Design, development and pilot evaluation of POD Adventures, a digital game-based intervention to improve adolescent mental health in schools in India

Mental disorders are a leading cause of disability among adolescents worldwide. Despite growing evidence for effectiveness psychosocial interventions, most adolescents do not receive appropriate mental health support, especially in low-and-middle-income countries (LMICs). Digital mental health interventions are increasingly being promoted as an important platform to deliver and scale up mental health care for adolescents with the potential to increase reach and reduce stigma and costs as compared with clinic-based service models, especially in lowresource settings. The present thesis incorporated three studies aimed at developing and evaluating ‘POD Adventures’, a smartphone-delivered digital intervention for common adolescent mental health problems in India. Study 1 comprised participatory qualitative research (N=118 adolescents; N=8 service providers) intended to co-design a game-based problem-solving intervention for school-going adolescents with or at risk of experiencing anxiety, depression and/or conduct difficulties. Results informed the specifications of ‘POD Adventures’ as an open-access, smartphone-enabled, low-intensity intervention for adolescents with a felt need for psychological support. Delivery was endorsed in a guided format, i.e., the POD Adventures app accompanied by brief lay counsellor guidance. Study 2 used a mixed-methods pre-post cohort design (N=248) to evaluate the feasibility and acceptability of the POD Adventures intervention, and to explore the effects of the intervention on self-reported mental health symptoms, prioritised problems, stress, and well-being. Results showed high completion and satisfaction rates and that the intervention was associated with large improvements in problem severity and mental health symptom severity. Findings also showed 9 that POD Adventures was feasible to deliver with guidance from lay counsellors and that the participants were satisfied with the guidance provided. Study 3 was originally planned as a full-scale randomised controlled trial (RCT) but was modified due to local COVID-19 school closures. The modified study comprised a pilot feasibility RCT of POD Adventures (N=11) when remotely delivered with telephone guidance from counsellors. The study aimed to assess whether the feasibility and acceptability of POD Adventures would be replicated when delivered online with remote telephone-based support. The study also aimed to generate preliminary effect size estimates for use in designing a full-scale trial. Despite modifications made to conduct the study online, this format of intervention delivery was not feasible in the study context. It was concluded that the biggest barriers may have included difficulties accessing the online research procedures, the remotely delivered intervention delivery or a combination of both, which may have been exacerbated by the ongoing COVID-19 pandemic conditions at the time. Overall, results across the three studies illustrate the role and opportunity that context-specific digital interventions offer in providing early intervention support to school-going adolescents with a felt need for psychological support in low-resource settings.