Introduction

Mental health disorders are one of the leading causes of burden of disease worldwide and their prevalence is rising. In 2016, it was estimated that they affected more than 1 billion people and were responsible for 19% of all years lived with disability [1]. More concerning, is their impact on the youth; globally, it is estimated that approximately 10–20% of children and adolescents are affected by mental health disorders [2, 3]. This may be due to the intrinsic vulnerability of children and adolescents to mental health problems resulting from key biological, psychological and social changes that affect individuals during this period [4]. Despite their prevalence, the mental health needs of children and adolescents are often overlooked, particularly in Low and Middle-Income Countries (LMICs) [2].

Colombia is an upper middle-income country with a history of armed conflicts, forced internal displacement and violence that has significantly impacted the lives of its population [5]. Consequently, some attempts have been made to give special attention to the mental health needs of Colombian adolescents in recent years [6, 7], however the impact of this endeavor is poorly studied. According to the National Mental Health Survey (ENSM-2015) the prevalence of any mental health disorders in adolescents between 12 and 17 years old was 7.2%, with anxiety and affective disorders being the most frequent [8].

To help address the considerable impact of mental health disorders, different interventions have been developed which aim to improve a range of health outcomes. Patient involvement in the development of interventions has gradually gained importance in research and in clinical practice [9], especially due to evidence suggesting that patient-centered interventions may improve quality of life and enhance adherence to treatments [10, 11]. Although, most studies involve adult individuals, some studies suggest that patient-centered interventions in youth populations -allowing active involvement in the decisions of their health care- improve symptoms and provide greater overall satisfaction too [12, 13]. Shared decision-making may increase adolescent engagement because with this approach, the patient and clinician work together as a team and trust is improved [14]. Additionally, the use of technology can make interventions that are aimed at young people more appealing due to greater access and more engaging and interactive content. Furthermore, the use of certain mental health intervention applications (or apps) has been positively received by adolescents, carers and clinicians in some settings [15].

The aim of this study is to explore the views of adolescents, parents, teachers, and clinicians regarding an existing patient-centered digital intervention called DIALOG+, as well as our experience involving young people as an active part of our research. DIALOG+ is a patient-centered intervention mediated by an app that focuses on structuring communication between clinicians and patients, offering a solution-focused approach [10, 16, 17]. The use of this intervention has evidence of effectiveness in adults in the United Kingdom, where improved Subjective Quality of Life scores, psychopathological symptoms and social outcomes were evidenced at follow up [16, 18]. Some of the strengths that the DIALOG+ intervention offers, in addition to a straight forward interface, is the structured nature that it gives to a routine consultation as well as the focus that it gives to the patients self-reported needs. This, added to the positive experience with adult populations, makes it a strong intervention to test with a different patient group like adolescents and in a different context like Colombia.

The intervention assesses 11 key life topics or domains, eight life-related (mental health, physical health, job situation, accommodation, leisure activities, partner and family, friendships, personal safety) and three treatment-related, (medications, practical help, and meetings with mental health professionals). The clinician asks the patient to rate their satisfaction in each of these domains on a scale of 1 to 7, where 1 is ‘completely unsatisfied’ and 7 ‘completely satisfied’. Domains and their descriptions can be found in S1 Table in S1 File [18]. After each question, the patient is asked if they require any additional support in that particular area of their life. This gives the clinician valuable information on the priorities and/or preferences of the patient. Following a review of the 11 items, up to three are then jointly selected by the patient and clinician. A 4-step approach, based on the principles of solution-focused therapy is used to address the patient’s concerns and agree on further actions. with a four-step approach based on brief solution focused therapy used to address the patients concerns. The process allows the clinician to give tailored assignments that target specific domains that are in need of improvement, which are then discussed in future consultations.

This paper focuses on the initial impressions of the DIALOG+ intervention, as a new intervention to improve adolescent mental health in this context. Specifically, it will indicate which aspects of the intervention do and do not appeal to adolescent users and other stakeholders. Investigating stakeholders’ views on the initial appeal and acceptability of the intervention will assist with adaptation and implementation.

Methods

This qualitative study was conducted within the context of a larger project called “Building Resilience in Adolescence -improving quality of life for adolescents with mental health problems in Colombia” (BRiCs) which aims to improve outcomes for adolescents with depression and/or anxiety in Colombia. The project was a collaborative research project between Queen Mary University of London, UK and the Pontificia Universidad Javeriana (PUJ) in Bogotá.

In order to adapt this intervention to the Colombian adolescent population and their context, we conducted Online Focus Groups (OFGs). This allowed us to obtain the perspectives of users, key stakeholders and gatekeepers (parents/guardians, youth workers and educators) regarding the appeal and usability of the intervention.

