[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids, a podcast series dedicated to exploring the latest advances in child and adolescent mental health research and practise. I'm Clara, an academic clinical fellow in child psychiatry. And I'm really interested in understanding and addressing the diverse mental health challenges faced by young people globally. In this series, I'm joined by renowned researchers and clinicians from around the world to discuss cutting edge research, interventions, and best practises in child and adolescent mental health. And today I'm really excited because I have the pleasure of receiving Dr. Ariadna Albajara. She is a research associate at the University of Cambridge. She's also a by-fellow at Hughes Hall and a research associate at the Child and Adolescent Resilience and Mental Health research group, ChARM. And I also have the huge pleasure of receiving Dr. Amirah Wahdi. She is an assistant professor at the University of Gadjah Mada in Indonesia, and she's also a PhD candidate at the University of Queensland. I'm really excited about receiving both of them because we're going to be discussing a paper that was recently published in JCPP advances about mental health measures among adolescents in 12 low and middle income countries. And we're also going to be talking about mental health in low and middle income countries more broadly. So without further ado. Ariadna and Amirah, it's a huge pleasure to have you both here and to see you again as well. And to start, I wondered if you could share a little bit about your research journey so far and your experience in researching mental health in low and middle income countries, and what brought you to the places you are at the moment. ARIADNA ALBAJARA SÁENZ: Thank you Clara. So hello. As Clara said, my name is Ariadna Albajara Sáenz, and I'm a research associate in the Department of Psychiatry at the University of Cambridge. And I currently work on projects related to children and young people's mental health, particularly school-based interventions. And before that, during my PhD at the Université Libre de Bruxelles in Belgium, my research focused on the association between autism and ADHD. So when I arrived at Cambridge, I had the opportunity to work on a project looking at mental health measures among adolescents in 12 in low and middle income countries. And this was a collaboration with Professors Tamsin Ford and Amy Orben, Jennifer Saxton and Sebastian Kurten at Cambridge, and also with Daniel Kardefelt-Winther from UNICEF Innocenti. I'm a medical doctor by training, but soon after starting practicing medicine, I found that I wasn't really enjoying it. And at that time I took several courses on research methodologies and biostatistics. So I was trying to find a position where I start as an apprentice, doing research with a better mentorship compared to my medical school education. At that time, I got a position at the Centre for Reproductive Health. So I started my career as a reproductive health researcher. But after I finished my master, there wasn't any reproductive health studies to manage. The only one available was what we will discuss later on, I guess, a multi-country survey called national adolescent mental health survey. I was like, OK, if that was the only available one, I'll take it, I guess. At that time, I didn't have any expectation because I was eager to get my skills and knowledge into practise. But I guess, we were adolescents once, so it wasn't really hard to-- oh, this is an important stuff. Oh, this is interesting. And it got me also reflect on my experience and my mental health state. And now my focus is on adolescent mental health in Indonesia. Indonesia is one of low and middle income countries in the world. We can argue, one of the biggest one because we have 270 million people in Indonesia and 18% is between 10 and 19 years old. That's a really fascinating story. I love how ended up being a serendipitous area for you. It wasn't what you were originally aiming at first, but then you fell in love with it. And now you're an assistant professor and completing a PhD in the topic. So that's really fascinating. I suppose I can resonate a lot with what you said because I come from Brazil and I still practise medicine, I still practise as a doctor. But sometimes what I see in low and middle income countries in general, I'm sure you see as well, is because of the distribution of the population, we have a huge population of young people. And then what happens as well is with the increase in mental health needs, which you're going to talk about later in this podcast, there's a huge demand for service provision and for child and adolescent psychiatrist. I'm not sure if that's your experience in Indonesia as well, Amirah. And then, obviously, it's really important and we need child psychiatrists to be there on the front line. But I also find that research is so impactful in those contexts as well because we need good data to inform services and services in this country, not always, but often, they are less structured compared to high income countries. Is that your experience of Indonesia as well? Well, what we found out from NAMHS, the service used in Indonesia is really, really low. And a part of my PhD is to figure out why is that? But it is low even after we broaden the definition of service use. And we asked the parents or caregivers of adolescents about service without really defining service as a formal service because the thought at that time was, in Indonesia, it was hard to access formal service because first, like you mentioned, like stigma, just like social barriers. And then even when parent or adolescent are willing to, to access service, there are limited numbers of mental health professionals, especially the ones specialised in child and adolescent. So it is really hard. So in general, the