolescents identified trustworthy relationships as one of the most important facilitators of seeking help for mental health challenges. Participants stressed the importance of having close friends or family members who could be trusted to support them without judgment, anger, or betrayal of their confidences. If we find someone we trust and want to talk to, we want to tell our stories. It’s easy to share [your problems] with someone you trust. – Younger girl, Switzerland Many adolescents also emphasized the role of friends and family as gatekeepers in helping or encouraging them to access more formal services when necessary. This was seen as particularly important for ongoing problems or those that were understood to be more severe. [If a friend is having a problem] you just give your support. If it’s to a severe degree, you should get an adult involved so that they get them help, get them into like therapy or something. – Younger girl, Jamaica It becomes like a trade-off as well, if you think [your friend’s problem] is so serious that you kind of have to tell someone else, who can actually help, or if it's actually just that you should be there for the person. – Older girl, Sweden Individual facilitators. Finally, at the individual level, a number of adolescents reflected on the importance of internal motivation as a first step to seeking help. Participants illustrated the necessity of not “running away” from mental health challenges – and of reaching a point at which they realized that they could no longer handle these challenges without outside support. As stated succinctly by one older boy from Switzerland, “To get better, you have to want to get better.” Discussion To our knowledge, this study is the largest and most diverse qualitative study exploring adolescent mental health help-seeking behavior to date. From a total of 71 FGDs across 13 countries, adolescents reflected on both informal and formal supports for dealing with mental health challenges. Unsurprisingly, this study highlighted adolescents’ preference for seeking help from informal sources, with an overall preference for turning to friends over families. Similar patterns have been reported by numerous previous studies across a diverse range of settings [21–25]. For instance, a large cross-sectional study involving 46,691 adolescents in Norway found that most (88.5%) preferred to seek help or advice from their friends when dealing with a personal problem, followed closely by their parents (82.1%) [21]. Likewise, in a study of 3,480 adolescents in China, among those who reported seeking help for mental health problems during the past year, 85.8% turned to friends and 64.5% turned to family [22]. These patterns highlight the role of friends and family as gatekeepers in helping adolescents cope with mental health challenges and directing them towards further services when necessary [26]. Indeed, adolescents themselves suggested that trustworthy relationships with friends and family are a central facilitator in helping them to access formal supports, particularly when problems are deemed severe. As such, it is clear that interventions targeting peers or caregivers could be beneficial in increasing adolescents’ access to mental health care. While adolescents’ willingness to share their problems informally is encouraging, participants also highlighted significant barriers in seeking support for mental health challenges. In particular, adolescents discussed the pervasive impacts of mental health stigma, and the associated shame, embarrassment, judgment, ostracization, and invalidation that frequently deters adolescents from seeking help either informally or formally. This aligns with a substantial body of evidence which has documented perceived stigma – alongside experienced or anticipated shame and embarrassment – as the most commonly cited impediment to seeking help among adolescents globally [10,15]. In addition, adolescents highlighted that adolescent boys face additional stigma due to stereotypical gender norms equating emotional vulnerability with a lack of masculinity. This is again supported by myriad studies detailing the ways in which masculine norms impede help-seeking behaviors [27] – and the resultant harms on boys’ and young men’s mental health [28,29]. Together, these findings suggest the need for gender sensitive efforts to increase mental health literacy, normalize help-seeking, and reduce negative attitudes towards mental health problems globally. While a number of participants did mention seeking formal support from school or community mental health services, it was clear that adolescents often face serious structural and logistical constraints on accessing professional help. In particular, adolescents highlighted low service availability and financial challenges as greatly impeding their help-seeking behaviors. These barriers may have particular salience given the predominant inclusion in the current study of adolescents from low-resource settings. Notably, since most mental health services require multiple meetings, the associated costs can easily exhaust a family’s financial capacity [30] and this does not factor in opportunity costs such as parents missing work. Further, even in countries with universal healthcare, the coverage for mental health services has been shown to be far below the target [31]. The situation is exacerbated by acute shortages in the mental health workforce (including psychiatrists, psychologists, nurses, and social workers), particularly in LMICs where studies have consistently documented coverage of less than two providers per 100,000 of the population, with providers largely concentrated in urban areas [32,33]. In addressing these treatment gaps, it has been argued that there is an urgent need for increased country-level investment into adolescent mental health, the development of legislative policies to help organize service delivery, greater intersectoral collaboration, and task-shifting approaches to optimize available human resources [17]. In addition, given participants’ reflections on the merits of digital technologies in helping them access mental health support, it is apparent that these technologies present additional opportunities for overcoming treatment gaps among adolescents globally [34]. The findings from this study also emphasized that the availability of mental health services alone does not mean that adolescents would use them. Rather, it was clear that adolescents are also aware of the quality of services, and are much more likely to seek formal support when they perceive that these services are accessible, confidential, and youth friendly. This may be particularly relevant when considering school mental health services: as the majority of adolescents globally already spend a significant portion of their time in school [35], services offered in this setting may present fewer structural and logistical barriers to entry than those in the community [36]. Indeed, a large body of evidence suggests the value of implementing school-based mental health services across low-, middle-, and high-income country settings [37–39]. Our findings imply, however, that greater sensitivity and mental health literacy among school staff including teachers, school nurses, and school counselors may be necessary in order to increase adolescents’ willingness to seek help from these services. In interpreting the results of this study, it is important to note several limitations. First, while we have summarized themes with broad salience across the included countries, individual results cannot be considered representative of all of the participating countries. Likewise, findings from one country setting may not be transferable to adolescents across other settings within the country. For