The OFGs were conducted between June and November of 2020 and were initially planned to take place as traditional face-to-face focus groups. However, the sudden surge of the COVID-19 pandemic caused a state of emergency in Colombia in March 2020 and subsequent lockdown and physical distancing measures were imposed. In order to continue the research, an ethics amendment was requested to change the Focus Group (FG) methodology from face-to-face to synchronous OFGs through a videoconferencing platform (Microsoft teams^®). Changes to the research protocol were approved by the Institutional Review Board (IRB) of both academic institutions and clinical settings (Protocol FM-CIE-0084-20).

Results

We conducted 10 OFGs with a total of 45 participants. Throughout all of the OFGs, the majority of participants (77% n = 35/45) were female. Details on the sociodemographic characteristics of participants can be seen in Table 1.

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Table 1. Sociodemographic characteristics of participants.

https://doi.org/10.1371/journal.pone.0272066.t001

A total of 13 adolescents participated, the mean age of this group was 16 years old and the majority were enrolled in middle school at the time. Mental health problems, in particular anxiety and depression, were investigated in the adolescent population. The majority of participants reported having experienced mental health disorders: 4 reported having both disorders, 4 reported having only anxiety and 4 having neither. Depression without anxiety was only reported by one participant.

Information was collected on the time (in years) of working with adolescents for clinicians and educators/youth workers. Educators/youth workers had more experience (MED = 10, IQR = 7.2, 15.2), working with adolescents than clinicians. Clinicians had the highest educational level.

The parents/guardian’s group had the highest mean age and the lowest educational level, with only 2 participants with college education.

In order to assess the initial impressions of the intervention, we divided participants views into positive features or appeal (strengths and benefits of DIALOG+) and potential barriers. In the latter, the views of participants on four different categories (privacy and patient-physician relationship, time and connectivity, interface and terminology and additional categories) are shared.

Discussion

The feedback obtained with the OFGs suggest that overall, the intervention and app are seen as acceptable, innovative and have appeal to adolescents as well as adult stakeholders. However, concerns were raised about the availability of time to apply the intervention during a standard consultation, the app interface and the language and terminology used. Additionally, new categories that were considered important to adolescents, such as, school environment and academic performance were suggested.

In line with international organizations, such as, the World Health Organization (WHO) and previous research, this study demonstrates the importance of engaging end-users in the adaptation and development of digital mental health interventions [22]. Overall, the implementation of a patient-centered digital intervention was well received by adolescents, clinicians and stakeholders alike, which is consistent with findings from other studies [23–26]. The incorporation of technology during consultation is particularly appealing to young people who are more likely to be familiar with digital devices and the internet in general [27].

Consistent with the most recent Lancet Commission digital technologies [28], this paper supports the importance of digital health in increasing the access to evidence-based interventions specially in a LMIC setting. In order to make digital interventions widely available in these contexts, it is important to test the use of tools that are already available in different settings and for different age groups. Additionally, in order to make digital interventions relevant a participative process is needed where end users could express their ideas, needs and requirements [26].

The structured nature of DIALOG+ was considered useful by adolescents because it gave them an opportunity to recognize emotions and feelings in an easier way. Also, clinicians felt that they could identify problems in a direct manner with the benefit of knowing the main concerns and priorities of their patients. A key element that is mentioned in the literature regarding technology-mediated interventions in general, is their ability to empower patients by giving them an active role in their mental health, which also makes them more likely to engage in the process [29–31]. Participants considered that DIALOG+ also offered this empowering characteristic because it allows them to express their feelings and what they want to improve.

As expected, however, there are several aspects of the DIALOG+ app and intervention that can be improved and tailored to be more suitable for the adolescent population.

Firstly, the app was considered slightly cold and serious. In order to increase user friendliness and engagement on any app, an appropriate interface and use of language are crucial [9, 21]. Participants suggested modifications that would increase interactivity, such as adding images or symbols to each key life topic, personalization of the app according to age and making it more vibrant and colourful. All of these have been commonly used in other mental health apps [32].

Regarding terminology and language used, participants suggested different modifications. These were considered necessary to clarify the life domains and to avoid misunderstandings. A brief description of what each category is aiming to ask, could be added as a “pop-up” to minimize confusion as suggested by some clinicians. Specifically, we consider that the Spanish translation of “personal safety” could be modified to “environmental safety” (seguridad en el entorno) since most participants were confused by its meaning. This modification makes the objective of the category clearer, both for the clinician and the adolescent. Similarly, all participants were especially confused by the category “Practical help”. The latter aims to inquire about the resources available to support the patient (government aids, requirement of wheelchair/equipment or any other assistances) [18], but in Colombia these are scarce which makes the category confusing. Therefore, we consider that a modification to “external aids” (ayudas externas) could be helpful.

