Faith Martin

Improving the quality and safety of community mental health care for children and young people (CYP) is a global public health priority. Mental health problems affect 10%–20% of CYP globally. While many high and low- and middle-income countries (LMICs) face significant structural barriers to accessing safe, person-centred mental health services, there have been innovative developments in service delivery emerging from low resource settings that are pertinent to address quality and safety of CYP mental health services globally. In this paper, we critically review emerging evidence from these contexts to highlight best practices and innovations. We focus on six key domains: task-sharing with non-specialists including peer and near-peer approaches; socio-economic interventions; alternative models of access; advances in routine outcome measurement; developing quality standards; and digital interventions. Through three case studies from Malaysia, Rwanda, and South Africa and other contexts within Sub Saharan Africa and high-income countries (HICs), we demonstrate how locally responsive, contextually appropriate solutions can strengthen mental health services in community settings. We argue for reciprocal co-production in global mental health, positioning LMICs as sources of innovation rather than passive recipients of external expertise. We conclude by discussing how these innovations offer transferable lessons for all contexts and identifying pathways to support their sustainability and scalability.

BACKGROUND Self-harm among children and young people (CYP) is a major public health concern and is associated with increased risk of suicide and ongoing mental health difficulties. Parents frequently play a central role in supporting a young person who self-harms, yet many report experiencing intense emotional distress, uncertainty, and isolation. Despite this, few interventions have been developed specifically to support parents’ own wellbeing. Existing interventions typically involve parents as part of treatments targeting the young person rather than addressing parents’ emotional needs directly. OBJECTIVE This study aimed to develop a digital intervention designed to support the wellbeing of parents of CYP who self-harm using a Person-Based Approach (PBA). METHODS Intervention development followed the stages of the Person-Based Approach. Evidence gathering included using an existing systematic review of parents’ experiences and conducting a novel a systematic review of interventions containing components aimed at improving parental wellbeing in the context of youth self-harm. Qualitative data were collected through interviews, focus groups, and co-design workshops with parents, young people, clinicians, and third-sector professionals to understand user needs and preferences. These findings informed the development of guiding principles and a theory of change. Intervention content was then developed iteratively with input from a parent advisory group and refined through early user feedback. RESULTS The systematic review identified few interventions that explicitly targeted parental wellbeing, with substantial variation in content, delivery, and evaluation. Qualitative findings highlighted parents’ needs for support in managing emotional distress, understanding self-harm, responding to their child, and reducing isolation. These insights informed the development of a modular digital intervention including psychoeducation, strategies for managing parental distress, communication guidance, and reflective activities to support wellbeing. Early feedback from parents suggested that the intervention content was acceptable and aligned with their experiences and support needs. CONCLUSIONS This study describes the development of a digital intervention to support the wellbeing of parents of CYP who self-harm. Grounded in systematic review evidence, qualitative research, and user input, the intervention addresses an important gap in available support for families affected by youth self-harm.

Background: Self-harm (with and without fatal intent) among young people in low- and middle-income countries (LMICs) remain under-researched despite disproportionately high rates. Little is known about the social, cultural, and psychological factors influencing these behaviours in settings such as Rwanda. The study aimed to explore how young people in Rwanda, their parents, and healthcare providers perceive and experience self-harm, including the psychological, social, and cultural factors that contribute to self-harm. Methods: This qualitative study used a phenomenologically informed approach. Semi-structured interviews were held with 102 participants across two districts of Rwanda: Gasabo (urban) and Nyagatare (rural), which have high prevalence of self-harm/suicidality, including young people with and without self-harm experience, parents of young people with and without such experience, and healthcare professionals. Data were analysed thematically, using iterative coding, with triangulation and member-checking to enhance rigour. Results: Five themes emerged: 1) Diverse triggers and reasons—including family conflict, abuse, poverty, peer dynamics, and school-related stress; 2) Build-up of emotional and psychological distress—highlighting feelings of entrapment, isolation, and worthlessness; 3) Functions and characteristics of self-harm, ranging from emotional regulation to communication of distress; 4) Maintenance and cessation, showing the role of coping strategies, social support, and barriers to seeking help; and 5) Duality of community responses, where community responses both exacerbated stigma and provided support. Self-harm was shaped by cultural beliefs, stigma, family and social structures, and poverty, challenging individualistic framings of self-harm. Reflexive insights highlight the importance of team communication during cross-cultural research and provide practical strategies. Conclusions: Findings extend existing psychological theories by evidencing culturally embedded pathways to youth self-harm, where distress is produced and sustained through a mixture of individual experience, structural hardship, social exclusion, and cultural belief systems. Effective prevention requires cross-sectoral strategies addressing poverty, education, family support, and community mental health. Community-based approaches fostering emotional expression and reducing stigma could play a crucial role in prevention and recovery. The insights generated are transferable to other LMICs facing similar social and structural challenges.