percentage, the prevalence of seeking health care for mental health problems or for what we ask in them, for their behavioural and emotional problems was really low in Indonesia. But in Vietnam and Kenya, it was a little bit higher. That's a part of the question for my PhD. Why is that? Whether it's really because of something specific to Indonesia or maybe because of the shared cultures, practise, or beliefs in Southeast Asia region, for example, then maybe that's why people in this region don't necessarily go to seek service or it is something else. The I-NAMHS the Indonesian NAMHS data is a national number. Indonesia is a big country. I can argue that it is also a country with a huge disparity. So Indonesia, it could be just like, yeah, this is the average number. When we look deeper, we can see any significant difference. But yeah, that's something that I still need to answer. I will look at the region to see whether it's something due to shared belief, practise, or culture. I will also look at cross-country analysis using NAMHS data, because I think that's something that related to Ari's work. When we see many, many data from many, many countries, sometimes it's hard to understand the data because there is a certain degrees of variance in the data set. But with NAMHS, because at that time, we work together, everything was the same standardised. So I will look at NAMHS to see whether the difference is because of the variance or not, or because of the country characteristic or not. And fortunately, with I-NAMHS, we have district representative data as well. So I can compare the national data with the subnational data. So hopefully with that I can understand why adolescents in Indonesia only access mental health service "limitedly" quote unquote, despite what we know so far, like conversation in social media in the popular articles. For example, everybody talks about mental health, but it doesn't necessarily-- meaning that they will actively searching for help. So well, still a big question to be answered. And actually, your answer gives me a really nice hook to ask Ari about her paper, because you mentioned something really interesting. You talked about the variants, and in Ari's paper, which we're going to put a link to in the podcast because we just published in JCPP Advances. So, Ari, I know you looked at 12 different countries, and I wondered if you could tell us a little bit more about the data set you used and also the literature gaps that your paper tried to address. Sure. Yeah, so in this study, we analysed data from the Disrupting Harm project. So this was a project which actually focused on technology-facilitated sexual exploitation and abuse of children. And this project was conducted by ECPAT International, INTERPOL, and UNICEF Innocenti, and it was funded by Safe Online. So in our specific study, we used mental health questions from the Disrupting Harm survey. And this survey was designed by UNICEF Innocenti, and it surveyed adolescents aged 12 to 17 years old. And one of their caregivers across 12 countries. So these were six countries in Eastern and Southern Africa. So these were Ethiopia, Kenya, Mozambique, Namibia, Tanzania, and Uganda, and then six countries in Southeast Asia. So these were Cambodia, Indonesia, Malaysia, the Philippines, Thailand, and Vietnam. So as I said, the survey included, yeah, a set of mental health questions, which were the ones that we analysed in our study. And so one of the motivations for our study is that most of the existing evidence on adolescent mental health comes from high income countries. So there is less nationally representative data coming from low and middle income countries. So this is also the case for mental health, disaggregated by factors such as gender and age, and also the relationship between adolescent mental health and food insecurity, which is more prevalent in these two regions has been less explored. And so these gaps are important in the sense that understanding how mental health varies across different groups will help us identify particularly vulnerable groups. Amirah mentioned conducting mental health across countries has some methodological challenges. So, for example, language barriers, but also differences in how subjective mental health concepts are understood and interpreted. So there's something called measurement invariance testing, which allows us to address this by assessing whether a mental health scale measures the same construct in the same way across different groups. So in our case across different countries. But there is limited research on this. And actually the available evidence that exists shows measurement invariance in just a few scales. So what we wanted to do in our study was to test the cross-country measurement invariance of the mental health scales that we use that were used in the survey, also provide country level estimates of adolescent mental health, and then explore how mental health varied by age, gender, and food insecurity. As you said. And Amirah said before as well, I think the measurement invariance bit is so important, especially in low and middle income countries. When we think about the scales that have been validated, lots of those scales haven't been validated for those populations. And as Amirah was saying, sometimes is a real challenge to compare findings across countries. And speaking of findings, can you summarise to us the main headline findings of the paper. ARIADNA ALBAJARA SÁENZ: Regarding measurement invariance. So we tested measurement invariance for the two multi-item scales that were included in the survey. This was a well-being scale, which is called the children world psychological well-being scale, which includes six items. And then the second one was a four-item anxiety scale from the UNICEF youth empowerment project. So our findings showed that measurement invariance was