A specific modification discussed by adolescents in our OFGs, was to include a “not-applicable” response to the 1 to 7 grading scale system. This was considered important for categories that may not apply to some adolescents due to their age and for categories where the adolescent does not wish to provide an answer. According to them, a clear option that allows the adolescent to avoid answering any category or question is crucial to recognize their autonomy [14, 29]. Adolescents also underscored the central role of clinicians in making them feel at ease sharing their experiences without feeling judged or lectured. Thus, the confidence in the use of the intervention as well as the clinician’s ability to convey trust and comfort is vital.

To apply the DIALOG+ intervention in an efficient but thorough manner, clinicians must be familiar with the app so that they feel at ease using it. However, even if clinicians agreed on the importance of thoroughly knowing the app and all its functions, the time availability to apply the intervention was considered a major barrier for uptake. In the Colombian context medical visits are usually limited to 20 minutes, this was considered insufficient to perform a traditional consult and the DIALOG+ intervention. The discussion of sensitive topics related to mental health is time consuming and addressing them in a fast-paced manner would be counterproductive, particularly for adolescent populations, where the aim is to create trust and improve health outcomes.

The addition and modification of the existing domains may be relevant to adapt the DIALOG+ intervention to the needs of Colombian adolescents. Two main modifications stood out, 1) dividing the “partner/family” domain into two separate ones and, 2) including a school and academic life domain. Both were considered essential by all participants since they relate to key aspects that are particular to the mental health of adolescents. The first one was considered given that adolescence is generally the initial period of sexual exploration and it has been reported that the discussion of sexuality between physicians and adolescents is generally insufficient or lacking [33].

Despite the consensus that for adolescents the domains “Job situation” and “Housing” were strongly related to their parents or guardian’s socio-economic status, most of the participants considered that these aspects frequently affect the well-being of any adolescent and thus should remain on the app. It is important to notice that these two domains may have gained relevance after the onset of the COVID-19 pandemic, because of the impact on household income in general and how it has increased poverty and inequality in Colombia [34].

Since pharmacological treatment is seldom used for adolescents with depression and/or anxiety and limited to severe cases where psychosocial interventions were unsuccessful [35], treatment-related categories such as, “practical help” and “medication” would predominantly apply to adolescents with chronic diseases or physical disabilities. We believe that these categories are important to keep, to promote inclusion of a marginalized group, even if these conditions are not highly prevalent during adolescence [36]. These two categories could be grouped under a category of “professional accompaniment” as suggested by participants.

Other aspects of adolescent life were suggested as individual domains. However, some of them can be examined on the already existing domains. For example, the discussion on career projects or future plans that older adolescents experience could be addressed under the domain that includes their academic or school life. Also, aspects regarding the “body image” category and beauty standards, could be included under the “physical health” domain, where questions on body image and self-perception are asked. Finally, the use of social networks and internet as well as the use of substances could be explored when the “friendships” domain is evaluated.

Ultimately, the data obtained provided valuable insight into the areas of DIALOG+ that are susceptible to modification in order to correctly adapt this intervention to the context of Colombian adolescents. Perhaps in the long run the DIALOG intervention could become routinely used in the clinical practice as part of the mental health evaluation of the Colombian youth in order to improve their outcomes, and our experience may facilitate its adaptation into other LMIC countries.

Barriers to the implementation of this type of interventions have to be taken into account since these are often shared by LMIC such as a lack of digital literacy, limited connectivity and access to technology, and availability of time during a consultation in order to properly apply this intervention.

Limitations

Performing OFG due to the physical distancing required by the COVID-19 pandemic meant that participants not only had to have access to a digital device, but also have a high enough level of computer literacy with a stable internet connection. These characteristics are not predominant in a LMIC like Colombia. Additionally, OFGs were performed with participants from two urban areas of Colombia. Therefore, these findings may not be representative of adolescents, clinicians and stakeholders from rural settings.

Conclusions

Overall, the use of a technology-based intervention was perceived in a positive manner by all participants, and they considered that it might enhance the relationship between physicians and adolescents in the context of primary health care in Colombia. Modifications of language in order to clarify the objective of the intervention and to assess the adolescent’s reality in a more accurate way should be considered. Additionally, making the interface more interactive can make the intervention more approachable and less intimidating to the adolescent. The limitations of time during consultations are a major issue that have to be taken into account as well as the parent or guardian presence during the session.

Supporting information