instance, the majority of interviews were conducted with urban adolescents and may therefore not reflect the concerns of those living in rural areas. Further, while the FGDs were conducted in the local language in each study country, the majority of data analysis was undertaken in English. The English transcripts used for analysis were checked and reviewed by bilingual researchers in order to help address these challenges, but this does not eliminate the likelihood that some salient information was lost in translation. Finally, while not a limitation, it is important to acknowledge that this study was conducted in the context of the COVID-19 pandemic which has had well-documented impacts on adolescent mental health globally [6]. While the questions asked during the FGDs focused generally on mental health help-seeking, it is likely that the contextual realities of the pandemic influenced adolescents’ responses. In summary, this study highlights the critical role of informal supports including friends and family in helping adolescent cope with mental health challenges and facilitating access to formal supports when necessary. While this is encouraging, participants also described significant barriers to seeking help, including mental health stigma, limited service availability, poor quality services, and financial challenges. These findings emphasize the need for gender-sensitive efforts to increase mental health literacy and reduce negative attitudes towards mental health challenges, as well as increased investment in adolescent mental health programs and policies at the country-level. Further, while school-based mental health services may present an opportunity to overcome structural and logistical barriers, greater sensitivity among school staff is required. Overall, these findings provide critical insights for developing interventions that aim to increase adolescents’ access to mental health care. Abbreviations COVID-19 coronavirus disease 2019 FGD focus group discussion LMICs low- and middle-income countries UNICEF United Nations Children’s Fund Declarations Funding Information: This work was supported by Wellcome Trust through a contract with UNICEF Headquarters for the preparation of the State of the World’s Children 2021 report, On My Mind: Promoting, protecting and caring for children’s mental health. Acknowledgements: This study was developed in conjunction with UNICEF’s State of the World’s Children 2021 report, On My Mind: Promoting, protecting and caring for children’s mental health . The study was initiated by UNICEF Headquarters in collaboration with the Johns Hopkins University Global Early Adolescent Study, and was made possible through partnerships with organizations across 13 countries. These include: Centre de Référence en Santé Mentale, Steunpunt Geestelijke Gezondheid, Universidad de Santiago de Chile, Shanghai Institute for Biomedical and Pharmaceutical Technologies, Kinshasa School of Public Health, Assiut University, Universitas Gadjah Mada, University of the West Indies, Terre des Hommes, African Population and Health Research Center, Kamuzu University of Health Sciences, Karolinska Institutet, Unisanté, and Institute of Women and Ethnic Studies. We are immensely grateful to the researchers and program specialists from these organizations who helped to shape the research questions and then organized, facilitated, recorded, transcribed, and translated focus group discussions with adolescents. We would also like to gratefully acknowledge the support from the Wellcome Trust and from UNICEF country offices. Above all, we are thankful for the young people around the world who gave their candid insights during 71 focus groups discussions. 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Stiffman AR, Pescosolido B, Cabassa LJ. Building a Model to Understand Youth Service Access: The Gateway Provider Model. Ment Health Serv Res 2004;6:189–98. Seidler ZE, Dawes AJ, Rice SM, et al. The role of masculinity in men’s help-seeking for depression: A systematic review. Clin Psychol Rev 2016;49:106–18. Rice SM, Purcell R, McGorry PD. Adolescent and Young Adult Male Mental Health: Transforming System Failures Into Proactive Models of Engagement. J Adolesc Health 2018;62:S9–17. Exner-Cortens D, Wright A, Claussen C, et al. A Systematic Review of Adolescent Masculinities and Associations with Internalizing Behavior Problems and Social Support. Am J Community Psychol 2021;68:215–31. Kapphahn CJ, Morreale MC, Rickert VI, et al. Financing Mental Health Services for Adolescents: A Position Paper of the Society for Adolescent Medicine. J Adolesc Health 2006;39:456–8. Patel V, Saxena S. Achieving universal health coverage for mental disorders. BMJ 2019;366:l4516. World Health Organization. Mental Health Atlas 2020. Geneva: World Health Organization; 2021. Rathod S, Pinninti N, Irfan M, et al. Mental Health Service Provision in Low- and Middle-Income Countries. Health Serv Insights 2017;10:1178632917694350. Lehtimaki S, Martic J, Wahl B, et al. Evidence on Digital Mental Health Interventions for Adolescents and Young People: Systematic Overview. JMIR Ment Health 2021;8:e25847. United Nations Children’s Fund. Secondary Education and Enrollment Statistics. Available at: https://data.unicef.org/topic/education/secondary-education/. AccessedMarch 16, 2023. Masia-Warner C, Nangle DW, Hansen DJ. Bringing Evidence-Based Child Mental Health Services to the Schools: General Issues and Specific Populations. Educ Treat Child 2006;29:165–72. Fazel M, Patel V, Thomas S, et al. Mental health interventions in schools in low-income and middle-income countries. Lancet Psychiatry 2014;1:388–98. Grande AJ, Hoffmann MS, Evans-Lacko S, et al. Efficacy of school-based interventions for mental health problems in children and adolescents in low and middle-income countries: A systematic review and meta-analysis. Front Psychiatry 2022;13:1012257. Karukivi J, Herrala O, Säteri E, et al. The Effectiveness of Individual Mental Health Interventions for Depressive, Anxiety and Conduct Disorder Symptoms in School Environment for Adolescents Aged 12–18—A Systematic Review. Front Psychiatry 2021;12. Additional Declarations The authors declare no competing interests. Supplementary Files PreprintsAdolescentMHSupplementalFiles.docx Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-6823046","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466613588,"identity":"60d4a542-ae76-46ee-86fe-8e6b450e996b","order_by":0,"name":"Amirah Ellyza Wahdi","email":"","orcid":"","institution":"Universitas Gadjah Mada","correspondingAuthor":false,"prefix":"","firstName":"Amirah","middleName":"Ellyza","lastName":"Wahdi","suffix":""},{"id":466613589,"identity":"d72aa13d-cd80-45eb-a70e-e011666fadab","order_by":1,"name":"Caryl James","email":"","orcid":"","institution":"University of the West Indies","correspondingAuthor":false,"prefix":"","firstName":"Caryl","middleName":"","lastName":"James","suffix":""},{"id":466613590,"identity":"789fe75f-e919-49b5-9cc5-c8fe013f550f","order_by":2,"name":"Dita A. Nadhira","email":"","orcid":"","institution":"Universitas Gadjah Mada","correspondingAuthor":false,"prefix":"","firstName":"Dita","middleName":"A.","lastName":"Nadhira","suffix":""},{"id":466613591,"identity":"8ed3aa9b-d653-4ede-bf27-5bd240fd9b00","order_by":3,"name":"Shoshanna L. Fine","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYDACdsYHBxgYbJgNQBweorQwMxsAtaSRqAVIHmYgXot8MzPj4YKK8+zmEgmMD962EaHF4DAzw+EZZ24zW85IYDacS5QWZv4Dh3nbbjMb3Ehgk+YlRgvQYQyHef+dA2lh/02UFgaQw3gbDoBtYSZKC9gvPMeSmQ3OPGyWnHOOGIe1NzN/5qmxSzY4nnzww5syYhwGBckMDIwNJKgHAjvSlI+CUTAKRsGIAgCDnjG8qjv6vAAAAABJRU5ErkJggg==","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Shoshanna","middleName":"L.","lastName":"Fine","suffix":""}],"badges":[],"createdAt":"2025-06-04 18:40:43","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6823046/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6823046/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84046146,"identity":"a78e267d-3736-4129-8590-0a11e9652fc2","added_by":"auto","created_at":"2025-06-06 07:23:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":604690,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6823046/v1/142e13f6-15ca-430f-bdae-6b2ee0a7f2cb.pdf"},{"id":84045765,"identity":"aa226a06-f87d-4262-b3d9-13b2c1bb529f","added_by":"auto","created_at":"2025-06-06 07:23:31","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":40919,"visible":true,"origin":"","legend":"","description":"","filename":"PreprintsAdolescentMHSupplementalFiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-6823046/v1/f1b4bd90aa888f3c677dfddd.