Question: What are the experiences and needs of parents of children and young people (CYP) aged 5–18 with diagnosed mental health difficulties, particularly in relation to the parents’ own well-being? Study selection and analysis: A systematic review with thematic meta-synthesis was conducted, including qualitative studies published in English. Seven databases were searched (MEDLINE, PsycINFO, CINAHL Ultimate, AMED, EMBASE, Web of Science and Cochrane Library) from inception to September 2024. Studies focused on parents of CYP aged 5–18 years, where the CYP had a confirmed mental health diagnosis. Findings: Of 75 862 screened studies, 46 met inclusion criteria. Six overarching themes were identified: support needs and gaps; impact on everyday life; altered family dynamics; parental worries and fears; emotional experience of caregivers and self-care paradox. Parents face significant challenges, including unmet support needs from healthcare and education systems, substantial impacts on daily life and altered family dynamics. Emotional experiences such as worry, guilt and stigma were pervasive, compounded by systemic gaps in information and resources. Parents often prioritise their child’s needs over their own, creating barriers to self-care. These challenges were consistent across diagnoses but heightened in cases of life-threatening conditions like eating disorders and depression. Conclusions: The findings highlight support needs for parents of CYP with mental health difficulties. Tailored interventions, better professional training and family centred care are needed. Future research should focus on developing theoretical models of parental distress to guide interventions and inform support mechanisms that mitigate these broad impacts on parents’ well-being.

Introduction: Sub-Saharan Africa bears the greatest burden of HIV, with comorbid mental conditions highly prevalent in people living with HIV. It is important to evaluate the mental health of adolescents and young adults living with HIV (AYALHIV) comprehensively by measuring both negative and positive psychological constructs. There has been a proliferation of interest in positive psychological outcome measures, but the evidence of their psychometric robustness is fragmented. This review sought to: 1) Identify positive psychological outcomes and corresponding outcome measures used in AYALHIV in sub-Saharan Africa. 2) Critically appraise the psychometrics of the identified outcome measures. Methods and analysis: Two reviewers independently searched articles in PubMed, Scopus, Africa-Wide Information, CINAHL, Psych INFO and Google Scholar. Searches were conducted from November 2022 to February 2023. Two separate reviewers independently reviewed retrieved articles. We applied a narrative synthesis to map the key constructs. The risk of bias across studies was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. The quality of the psychometric properties was rated using the COSMIN checklist and qualitatively synthesized using the modified Grading of Recommendations Assessment, Development, and Evaluation checklist. Results: We identified 15 positive psychological constructs: body appreciation, confidence, coping, flourishing, meaningfulness, personal control, positive outlook, resilience, self-management, self-compassion, self-concept, self-efficacy, self-esteem, self-worth and transcendence, that had been used to assess ALHIV. The most measured constructs were resilience, self-concept, self-esteem, coping and self-efficacy. Construct validity and internal consistency were the properties most frequently considered, while content validity and structural validity were assessed less often. Conclusions: Few studies performed complete validations; thus, evidence for psychometric robustness was fragmented. However, this review shows the initial evidence of the feasibility of using positive psychological outcomes in low-resource settings. Instead of creating new outcome measures, researchers are recommended to leverage the existing measures, adapt them for use and, if appropriate, strive to maintain the factorial structure to facilitate comparisons. Registration: PROSPERO-CRD42022325172.

Background: Self‐harm in children and young people is increasing. Parents are vital in supporting young people; however, parents may experience distress linked to the self‐harm. Previous reviews have highlighted the emotional impact and need for information and support, however, have not elucidated the relationships between these themes, nor examined the quantitative data examining parents' well‐being. Methods: We conducted a mixed methods review, with qualitative meta‐synthesis focusing on links between themes and quantitative synthesis of parental well‐being findings, including pooled means. PsycInfo, Medline, EMBASE, AMED, CINHAL and Web of Science were searched to identify relevant records. References of included studies were also searched. Every abstract was screened by two authors. Data were extracted by one author and checked by another. Results: We identified 39 reports of 32 studies: 16 with qualitative data and 17 with quantitative data (one had both). Qualitative findings showed how parents' emotions were associated to their knowledge and beliefs about self‐harm. Parents' emotions often evidenced the need to self‐care, but emotions of guilt reduced engagement in self‐care. How parents supported their young person was linked to their knowledge, and the management of their own emotions, and influenced if they could engage in self‐care. Quantitative findings were mixed, however suggested poor general mental health amongst these parents. Conclusions: Further good quality quantitative studies are needed, with measurement of psychological mechanisms that may underpin parental distress. Current evidence supports peer‐support and interventions that go beyond information provision to address the connected factors of knowledge, emotion, self‐care, and parenting behaviours.

