Pattie Gonsalves leads a national public engagement initiative “It’s Ok To Talk” (www.itsoktotalk.in) and digital program development for PRIDE , one of the world’s largest adolescent mental health research programmes at Sangath, a mental health research organisation in India. Talking to her about PRIDE’s problem-solving app, POD Adventures, gives me hope that through the use of technology, we might be able to break down the stigma associated with mental health and offer accessible and engaging interventions to adolescents.
As a young Teach For India fellow, in an under-resourced school in Mumbai, I experienced the crushing helplessness brought on by the lack of understanding of mental health by the ecosystem of stakeholders that surround children. School administration that viewed mental health as an extracurricular activity, other teachers who attributed behaviour challenges to the environment in the slums and parents who were often so busy making ends meet that providing for empty stomachs became more important than troubled minds.
Mental health problems are a major worldwide concern but progress especially in low and middle income countries (LMICs) has been slow. The burden of mental issues on the adolescent and young adult population is especially severe. Stigma and lack of awareness about the importance of good mental health are major obstacles in uptake of mental health services in healthcare settings in India. Some other barriers include the existing public-health priorities and funding, impaired delivery of mental health care in primary-care settings, the low numbers of trained personnel, and the lack of mental health perspective in public-health leadership.
These systemic issues are reflected at the school level, with academics taking precedence over mental wellbeing, lack of funding for school based counsellors, the lack of physical space for counselling and most importantly, teachers and management who have little understanding of child development psychology. Pattie shared how Sangath’s methodology works at a whole school level with “everybody in school and all young people”, creating an enabling environment for children to seek mental health support. Conversations around the different problems and challenges we face and stress management create a pathway for students to access either the app or face-to-face counselling services by trained counsellors.
Having implemented Sangath’s POD face-to-face counselling programme in the schools we work with at Swasti, I’ve seen first-hand how perceptions of not just children, but the counsellors themselves change over a period of time. Trainees who came in being prescriptive and teacher-like now spend their sessions engaging in friendly banter with the children, making counselling a safe, non-judgmental space. I was interested to know more about the design process that went into the development of POD Adventures and how technology complemented the work of lay-person counsellors.
Pattie explained how increasing mobile phone penetration rates and the challenges of providing counselling to many students in need in schools, culminated in the design of POD Adventures. POD Adventures was developed as a part of PRIDE research programme that aims to develop ‘trans-diagnostic’ interventions (meaning a solution that can be applied for a range of mental health disorders) for school-going adolescents. . The app was built around three problem-solving steps that had been developed and evaluated for use in non-digital intervention formats through PRIDE: (1) ‘Problem identification’; (2) ‘Option generation’; and (3) creating a ‘Do it’ plan. This intervention, she said, is a unique blend of digital innovation and a counselor-led problem-solving model that will help adolescents to both cope with stressors and improve their problems. POD Adventures is delivered during school hours in school-allotted rooms and on devices provided by Sangath. During COVID, the programme was being offered online with telephone support. The app itself is divided in two sections; the ‘Adventures’ section aims to teach problem-solving concepts and methods through contextually-appropriate games while the second part, ‘My POD’ which prioritizes the problems of individual users.
The needs of children from low-resourced backgrounds can differ from those that come from more affluent households, so would such an app and its contents be applicable to them as well?
POD Adventures was developed to meet the rising demand for support faced by the PRIDE team delivering its face-to-face variant of POD in New Delhi. Pattie emphasised that the intervention was designed using a person-centered and co-design approach and for low-resource settings and was contextualised to this setting. The aim was to improve students’ problem-solving skills using a medium that is highly popular among this age group. The spirit of this innovation was collaboration and participation from the students; the goal was to engage the users and get them invested in their own mental health.
Context for Success:
Pattie shared the results of a feasibility study Sangath completed for POD Adventures involving 248 students in 2019-20. The high engagement and satisfaction scores the application received stood out to me. 93% of all students completed all 4 sessions and 97% of students said POD adventures helped solve their problem! I was curious to understand those factors that contributed to the success of the application.
“ Implementing this innovation in a school setting and as a “stress management” intervention also added to high uptake because of a conducive and judgment-free environment where the children received information on its benefits and significance.”
Interestingly, the intervention was framed as a “stress management intervention” as compared to a “mental health” programme. Additionally, by administering the program in schools, Sangath was able to deal more effectively with challenges to uptake such as fear or stigma and access while at the same time providing counsellor supervision. Pattie recognises that implementing such programs outside of the school environment might be more challenging. The focus on self-guided help and counselor-led guidance at an impressionable age are key attributes of this app.