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eBarriers and facilitators of seeking help for mental health challenges among adolescents across 13 countries: A qualitative investigation\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdolescence (ages 10-19) is a period of developmental transition characterized by hormonal changes, physical maturation, experimentation, self-exploration, and a growing desire for deeper social connections with peers [1]. It is also a period marked by a high prevalence of mental health challenges when compared to other age groups [2]. Studies suggest that up to 20% of adolescents worldwide experience mental health challenges, including elevated rates of depression, anxiety, eating disorders, substance abuse, self-harm, and suicidal behaviors [2,3]. Further, there is recent evidence that these challenges have been exacerbated by the COVID-19 pandemic due to the detrimental impacts of prolonged social isolation, disconnection from school, economic instability, uncertainties around vaccines, and bereavement [4\u0026ndash;6].\u003c/p\u003e\n\u003cp\u003eThe emergence of mental health challenges during adolescence, as well as troubling recent trends in the context of the pandemic, underscores the importance of encouraging help-seeking behaviors among adolescents to mitigate negative short- and long-term psychological outcomes. The World Health Organization defines help-seeking behaviors as, \u0026ldquo;any action or activity carried out by an adolescent who perceives herself/himself as needing personal, psychological, affective assistance or health or social services with the purpose of meeting this need in a positive way\u0026rdquo; [7]. This can include both formal (e.g., healthcare professionals, teachers, religious leaders) and informal (e.g., family, friends) sources of support [7,8]. The use and impact of these forms of help-seeking have been found to vary depending on a wide range of sociodemographic characteristics including an adolescent\u0026rsquo;s age, gender, race/ethnicity, urbanicity, and socioeconomic status [9,10]. In the context of the pandemic, studies have also documented a greater reliance on the internet as the means of accessing both formal and informal support [11\u0026ndash;13].\u003c/p\u003e\n\u003cp\u003eDespite the high burden of mental health challenges in adolescence, studies have found that the majority of adolescents are reluctant to seek help for these challenges [14,15]. Further, research suggests that those with the most severe symptoms are often the least likely to pursue outside support [15,16]. In understanding the most prominent barriers to help-seeking among adolescents, one recent systematic review identified mental health stigma, negative family beliefs regarding mental health services, poor mental health literacy, and perceived self-sufficiency as key impediments to seeking help [15]. Conversely greater mental health literacy, prior positive experiences with mental health services, and trusting relationships with adults were identified as key facilitators of help-seeking [15]. These findings align with another recent review which highlighted the need to reduce stigma, improve mental health literacy, support self-help strategies, reduce structural barriers, and recognize young people\u0026rsquo;s autonomy in order to improve help-seeking behaviors [10].\u003c/p\u003e\n\u003cp\u003eIt is important to note that existing evidence on mental health help-seeking among adolescents has largely been drawn from high-income countries: for example, only 5 out of 90 included studies in the above-mentioned systematic review were conducted in low- and middle-income countries (LMICs) [15]. This is a significant gap in evidence as additional barriers may be present in LMICs due to inadequate funding, poor service accessibility, and limited mental health specialists in low-resource settings [17]. Further, research in this area has primarily been quantitative and while informative, there is a need for qualitative research to gain a deeper understanding of the lived experiences of adolescents [11]. Finally, research on adolescents\u0026rsquo; help-seeking behaviors in the context of the pandemic remains sparse [6,18]. Knowledge of the primary methods, barriers, and facilitators of help-seeking among adolescents is imperative as this can inform intervention development, increase access to care, and prevent the intensification of mental health challenges [14]. In response to these needs, the present study seeks to gain an in-depth understanding of mental health help-seeking behaviors among adolescents drawn from 13 countries. Conducted during the height of the COVID-19 pandemic, findings illustrate both challenges and opportunities for supporting mental health among adolescents across a diverse range of low-, middle-, and high-income country contexts.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current study draws on qualitative information that was collected as part of the United Nations Children\u0026rsquo;s Fund (UNICEF) 2021 State of the World\u0026rsquo;s Children Report. The methods from the primary study have been described in detail previously [19]. To summarize, 13 countries participated (Table 1), with partner organizations in each country conducting a minimum of four focus group discussions (FGDs) with adolescents. The FGDs were divided based on sex and age group such that there were at least two younger (ages 12-15) and two older (ages 16-19) FGDs held separately with boys and girls in each country. In total, 71 FGDs were conducted across the included countries. Depending on the COVID-19 regulations in each country, FGDs were either conducted online or in-person. All FGDs were conducted between February and June 2021 and were between 60 and 90 minutes each. The FGDs were conducted using the local languages. The country partner organizations were responsible for recording the FGDs, transcribing them verbatim, and then translating the transcripts into English when necessary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Adolescent mental health focus group discussions (FGDs)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGDs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eBelgium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eFrancophone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eFlemish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eChile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eSantiago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eShanghai\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eDemocratic Republic of the Congo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eKinshasa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eEgypt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eAsyut\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eIndonesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eYogyakarta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eJamaica\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eKingston\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eJordan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eAmman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eKenya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eNairobi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eMalawi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eBlantyre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eSweden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eStockholm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eSwitzerland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eLausanne\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eNew Orleans\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e[Insert Table 1 about here.]