Question: Depression and anxiety are common among children and young people and can impact on the well-being of their parents/carers. Dominant intervention approaches include parent training; however, this approach does not directly address parents’ well-being. Our objective was to examine the effect of interventions, with at least a component to directly address the parents’ own well-being, on parents’ well-being outcomes, including stress, depression and anxiety. Study selection and analysis: A systematic search was performed in the following: MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Scopus, CENTRAL, Web of Science Core Collection (six citation indexes) and WHO ICTRP from inception to 30 December 2023. Interventions that aimed to support parents/carers managing the impact of their child’s/young person’s mental health were eligible. EPHPP (Effective Public Health Practice Project) was used to quality appraise the included studies. A meta-analysis of relevant outcomes was conducted. Findings: Fifteen studies were eligible comprising 812 parents/carers. Global methodological quality varied. Seven outcomes (anxiety, depression, stress, burden, self-efficacy, quality of life and knowledge of mood disorders) were synthesised at post-intervention. A small reduction in parental/carer anxiety favouring intervention was indicated in one of the analyses (g=−0.26, 95% CI −0.44 to –0.09, p=0.02), when excluding an influential case. Three outcomes were synthesised at follow-up, none of which were statistically significant. Conclusions: Interventions directly addressing the well-being for parents of children with anxiety and/or depression appear not to be effective overall. Clearer conceptualisation of factors linked to parental distress is required to create more targeted interventions. PROSPERO registration number: CRD42022344453.

Question For parents of children and young people (CYP) with diagnosed mental health difficulties, what are the levels of parents’ well-being and psychological need? Study selection and analysis Medline, PsycINFO, EMBASE, AMED, CINAHL, Web of Science and Cochrane Library of Registered Trials were searched from inception to June 2023. Inclusion criteria: parents of CYP aged 5–18 years with formal mental health diagnosis. Data were extracted from validated measures of well-being or psychological needs with established cut-off points or from a controlled study. Findings 32 of the 73 310 records screened were included. Pooled means showed clinical range scores for one measure of depression, and all included measures of anxiety, parenting stress and general stress. Meta-analyses showed greater depression (g=0.24, 95% CI 0.11 to 0.38) and parenting stress (g=0.34, 95% CI 0.20 to 0.49) in parents of CYP with mental health difficulties versus those without. Mothers reported greater depression (g=0.42, 95% CI 0.18 to 0.66) and anxiety (g=0.73, 95% CI 0.27 to 1.18) than fathers. Narrative synthesis found no clear patterns in relation to CYP condition. Rates of parents with clinically relevant levels of distress varied. Typically, anxiety, parenting stress and general stress scored above clinical threshold. Quality appraisal revealed few studies with a clearly defined control group, or attempts to control for important variables such as parent gender. Conclusions The somewhat mixed results suggest clinical anxiety, parenting and general stress may be common, with sometimes high depression. Assessment and support for parents of CYP with mental health problems is required. Further controlled studies, with consideration of pre-existing parental mental health difficulties are required. PROSPERO registration number CRD42022344453.

Introduction: Sub-Saharan Africa bears the greatest burden of HIV/mental disorders combined. It is important to evaluate the mental health of adolescents and young adults living with HIV (AYALHIV) comprehensively by measuring both negative and positive psychological constructs. There has been a proliferation of interest in positive psychological outcome measures, but the evidence of their psychometric robustness is fragmented. This review sought to: Identify positive psychological outcomes and corresponding outcome measures used in AYALHIV in sub-Saharan Africa Critically appraise the psychometrics of the identified outcome measures Methods and analysis: Independent and blinded reviewers searched articles in PubMed, Scopus, Africa-Wide Information, CINAHL, Psych INFO, and Google Scholar. Separate independent reviewers screened the retrieved articles. We applied a narrative synthesis to map the key constructs. The risk of bias across studies was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. The quality of the psychometric properties was rated using the COSMIN checklist and qualitatively synthesised using the modified Grading of Recommendations Assessment, Development and Evaluation checklist. Results: We identified 15 positive psychological constructs: body appreciation, confidence, coping, flourishing, meaningfulness, personal control, positive outlook, resilience, self-management, self-compassion, self-concept, self-efficacy, self-esteem, self-worth and transcendence that had been used to assess ALHIV. Resilience, self-concept, self-esteem, coping and self-efficacy were the most measured constructs. Construct validity and internal consistency were the properties most frequently assessed, while content validity and structural validity were assessed less often. Conclusions: Few studies performed complete validations; thus, evidence for psychometric robustness was fragmented. However, this review shows the initial evidence of the feasibility of using positive psychological outcomes in low-resource settings. Instead of creating new outcomes, researchers are recommended to leverage the existing measures, adapt them for use, and, if appropriate, strive to maintain the factorial structure to facilitate comparisons. Registration: PROSPERO-CRD42022325172