not supported for either of the scales across the countries included in this study. So, for example, for the well-being scale, we did not find the metric invariance. This means that adolescents in different countries interpreted or bonded to items differently. And then for the anxiety scale, we did not find configural invariance. So this means that the way anxiety was conceptualised or structured was different also across countries. So this is consistent with the literature, but it meant that we could not compare the measures across the countries. And so these were the two multi-item scales we use with also use other single scale items. But of course, we couldn't test measurement invariance for these items. And then we reported estimates. But again, this need to be cautiously interpreted due to this-- however, when we explored the impact of age, gender, and food insecurity, it is true that we found results that were consistent with the literature. So the most common correlate was food insecurity. And then it seemed that the impact of gender was less important. So what we see during adolescence is that generally girls will have worse mental health than boys, but from a study published by Campbell, they showed that this-- yeah, this gender gap was reversed in a minority of countries. And this was also the case in our results. So in a minority of countries, this gender gap was reversed. So the hypothesis is that maybe gender has less of an impact in these countries that we studied. I think these results need to be interpreted with a lot of caution, again, because of the measures used, that as you see, showed that measurement invariance was not supported for the skills. I find this is so fascinating because there is such a large variation among what each country reported. So, for example, I think for loneliness, it was 18.3% in Vietnam versus 70% in the Philippines. And because we know that measurement invariance, which, as Ari explained, just explaining, again, because I know it's a very unsexy concept, basically means that if measurement invariance is supported, it means that that scale or that instrument that we're using is measuring the same underlying concept for different populations. But what I think is fascinating is-- and how it's counterintuitive. Because you would think that if you're asking about if someone is feeling lonely, that would generate the same. You're asking the same thing, but actually you're not because culture plays such a huge role in how we perceive things. And yeah, you have really fascinating findings. And so, Amirah, you have a lot of experience in the NAMHS survey. And I know NAMHS also included Vietnam. And you're also involved in the Vietnamese NAMHS, which is also one of the countries that Ari included in her paper. So I was just wondering, how do you make sense of these findings? Do you have any insights? So the way NAMHS's work, we had three countries-- Indonesia, Vietnam, and Kenya, and each country had their own implementing partner, so to speak. I was responsible mainly for Indonesia, but we work closely together. So everything was discussed together. And I can only nod every time when Ari's explaining her findings because it brought me a huge, a whiplash of déjà vu. When we were developing the NAMHS instruments, I remember we spent hours just to discuss one question, for example, again, loneliness. We wanted to ask the adolescents, do you have a friend that you usually spend time with talking, sharing your experience? And then each of countries were just like, what is a friend? A basic question. What is a friend? Because in Indonesia we only have one word friend. Everyone is a friend. But in English you have friends, peers, colleagues, acquaintances. So it's just like when we talk about friend here in English, are we asking about the same thing that we refer to in our own language? And it was we went for hours just to discuss friend. And then also we use [? DMS-5 ?] to assess the mental disorders in all countries. And I remember conduct disorder instruments was the most difficult one to back translate and then discuss together. Because it was really culture-based. Because when we talk about conduct disorder, we're talking about a condition when somebody would just going against the norms and the norms is really subjective based on the culture. So there was a question, have you ever tried to start a fire, for example? If I ask that in certain places in Indonesia, every day because they still have this open like using wood for cooking. So they start fire almost every day, which is that's not what we are asking for. And also the concept about truancy like, have you ever ditch school to the point that police got involved? And I was like, maybe United States is the only country in the world that has this concept because I ditched school when I was in high school. I was in a gifted class, gifted programme, and I ditched school. It was a common thing, sometimes you are being teenagers, a rite of passage, basically. But Big Five, which was developed by our colleagues in Columbia University in New York, was obviously really Western-based. So the cultural adaptation of NAMHS was really long. It was almost two years because, of course, we also had COVID-19 at that time. So our field work got postponed because of the pandemic, which gave us more time to perfect our cultural adaptation. But it was really a labour of love, basically. So I totally can understand Ari's hard work and I cannot say whether we got it because we have to do what Ari did with her data set and implement it with NAMHS data set, just to see whether we got it right, so to speak, quote unquote. Again, what works in Indonesia can be really different to Vietnam and Kenya. And when the result came up, one of my colleagues from Kenya was the first author for our paper on ACEs at first. And the prevalence of ACEs in