\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary data analysis was conducted using the English transcripts. These transcripts were coded using an inductive thematic approach [20]. Following a process of open coding, initial codes were compared, grouped, refined, and organized into a codebook. The codes were also checked for consistency across countries. Finally, these codes were applied across the full qualitative dataset by two data analysts. Coded data specifically related to help-seeking behaviors were subsequently reanalyzed by the authors of the current study. ATLAS.ti version 9.1 and MAXQDA 2022 were used to facilitate the data analysis process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach country partner organization obtained ethical approval locally prior to the study\u0026rsquo;s commencement. In accordance with ethical principles, county partner organizations worked together with schools or community organizations to obtain consent from adolescents\u0026rsquo; caregivers and assent from adolescents prior to data collection. Adolescents older than the legal age could give consent for themselves.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur findings are presented in three main themes: help-seeking strategies, barriers to help-seeking, and facilitators to help-seeking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Help-Seeking Strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Informal support\u003c/em\u003e. \u003c/strong\u003eAcross participating countries, the majority of adolescents discussed relying on close support networks for help dealing with social, emotional, and behavioral problems. Most commonly, this included connecting with trusted friends. Participants reflected on the ways in which their friends provided them with relief, comfort, encouragement, understanding, and solidarity when faced with mental health challenges. Many also mentioned turning to their friends for help thinking through different problem-solving strategies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOnce you have removed something from your heart and spoken about it you feel free... you feel relieved not like before when you felt your heart was heavy carrying something. At least when I tell my friend, they will carry something for me. \u0026ndash; Older girl, Kenya\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBeyond their friends, many adolescents also mentioned seeking support from their families: most frequently parents, but also siblings, grandparents, and other relatives. For adolescents with close relationships with their families, a common refrain was the idea that their families knew them best and were therefore most able to offer support, safety, and trust.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI grew up with [my parents], they know everything about me, so I think the people that I can trust the most are my parents. \u0026ndash; Younger girl, Switzerland\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI like to take refuge in my grandmother\u0026hellip;I feel very safe with her. \u0026ndash; Older girl, Chile.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNotably, in determining the most appropriate individuals to turn to, several adolescents specified that they would seek help from their parents for more serious problems, when they felt that adult advice or intervention was necessary.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt depends on the magnitude of the problem. If it is a small problem, you can discuss with a friend\u0026hellip;But if you are struggling a lot, most young people go and inform their parents so that they can help them with wisdom. \u0026ndash; Older boy, Malawi \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite the clear importance of their families, adolescents around the world often described greater comfort in seeking support from their friends. In reflecting upon this preference, participants discussed the feeling that peers their own age were better able to relate to them with regards to their experiences and feelings. Many also perceived an intergenerational divide with older family members when it came to the topic of adolescent mental health, with parents or grandparents seen as dismissive of their problems due to their \u0026ldquo;old fashioned\u0026rdquo; or \u0026ldquo;traditional\u0026rdquo; thinking.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI as an individual can\u0026rsquo;t go to my parents about certain things...Even though our peers are young and inexperienced, they are the ones who we can talk to because they may understand and share the same feelings and thoughts as we. \u0026ndash; Older boy, Jamaica \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI also don\u0026rsquo;t communicate with my family frequently, I just feel that we don\u0026apos;t have common topics, their thinking is old-school\u0026hellip; I usually tell my friends about everything. \u0026ndash; Older girl, China\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBeyond friends and family, some adolescents also mentioned seeking support from their teachers, although this strategy arose far less commonly across countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Formal support.\u003c/em\u003e \u003c/strong\u003eWhile it was clear that most adolescents relied on informal sources of support for help dealing with mental health challenges, a number of participants did discuss seeking professional support through school or community mental health services. The specific services that arose most widely included school counselors, therapists, psychologists, psychiatrists, primary care doctors, peer support groups, hotlines, and substance use treatment programs. Notably, adolescents living in middle- and high-income country settings placed a greater emphasis on these formal sources of support than those living in low-income countries. Also, it was clear that many adolescents saw community mental health services as a last resort for the most serious problems: for example, severe anxiety or depression, traumatic stress, eating disorders, or suicidal behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[My friend] went to the emergency room last month\u0026hellip;for taking sleeping pills. Because she felt that life wasn\u0026rsquo;t worth living\u0026hellip;.