- Digital Innovation: The mode of service delivery was unique at such a wide scale and considering the target group, school-going adolescents. POD adventures used graphic, audio-visual content about mental wellbeing, addressed myths surrounding counselling and provided a framework for problem solving on an easy to use, non-technical platform. These were key attributes of its success amongst adolescents. In fact Pattie mentioned that they found it challenging to accommodate all the children who actually wanted to participate in the programme!
- Non-specialist counsellors: Pattie was quick to point out that the non-specialist counselors working in tandem with the application was crucial to the success of the intervention. When the application was trialed following Covid, with schools shut, the uptake of the application actually fell due to the absence of this in-person guidance. Counsellors play a critical role in bridging the digital divide and blended models saw more referrals, engagement and acceptability. Thus, it was seen that the presence of a counselor-aided in acceptability and uptake.
It’s clear that this unique blend of human and digital components offers a feasible and sustainable solution to improving healthy coping skills and problem-solving attitude early in life. Designing a gamified platform and utilizing existing human capital (or training non-specialist counsellors) also reduces the burden on trained mental health professionals.
“ The POD adventures app allows students to explore issues affecting their mental health on their own. This intervention can be applied in conjunction with a counselor, a lay-counselor, or by themselves, freeing up time for counselors who already are heavily burdened due to staff shortages.”
Lessons, next steps:
The pilot success and high acceptance of this gamefied, self-help application in schools paves the path for further rigorous evaluation and potential scaling up of such digital healthcare models. The increased awareness and cases of self-referral also shed light on the need and demand for mental health care among adolescents. Non-judgemental and personalized care, especially for mental health is needed and can be provided through innovations like POD Adventures. Why then shouldn’t we jump into a full-blown scale up I asked? Pattie however pointed out the limitations of POD Adventures.
Limited trained human capital
The innovation does demand some personnel as the uptake and impact was greater among counselor-assisted users as opposed to only application users. From my personal experience with the problem-solving framework, working through pre-existing biases and behaviour patterns and then modifying them takes a significant amount of time, effort and training and therefore needs to be factored into program timelines and budgets. However, the involvement of lay-counselors also points towards a promising trend of involving non-medical personnel and increasing the reach of mental health care in India.
The digital divide
The need for digital resources such as smartphones and/or internet can be an obstacle in some regions; but with the increasing number of mobile phone users in India, especially among adolescents and young adults, such digital delivery models can prove to be a sustainable option for care integration. The gendered nature of uptake though was not clear through the evidence and would be an interesting trend to monitor.
“Involvement of end-users in the design of any digital intervention is important to make sure that the technology being designed is fit-for-purpose and is acceptable to the audience it is intended for.
We designed the POD adventures app through a collaborative co-design process over 1.5 years to make sure that it was reflective of young people’s context and reality and that they find it engaging and easy to use” – Pattie Gonsalves
The beauty of Sangath’s POD Adventures lies in the simplicity of its POD framework, it’s easy for children to understand, recall and retain. The transferable nature of the POD framework makes it a life-skill that builds resilience and coping mechanisms in adolescents, a skill-set that will take them a long way as well-functioning adults. The means of delivery of the POD framework can be compared to teaching strategy through chess, once you’ve understood the rules and contours of the game, the same set of skills will take you through multiple permutations and combinations of the board itself. POD Adventures, through its engaging user interface will hopefully leave children with an invaluable skill-set that is complemented by a sustainable and truly grassroots approach of non-specialist counselling.
Pattie Gonsalves (Protagonist)
Project Director, Digital Program Development & Evaluation, PRIDE Project · Sangath
Pattie Gonsalves leads a national public engagement initiative “It’s Ok To Talk” (www.itsoktotalk.in) and digital program development for PRIDE , one of the world’s largest adolescent mental health research programmes at Sangath, a mental health research organisation in India .Pattie works in the areas of mental health, public engagement, digital interventions and research to improve adolescent and youth mental health.
Radhika Chhabria (Author)
Social Innovation and Entrepreneurship Catalyst at Swasti
Radhika is a former Teach For India Fellow who went on to study social innovation and entrepreneurship at the London School of Economics. She currently manages Swasti’s school-based wellbeing program that aims to improve the socio-emotional wellbeing of adolescents through the provision of life-skills education and counselling services.