Kenya based on NAMHS data was really high. And then we were just like, what's going on? Because compared to Vietnam and Indonesia, it was really, really striking. But then maybe it's because we already standardise everything else. The question, the way we ask the question to the children. And then we gave the definition. So we kind of like, oh, maybe there was something that inherent to the context, the situation. Because when we say Kenya, Kenya findings were high. It was not all places in Kenya. It's the National data in Kenya, which came from whole Kenya. So there I'm assuming that Kenya is like Indonesia. There are several places where the ACEs are extremely high, but there are also some places where the ACEs may be comparable to what we found in Indonesia and Vietnam. And it's the same, why only 2% of adolescents in Indonesia seek care for their emotional and behavioural problems compared to Vietnam around 6% and Kenya around 10%? There must be something. That's what I'm trying to learn more. Like, what is this something that might be inherent to Indonesia context? And comparing it with other countries, hopefully, I can find some low-hanging fruits that can be adapted in Indonesia or can be a source of mental health system improvement, for example. This is super interesting, and you've touched on some of the challenges. So the question I was going to ask you next is basically conducting National Mental Health Surveys is a huge challenge, I think, anywhere in the world. And Ari and we work with the English National Mental Health Survey for Young People, MHCYP. And we know the challenge that it is to access data and curate data. And we know that there are logistical challenges as well. Because, for example, in the English mental health surveys, for the latest survey, they did online and phone interviews. So everything was fairly remote. But I know that sometimes because of infrastructure issues this is not always possible. So how did you guys overcame those challenges to adapt to each country like in-- So basically we did many, many what we call DHS, Demographic and Health Survey. So it's like there are before, of course, before what's going on in the United States now. The Department of State, the USAID office usually funded or provided technical assistance for low and middle income countries in the world so they can have their own demography and help survey. We did that multiple times in Indonesia and that's how we learned how to conduct population-based survey. And it's basically a mini census. The unit to be really specific with the sampling frame because you're trying to yield a national number. In NAMHS, each country has their own prerogative to develop their own sampling frame. This is, again, a testament of the leadership from the University of Queensland and the technical assistance from Johns Hopkins Bloomberg School of Public Health. In this survey, trust is beyond everything. So we had full control on how we develop our sampling frame, how we develop our survey organisation because NAMHS is a enumerator assisted survey. So the train enumerator will ask the caregiver or the adolescent about the question that we have in our instrument. And everything was standardised, of course, but, for example, in Indonesia, because we are a big country and it was in the middle of the downturn of the first COVID-19 before we got to the new wave in 2022. So in Indonesia, we had three waves of data collection based on the COVID status. It meant that we had to do the training also gradually because we used ODK to assist us collect the data. The data quality assurance was also tailored to the country specific law and regulations regarding data and information security. Our colleagues in Kenya and Vietnam used a different platform. So their data was managed together simultaneously. But Indonesian law doesn't allow that. So we had to manage our data quality assurance and then transfer the data to our pull server when the data was already identified. So that's just like a one sample how each country still has its own-- how to say it-- flexibility independence without compromising the overall data standardisation. We in Indonesia, we have one module that is not available in Kenya and Vietnam. So in Indonesia everything is single payer insurance a little bit like in the United Kingdom. So because of that, we have that module. So you can imagine that the sequence of the module, the sequence of the interview was a little bit different for Indonesia compared to Kenya and Vietnam, for example. So yeah, it can be done only because of mutual respect. I count myself extremely lucky because I started my career surrounded by people who not just like, sometimes you read this on paper on-- you hear this from lecturers saying how you manage partnership, global partnership, for example. But I got to experience it firsthand. And I was just like, oh, this is the standard. This is the gold standard. And that's something that I try to replicate in any other multi-country projects that we're working on. And it's about to get to know you partners again, get to hear each other's side of stories, opinion and how to come into a decision together without downplaying any other parties, which is not easy because you put together some of the most brilliant, strong opinion people in one place and you are striving for the same thing, the perfection or the high quality. And sometimes you can really into your opinion because you are invested on this work. So it is something that really something that I think I will take with me for the rest of my career because it is really incredible and it is really reflected in our work because anything good comes out of NAMHS it's because of that mutual respect and willingness to learn from each other. Now that's really beautiful. And I think in your answer, you also gave lots of useful learning points for