\u003c/em\u003e\u003cem\u003e At that time, I kept telling her that she should go to see a psychiatrist, and then she did go, she went to the mental health prevention and control center in her community, and then she went to talk to the doctor. [Now she] sounds well, she has been taking medicine. \u0026ndash; Older girl, China\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think that psychologists, it\u0026rsquo;s really for grave problems, [like] when there is trauma. Because it is easier to confide in someone we don\u0026rsquo;t know about some traumas. \u0026ndash; Older girl, Belgium \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Barriers to Help-Seeking\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Societal barriers. \u003c/em\u003e\u003c/strong\u003eAcross participating countries, adolescents reflected on the role of mental health stigma as a serious impediment to help-seeking behaviors. Adolescents described the ways in which people experiencing mental health problems were regarded as \u0026ldquo;crazy,\u0026rdquo; \u0026ldquo;abnormal,\u0026rdquo; \u0026ldquo;good for nothing,\u0026rdquo; \u0026ldquo;full of trouble,\u0026rdquo; or \u0026ldquo;untrustworthy.\u0026rdquo; A number of participants also discussed the taboo nature of discussing mental health problems \u0026ndash; and several adolescents described deep-seated beliefs, particularly among older generations, that such problems were fake. As a result of such stigma, adolescents around the world worried that they would face judgment or ostracization from their friends or family for disclosing mental health problems. Many also feared being labeled as \u0026ldquo;crazy\u0026rdquo; for seeking formal mental health services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe mentality of most Jamaican parents is that depression is not a real thing...I have seen memes or some parodies...on the internet where the child goes to the parent and says, \u0026lsquo;Mommy I\u0026rsquo;m depressed,\u0026rsquo; and her response is \u0026lsquo;Go depress the plates. Did you depress your books yet? You depress your uniform yet?\u0026rsquo; \u0026ndash; Older boy, Jamaica \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf you have psychological counselling [at school], sometimes the conversation may take a long time...If you go out for a long time, your teacher will wonder: Why did you have to go for so long? Where did you go? Why did you go to the mental room? Do you have a mental problem? \u0026ndash; Older boy, China \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt the societal level, gender norms also arose consistently as a central deterrent of help-seeking among boys. Adolescents around the world described norms around masculinity which dictate that boys should be strong, invulnerable, and able to handle problems on their own. As a result, boys who chose to share their feelings were often viewed as soft, weak, or feminine \u0026ndash; and many preferred to stay quiet about their mental health problems so as to avoid shame, humiliation, and disparagement. \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s harder for a boy to express his feelings because he is embarrassed about it, and he thinks that if he told other people about his problems, people would belittle him and mock him. \u0026ndash; Older boy, Indonesia\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Community barriers. \u003c/em\u003e\u003c/strong\u003eAt the community level, adolescents across participating countries discussed the lack of available school and community mental health services. Even where services did exist, a number of adolescents mentioned financial barriers that impeded accessibility, including the cost of both transportation and the services themselves.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhen you see that you don\u0026rsquo;t have anything or at your home there is no food, you cannot ask for transport money from your parents so that you can go and share your problems with someone. So, it just makes you to say, \u0026lsquo;Ah I will just see how to deal with it alone.\u0026rsquo; \u0026ndash; Older boy, Malawi \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to financial challenges, several participants highlighted concerns about the quality of mental health services that might deter adolescents from seeking help. Around the world, specific issues that arose included a lack of confidentiality, unskilled or unhelpful providers, antipathy towards adolescents, and a one-size-fits-all approach.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMany don\u0026rsquo;t want the help that, for example, the school provides, because, the help that the school provides is not always the best. People who don\u0026rsquo;t like to talk are still forced to talk. And that maybe doesn\u0026rsquo;t help. \u0026ndash; Younger girl, Sweden\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Interpersonal barriers. \u003c/em\u003e\u003c/strong\u003eWhile friends and families emerged as the most important sources of support for adolescents, participants also reflected upon steep interpersonal barriers to seeking help. Those which arose most widely included fears that others would judge or ridicule them, would not take their problems seriously, would not understand or care, or would not be able to truly help. A number of adolescents also shared instances in which their feelings or experiences were invalidated, particularly by their parents, and how this decreased their willingness to seek help in the future.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI find that it is difficult for [adolescents] to ask for help because of being criticized, judged...they prefer to keep quiet instead of expressing themselves to others.\u003cbr\u003e \u0026ndash; Older girl, Chile \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYou probably go to your parents and they\u0026apos;re like, \u0026ldquo;What do you have to be depressed about? You\u0026apos;re not paying bills\u0026hellip;\u0026rdquo; They\u0026rsquo;re saying that you don\u0026apos;t have any real problems. \u0026ndash; Younger girl, Jamaica\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile adolescents commonly relied on their friends for support, many also discussed challenges with trust. Specifically, they worried that friends would expose their secrets, leading others to find out about their mental health problems. \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI don\u0026apos;t like to confide in friends because they can expose your secrets, so I keep things to myself and this increases my suffering. \u0026ndash; Older girl, Egypt\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross participating countries, many adolescents also shared concerns that their parents or other family members would become angry or upset with them when they sought help. While this most commonly included verbal reactivity, adolescents in Egypt, Jordan, and Malawi also described physical aggression arising from help-seeking.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf I\u0026rsquo;m in trouble or sad about something, I keep it to myself because I think my parents are going to get angry. \u0026ndash; Younger boy, Chile \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eShe thinks that she will go to her family and tell them, but she is afraid that her family will beat her and they may humiliate her. \u0026ndash; Younger girl, Jordan \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Individual barriers.\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eAt the individual level, adolescents across participating countries most commonly discussed barriers arising from difficulties discussing their feelings. Specifically, participants expressed limitations with articulating their emotional distress as well as feelings of awkwardness or discomfort related to seeking help for such distress. This was seen as a particular challenge for boys given additional barriers imposed by masculine gender norms, as mentioned previously.