A total of 30 qualitative interviews in Pakistan (n = 19) and India (n = 11) were conducted between 28 Dec, 2020 to 9 Jan, 2021 and 12th November to 28th December 2020 respectively.
The mean age of the study participants was 20.6 (± 2.99) years. About 70% (24/30) of the participants were young females. Only 21% (4/19) participants in Pakistan were seeking psychiatric care services for their emotional problems. The characteristics of the participants are presented in Table 1. The average duration of the interviews was between 55 (± 7) minutes in both sites.
Table 1
Characteristics of study participants (N = 30)
Variables | f (%) |
Age in years (M[SD]) | 20.6 [2.99] |
Gender | |
Female | 22 (70%) |
Male | 8 (30%) |
Education | |
Matriculation (grade 10) | 2 |
Intermediate (grade 11–12) | 3 |
Undergraduate (grade 13–14) | 25 |
Currently seeking outpatient psychiatric care services | |
Yes | 15 (50%) |
No | 15 (50%) |
Perceived sources of stress, anxiety and depression in young people in India and Pakistan
Qualitative consultations with young PWLE identified several social and family factors as perceived sources of stress, anxiety and depression in young people. At the social level, unrealistically high expectations of society from young people; financial constraints and lack of employment opportunities for youth in their countries were identified by participants as contributing to mental health concerns. Further, a significant contributing factor was the impact of the COVID-19 pandemic, which, in addition to creating psychological stress, was also seen contribute to mental health problems by limiting contact with schools and social supports. “I feel like these problems are at their peak right now because it is really difficult for some young people to get out of that (situation). They don't have like an escape; when school/colleges were open, youth went there and found an escape that way but now I feel like they have to face their problems (at home) because they don’t have an escape from it.” (Female, 22; Pakistan)
Across both countries, participants noted that stigma was a contributor to youth mental health problems. “I think the barriers we face are first of all the stigma surrounding mental health. Even though I think it's starting to change a little bit. I don't think that change is coming fast enough or intensely enough. (Female, 21, India). Stigma and lack of awareness about youth mental health problems were described as a self-perpetuating cycle, driving underreporting of concerns and undermining service access, which in turn prevented these problems from being recognised and addressed on a broader scale. “In Pakistan, the issue of mental health among youth cannot be quantified accurately because many young people cannot access the mental health doctors and facilities to address their mental health problems. There are many people who suffer from mental illness, but they do not have services or they don’t access the mental health doctors.” (Male, 21; Pakistan)
On the contrary, participants reported that social media dialogue about mental health problems is helping to raise awareness, but the information was perceived to be ‘unreliable’ and there is misconception about manifestation of mental health illnesses due to which sometimes people overrate normal emotional reactions as mental health problems. "I guess now people have awareness about it through social media and other platforms; we see posts about it, and mostly people know about it. There is now so much information out there that people confuse their emotions with mental illness. If anyone feels stressed during a stressful period, then they think they are having an anxiety disorder. Because so much awareness is spreading all over the world, but this information is not from a proper authentic resource or from a therapist, people are confusing their periods of stress or sadness with mental illness. They are not able to see a line between normal emotions and mental illness." (Female, 15; Pakistan)
At the family level, participants identified pressure from family members and poor family relationships as important contributing factors to mental health concerns. Specifically, unrealistic academic demands were highlighted as a risk factor for causing stress in young people. Poor communication among family members further contribute to escalate the stress among young people. “…families should not pressurize children about their grades as students know the impact of good and bad grades on their future. Parents should let their children study what they want to study. Most families force children to study science, however, most of the children have an interest in the arts so they feel forced to study sciences... So, one should not pressurize them in that way”. (Female, 16; Pakistan). Stigma was also described as negatively affecting young people’s capacity to disclose mental health concerns within their family. "In our community, we don't really talk about mental health, if you talk about someone’s mental health, people would be like, oh, this guy might be too weak as a person, and his condition might not be considered a real issue. People just think that it (mental illness) is just something you make up in your mind. Like, people might be uncomfortable talking about (mental health) with other people, including their own parents" (Female, 24; India). Many participants perceived “suppression of emotions” as a cause of stress in young people.