other researchers from low and middle income countries who are trying to implement those big, nationwide surveys in their own countries. And to wrap up, actually, I wanted to ask something to both of you. So based on your experience, with your respective projects, researching mental health in low and middle income countries, what would be your hope or examples of research in the child and adolescent mental health world in those contexts that you would really like to see next? ARIADNA ALBAJARA SÁENZ: Yeah, so I think also taking into account Amirah's work and the findings from our paper. So I think one important direction for future research is to develop but also evaluate the indicators we're using, especially when we're doing cross-country research in a way that we can better measure mental health in adolescents. I think it's particularly important in research across countries. Yeah, as Amirah I mentioned, I think another key priority is ensuring that this research is designed and also led and implemented by, or at least in close collaboration with researchers based in those countries, in the countries involved. So I think a focus in creating strong partnerships is essential for producing this kind of research. So that it's contextually relevant and also culturally appropriate. So we can see the examples that Amirah gave regarding the concept of friend. For example, in Indonesia, we cannot simply take one measure and implement it in another country, just assuming that it will work. So I think for me, measurement is one of the big gaps and one of the big topics we should focus on right now. Yeah, it is really important. I remember when we developed NAMHS, we really wanted to look at the internet use. We started with them 2018 and the tools, the instruments was basically finished or locked in in 2019 for piloting. So at the time we were really like, OK, we wanted to assess internet use, but we couldn't do that because the pilot result was not promising. So we dropped that. But now we know that it is not internet use. It's social media use. It's different thing. So again, measurement in different contexts. And to see and this is something that you mentioned. You wrote down in your paper, Ari, that there is a huge discrepancy in data availability between high income countries and low and middle income country, despite almost 90% or maybe more than 90% of adolescents live in low and middle income countries. Of course, this is an important part. And for me personally, coming from reproductive health background [INAUDIBLE] to a mental health problem or mental health interest like focus, I think I count myself lucky because logistically speaking, the funding on reproductive health is really difficult right now. And it's just the right time for me to start my career on this because the funding for mental health was considered as flourishing. But we don't know now because what's going on in the world. But at the time, it was good. So I hope that we will not lose our focus because a new thing will come. And then with what's going on in the world, who knows if we will have even enough money to keep looking on these problems. So I hope that we will not lose our focus on adolescent mental health because I know in especially in a country like Indonesia, who is really depending on the youth to move the economy forward, it is really important to make sure that all children and adolescent and youth, young people, to have everything that they need to make sure that they can achieve their highest potential, and then in turn, will drive this country to "prosperity." I think both of you covered so many important points. And just to comment on something, is that that I thought it was fascinating how culture is shifting. And I think this is something Ari and I-- Ari and I work together. So when I say Ari and we talk about that because sometimes we're talking in the office and in the UK, this current new generation, it has a completely different set of values and culture than our generation. And as you said, sometimes the content that they see nowadays in the internet, sometimes worryingly, there is a really interesting podcast on, I think, by Jane and Umah on misogyny and the kind of content kids are getting exposed to online. But this is something that didn't exist. I mean, obviously misogyny always existed, but just to say that those influencers that are now propagating those misogynistic views that didn't exist. I grew up without-- now I'm going to sound really old, but I grew up without Instagram and Facebook. That didn't exist. So I think, as you said, culture and the cultural references are changing so fast. To have a cohort in Indonesia would be such a fantastic thing because then you would be able to track over time changes, and it would be so informative. I mean, obviously, there is still value in cross section. And I'm a firm believer of stopping like, it's hard to get funding from a cohort from the outside. But yeah, but I think I absolutely agree with you 100%. Yeah. And more people-- more country should have a national data on adolescent mental health as well. Because, again, right now only what? Maybe I can't even remember. It's my dear advisor's paper. I cited it many, many times, but I cannot-- there are so many numbers. I cannot remember which one is it. But I guess only 2% versus or 2% or 4% compared to the [INAUDIBLE] in high income countries like two digits already. So we need more countries conducting cross-sectional study. That's OK. We need to start somewhere, and then we can have more insight on how one country will be different or same consistent with another. That would be lovely. Thank you so much to both of you for a lovely conversation and a lovely podcast. I've learned so many things, and I've got so many insights on the work you've both been doing. And thank you so much for listening. [AUDIO LOGO]