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOur main difficulty is expressing how we feel...we know how we feel, you know, but we don\u0026rsquo;t know how to just come out and say it. \u0026ndash; Older boy, Jamaica \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI choose to hide my emotions and deal with them on my own. I am not good at communicating my inner thoughts. \u0026ndash; Older girl, China\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNumerous participants also mentioned feelings of shame or embarrassment that prevented adolescents from seeking help, clearly connected to pervasive mental health stigma in many communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eA lot of kids have...gone through something they don\u0026rsquo;t want they think is embarrassing. So, they don\u0026rsquo;t want to say nothing about it. \u0026ndash; Older girl, United States \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Facilitators of Help-Seeking\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Societal and community facilitators. \u003c/em\u003e\u003c/strong\u003eDespite the clear impediments to seeking support for mental health challenges, several factors arose widely as helping adolescents overcome these barriers. At the societal level, a number of adolescents discussed the ways in which digital technologies facilitated help-seeking by allowing for anonymity, continuous access, and connection to both formal and informal sources of support (e.g., helplines, chat groups, social media). At the community level, adolescents around the world highlighted the importance of school and community mental health services, previously mentioned barriers notwithstanding. As with digital technology-based supports, these types of services were seen as particularly appealing when they could ensure anonymity or confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLet\u0026rsquo;s say you don\u0026rsquo;t want your parents to know, or you need a somewhat more private space to talk other than the school, then you can seek help in the puskesmas [primary health care center]...I prefer to go to the puskesmas. I guess it\u0026rsquo;s because they don\u0026rsquo;t know us personally. \u0026ndash; Older boy, Indonesia \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf you feel quite sad, it is good to go to the school counselor. Because it can be good with someone you do not know, who has a duty of confidentiality. \u0026ndash; Younger boy, Sweden\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Interpersonal facilitators. \u003c/em\u003e\u003c/strong\u003eAcross participating countries, adolescents identified trustworthy relationships as one of the most important facilitators of seeking help for mental health challenges. Participants stressed the importance of having close friends or family members who could be trusted to support them without judgment, anger, or betrayal of their confidences.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf we find someone we trust and want to talk to, we want to tell our stories. It\u0026rsquo;s easy to share [your problems] with someone you trust. \u0026ndash; Younger girl, Switzerland \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany adolescents also emphasized the role of friends and family as gatekeepers in helping or encouraging them to access more formal services when necessary. This was seen as particularly important for ongoing problems or those that were understood to be more severe.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[If a friend is having a problem] you just give your support. If it\u0026rsquo;s to a severe degree, you should get an adult involved so that they get them help, get them into like therapy or something. \u0026ndash; Younger girl, Jamaica \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt becomes like a trade-off as well, if you think [your friend\u0026rsquo;s problem] is so serious that you kind of have to tell someone else, who can actually help, or if it\u0026apos;s actually just that you should be there for the person. \u0026ndash; Older girl, Sweden\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e Individual facilitators. \u003c/em\u003e\u003c/strong\u003eFinally, at the individual level, a number of adolescents reflected on the importance of internal motivation as a first step to seeking help. Participants illustrated the necessity of not \u0026ldquo;running away\u0026rdquo; from mental health challenges \u0026ndash; and of reaching a point at which they realized that they could no longer handle these challenges without outside support. As stated succinctly by one older boy from Switzerland, \u0026ldquo;To get better, you have to want to get better.\u0026rdquo;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this study is the largest and most diverse qualitative study exploring adolescent mental health help-seeking behavior to date. From a total of 71 FGDs across 13 countries, adolescents reflected on both informal and formal supports for dealing with mental health challenges. Unsurprisingly, this study highlighted adolescents\u0026rsquo; preference for seeking help from informal sources, with an overall preference for turning to friends over families. Similar patterns have been reported by numerous previous studies across a diverse range of settings [21\u0026ndash;25]. For instance, a large cross-sectional study involving 46,691 adolescents in Norway found that most (88.5%) preferred to seek help or advice from their friends when dealing with a personal problem, followed closely by their parents (82.1%) [21]. Likewise, in a study of 3,480 adolescents in China, among those who reported seeking help for mental health problems during the past year, 85.8% turned to friends and 64.5% turned to family [22]. These patterns highlight the role of friends and family as gatekeepers in helping adolescents cope with mental health challenges and directing them towards further services when necessary [26]. Indeed, adolescents themselves suggested that trustworthy relationships with friends and family are a central facilitator in helping them to access formal supports, particularly when problems are deemed severe. As such, it is clear that interventions targeting peers or caregivers could be beneficial in increasing adolescents\u0026rsquo; access to mental health care.\u003c/p\u003e\n\u003cp\u003eWhile adolescents\u0026rsquo; willingness to share their problems informally is encouraging, participants also highlighted significant barriers in seeking support for mental health challenges. In particular, adolescents discussed the pervasive impacts of mental health stigma, and the associated shame, embarrassment, judgment, ostracization, and invalidation that frequently deters adolescents from seeking help either informally or formally. This aligns with a substantial body of evidence which has documented perceived stigma \u0026ndash; alongside experienced or anticipated shame and embarrassment \u0026ndash; as the most commonly cited impediment to seeking help among adolescents globally [10,15]. In addition, adolescents highlighted that adolescent boys face additional stigma due to stereotypical gender norms equating emotional vulnerability with a lack of masculinity. This is again supported by myriad studies detailing the ways in which masculine norms impede help-seeking behaviors [27] \u0026ndash; and the resultant harms on boys\u0026rsquo; and young men\u0026rsquo;s mental health [28,29]. Together, these findings suggest the need for gender sensitive efforts to increase mental health literacy, normalize help-seeking, and reduce negative attitudes towards mental health problems globally.\u003c/p\u003e\n\u003cp\u003eWhile a number of participants did mention seeking formal support from school or community mental health services, it was clear that adolescents often face serious structural and logistical constraints on accessing professional help. In particular, adolescents highlighted low service availability and financial challenges as greatly impeding their help-seeking behaviors. These barriers may have particular salience given the predominant inclusion in the current study of adolescents from low-resource settings. Notably, since most mental health services require multiple meetings, the associated costs can easily exhaust a family\u0026rsquo;s financial capacity [30] and this does not factor in opportunity costs such as parents missing work. Further, even in countries with universal healthcare, the coverage for mental health services has been shown to be far below the target [31]. The situation is exacerbated by acute shortages in the mental health workforce (including psychiatrists, psychologists, nurses, and social workers), particularly in LMICs where studies have consistently documented coverage of less than two providers per 100,000 of the population, with providers largely concentrated in urban areas [32,33]. In addressing these treatment gaps, it has been argued that there is an urgent need for increased country-level investment into adolescent mental health, the development of legislative policies to help organize service delivery, greater intersectoral collaboration, and task-shifting approaches to optimize available human resources [17]. In addition, given participants\u0026rsquo; reflections on the merits of digital technologies in helping them access mental health support, it is apparent that these technologies present additional opportunities for overcoming treatment gaps among adolescents globally [34].\u003c/p\u003e\n\u003cp\u003eThe findings from this study also emphasized that the availability of mental health services alone does not mean that adolescents would use them. Rather, it was clear that adolescents are also aware of the quality of services, and are much more likely to seek formal support when they perceive that these services are accessible, confidential, and youth friendly. This may be particularly relevant when considering school mental health services: as the majority of adolescents globally already spend a significant portion of their time in school [35], services offered in this setting may present fewer structural and logistical barriers to entry than those in the community [36]. Indeed, a large body of evidence suggests the value of implementing school-based mental health services across low-, middle-, and high-income country settings [37\u0026ndash;39]. Our findings imply, however, that greater sensitivity and mental health literacy among school staff including teachers, school nurses, and school counselors may be necessary in order to increase adolescents\u0026rsquo; willingness to seek help from these services.\u003c/p\u003e\n\u003cp\u003eIn interpreting the results of this study, it is important to note several limitations. First, while we have summarized themes with broad salience across the included countries, individual results cannot be considered representative of all of the participating countries. Likewise, findings from one country setting may not be transferable to adolescents across other settings within the country. For instance, the majority of interviews were conducted with urban adolescents and may therefore not reflect the concerns of those living in rural areas. Further, while the FGDs were conducted in the local language in each study country, the majority of data analysis was undertaken in English. The English transcripts used for analysis were checked and reviewed by bilingual researchers in order to help address these challenges, but this does not eliminate the likelihood that some salient information was lost in translation. Finally, while not a limitation, it is important to acknowledge that this study was conducted in the context of the COVID-19 pandemic which has had well-documented impacts on adolescent mental health globally [6]. While the questions asked during the FGDs focused generally on mental health help-seeking, it is likely that the contextual realities of the pandemic influenced adolescents\u0026rsquo; responses.\u003c/p\u003e\n\u003cp\u003eIn summary, this study highlights the critical role of informal supports including friends and family in helping adolescent cope with mental health challenges and facilitating access to formal supports when necessary. While this is encouraging, participants also described significant barriers to seeking help, including mental health stigma, limited service availability, poor quality services, and financial challenges. These findings emphasize the need for gender-sensitive efforts to increase mental health literacy and reduce negative attitudes towards mental health challenges, as well as increased investment in adolescent mental health programs and policies at the country-level. Further, while school-based mental health services may present an opportunity to overcome structural and logistical barriers, greater sensitivity among school staff is required. Overall, these findings provide critical insights for developing interventions that aim to increase adolescents\u0026rsquo; access to mental health care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOVID-19 coronavirus disease 2019\u003c/p\u003e\n\u003cp\u003eFGD focus group discussion\u003c/p\u003e\n\u003cp\u003eLMICs low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eUNICEF United Nations Children\u0026rsquo;s Fund\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Information:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Wellcome Trust through a contract with UNICEF Headquarters for the preparation of the State of the World\u0026rsquo;s Children 2021 report, \u003cem\u003eOn My Mind: Promoting, protecting and caring for children\u0026rsquo;s mental health.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was developed in conjunction with UNICEF\u0026rsquo;s \u003cem\u003eState of the World\u0026rsquo;s Children 2021\u0026nbsp;\u003c/em\u003ereport, \u003cem\u003eOn My Mind: Promoting, protecting and caring for children\u0026rsquo;s mental health\u003c/em\u003e. The study was initiated by UNICEF Headquarters in collaboration with the Johns Hopkins University Global Early Adolescent Study, and was made possible through partnerships with organizations across 13 countries. These include:\u0026nbsp;Centre de R\u0026eacute;f\u0026eacute;rence en Sant\u0026eacute; Mentale, Steunpunt Geestelijke Gezondheid,\u0026nbsp;Universidad de Santiago de Chile, Shanghai Institute for Biomedical and Pharmaceutical Technologies,\u0026nbsp;Kinshasa School of Public Health, Assiut University, Universitas Gadjah Mada, University of the West Indies, Terre des Hommes, African Population and Health Research Center, Kamuzu University of Health Sciences, Karolinska Institutet, Unisant\u0026eacute;, and Institute of Women and Ethnic Studies. We are immensely grateful to the researchers and program specialists from these organizations who helped to shape the research questions and then organized, facilitated, recorded, transcribed, and translated focus group discussions with adolescents. We would also like to gratefully acknowledge the support from the Wellcome Trust and from UNICEF country offices. Above all, we are thankful for the young people around the world who gave their candid insights during 71 focus groups discussions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications and Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper highlights the barriers and facilitators that adolescents around the world face in accessing help for their mental health challenges. Focus on improving mental health literacy and reducing stigma are important. This information is critical for stakeholders in developing and implementing programs to address adolescent mental health challenges.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBonnie RJ, Backes EP, editors. The Promise of Adolescence: Realizing Opportunity for All Youth. Washington, D.C.: National Academies Press; 2019.\u003c/li\u003e\n\u003cli\u003eKieling C, Baker-Henningham H, Belfer M, et al. Child and adolescent mental health worldwide: evidence for action. The Lancet 2011;378:1515\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003ePatel V, Flisher AJ, Hetrick S, et al. Mental health of young people: a global public-health challenge. The Lancet 2007;369:1302\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eGuessoum SB, Lachal J, Radjack R, et al. Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. 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Adolescence during a pandemic: Examining US adolescents\u0026rsquo; time use and family and peer relationships during COVID-19 2020.\u003c/li\u003e\n\u003cli\u003ePalacio-Ortiz JD, Londo\u0026ntilde;o-Herrera JP, Nanclares-M\u0026aacute;rquez A, et al. Trastornos psiqui\u0026aacute;tricos en los ni\u0026ntilde;os y adolescentes en tiempo de la pandemia por COVID-19. Rev Colomb Psiquiatr 2020;49:279\u0026ndash;88.\u003c/li\u003e\n\u003cli\u003eDivin N, Harper P, Curran E, et al. Help-Seeking Measures and Their Use in Adolescents: A Systematic Review. Adolesc Res Rev 2018;3:113\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eAguirre Velasco A, Cruz ISS, Billings J, et al. What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review. BMC Psychiatry 2020;20:293.\u003c/li\u003e\n\u003cli\u003eRickwood DJ, Deane FP, Wilson CJ. When and how do young people seek professional help for mental health problems? Med J Aust 2007;187:S35-39.\u003c/li\u003e\n\u003cli\u003eBabatunde GB, van Rensburg AJ, Bhana A, et al. Barriers and Facilitators to Child and Adolescent Mental Health Services in Low-and-Middle-Income Countries: a Scoping Review. Glob Soc Welf 2019:1\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eDumas TM, Ellis W, Litt DM. What Does Adolescent Substance Use Look Like During the COVID-19 Pandemic? Examining Changes in Frequency, Social Contexts, and Pandemic-Related Predictors. J Adolesc Health Off Publ Soc Adolesc Med 2020;67:354\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eFine SL, Lai J, Baack MRM, et al. Adolescents\u0026rsquo; reflections on mental health around the world: Key findings from a 13-country qualitative study Under review.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. 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Am J Community Psychol 2021;68:215\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eKapphahn CJ, Morreale MC, Rickert VI, et al. Financing Mental Health Services for Adolescents: A Position Paper of the Society for Adolescent Medicine. J Adolesc Health 2006;39:456\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003ePatel V, Saxena S. Achieving universal health coverage for mental disorders. BMJ 2019;366:l4516.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Mental Health Atlas 2020. Geneva: World Health Organization; 2021.\u003c/li\u003e\n\u003cli\u003eRathod S, Pinninti N, Irfan M, et al. Mental Health Service Provision in Low- and Middle-Income Countries. Health Serv Insights 2017;10:1178632917694350.\u003c/li\u003e\n\u003cli\u003eLehtimaki S, Martic J, Wahl B, et al. Evidence on Digital Mental Health Interventions for Adolescents and Young People: Systematic Overview. JMIR Ment Health 2021;8:e25847.\u003c/li\u003e\n\u003cli\u003eUnited Nations Children\u0026rsquo;s Fund. Secondary Education and Enrollment Statistics. Available at: https://data.unicef.org/topic/education/secondary-education/. AccessedMarch 16, 2023.\u003c/li\u003e\n\u003cli\u003eMasia-Warner C, Nangle DW, Hansen DJ. Bringing Evidence-Based Child Mental Health Services to the Schools: General Issues and Specific Populations. Educ Treat Child 2006;29:165\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eFazel M, Patel V, Thomas S, et al. Mental health interventions in schools in low-income and middle-income countries. Lancet Psychiatry 2014;1:388\u0026ndash;98.\u003c/li\u003e\n\u003cli\u003eGrande AJ, Hoffmann MS, Evans-Lacko S, et al. Efficacy of school-based interventions for mental health problems in children and adolescents in low and middle-income countries: A systematic review and meta-analysis. Front Psychiatry 2022;13:1012257.\u003c/li\u003e\n\u003cli\u003eKarukivi J, Herrala O, S\u0026auml;teri E, et al. The Effectiveness of Individual Mental Health Interventions for Depressive, Anxiety and Conduct Disorder Symptoms in School Environment for Adolescents Aged 12\u0026ndash;18\u0026mdash;A Systematic Review. Front Psychiatry 2021;12.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Wellcome Trust","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adolescents, Youth, Mental health, Help-seeking behaviors, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-6823046/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6823046/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eAdolescence is a period of developmental transition marked by a high prevalence of mental health challenges. The emergence of these challenges underscores the importance of encouraging help-seeking behaviors among adolescents to mitigate negative psychological outcomes. Gaining a deeper understanding of the lived experiences of adolescents can inform intervention development and increase access to care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study draws on qualitative information collected from 71 focus group discussions across 13 countries with male and female adolescents aged 12\u0026ndash;19 years old. Focus group discussions were transcribed verbatim and translated into English, with transcripts coded and analyzed for emergent themes. Focused data analysis centered on themes related to help-seeking strategies for mental health challenges as well as related barriers and facilitators.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants emphasized the critical role of informal support systems, including friends and family, in helping adolescents cope with mental health challenges. Additionally, participants highlighted the importance of accessing professional support through school or community mental health services. Significant barriers to help-seeking were described, including mental health stigma, restrictive gender norms, limited service availability, poor quality or unaffordable services, low mental health literacy, and unsupportive interpersonal relationships. Participants emphasized the role of digital technologies, school and community environments, and trustworthy relationships as facilitators of seeking help.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWhile many adolescents are aware of the importance of seeking help for mental health challenges, there is a need for country-level interventions to increase mental health literacy and reduce mental health stigma in order to ensure optimal access to care.\u003c/p\u003e","manuscriptTitle":"Barriers and facilitators of seeking help for mental health challenges among adolescents across 13 countries: A qualitative investigation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-06 07:15:27","doi":"10.21203/rs.3.rs-6823046/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2860a58-b366-4043-95dc-7e50cd66b29d","owner":[],"postedDate":"June 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":49543245,"name":"Psychology"},{"id":49543246,"name":"Epidemiology"}],"tags":[],"updatedAt":"2025-06-06T07:15:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-06 07:15:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6823046","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6823046","identity":"rs-6823046","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}