Views about addressing youth mental health problems in Pakistan and India
Participant’ perspectives on how to effectively address mental health problems in young people also reflected the need for multiple levels of intervention. At the individual level, having positive characteristics of self-awareness such as being able to rely on oneself to manage one’s own life (‘self-reliance’) and being aware of ones’ own actions were considered important for self-improvement (‘agency’); to build a positive self-image and to positively promote mental health in young people. "You have to have self-discipline in your life. You need to organize what you want in your life, what you want to achieve, how you want to feel, what you want to have in your relationships, have self-discipline, and know what you want........And when I say self-discipline, I mean organize your life; you know what you need to achieve, make plans for it, and go by your plans like making future plans. I think you can achieve whatever it is, no matter what goal it is. No matter if it’s a health goal or a social goal, whatever it is, you need to break it down, make a mind map, go by it, and execute the plan that will prevent so many problems in your life." (Female, 24; Pakistan). In both countries, increased physical activity in young people was also highlighted as an individual protective factor.
Both in India and Pakistan, the role of immediate family support was emphasized. "First of all, from very childhood, the child’s upbringing should be in such a manner that the child should be comfortable within the family and parents to discuss the problems. When young people keep problems to themselves, it results in mental health issues” (Male, 21; Pakistan). Having healthy relationships with parents, specifically having an open and good communication among family members and less academic pressure from parents on youth, was identified as protective factor to promote positive mental health in young people. However, invalidation of young people’ feelings by immediate family members was highlighted as a risk factor for youth mental health illness. So, I really think that the first step is to just understand that it's okay to be mentally ill. And it's the same as being physically ill” (Female, 21; India). Having a strong support network consisting of family and friends has been identified as having a positive influence on young people’s wellbeing, as it provides an avenue for sharing problems and fosters a sense of belonging and support.
Young people reported that raising mental health awareness and addressing mental health stigma among immediate family is important as parents lack the knowledge on youth mental health problems and are not aware of how to help young people to deal with emotional challenges (that are often characterized as ‘dramatic’ ‘unreal’ and ‘self-created’ by the parents and the family) and this sometime lead to non-recognition of emotional problems in young people. In India, one participant highlighted lack of mental health awareness among older generations as a barrier to young people receiving adequate support.
Another barrier is that older generations such as families and teachers are not willing to understand and accept these problems. “So, education on mental health literacy for not only the youth but also for the older generations can help the youth feel better” (Female, 20; India).
Many young people reported having ‘someone to talk to’ and ‘being able to talk about one’s own feeling’ is the single most important factor to protect against developing distress in young people. Role of peers was frequently reported to be important in this regard. “I guess the important thing is that there is someone who is always there for you to talk to, whether it's a family member, a friend, or a therapist or anyone else, so at least there is someone to talk to and say everything that is going on with you without being judged (Female, 20; India).”
The role of social media was reported as “double-edged sword”; where on one hand social media usage was perceived to be helpful in raising mental health awareness among communities, its excessive use was identified as a potential risk factor that is negatively impacting young people’s self-worth and wellbeing by creating ‘unrealistic expectations from life’. At the school level, helping young people to build their character and teaching them life skills were considered important to promote mental health in young people.
In both countries having an employment opportunity for them were also highlighted as protective factors. There was an expectation that it is the government responsibility to “organize extra-curricular activities at school or community” levels and “offer employment opportunities” to young people to promote positive mental health.
How to address mental health problems in youth
All young people reported ‘active ingredients’ as relatable, valid, comprehensive, and helpful to prevent and treat youth anxiety and depression. There was an enthusiasm in young people to learn more about AIs initiative. Young people in India described Active Ingredients as anything (‘small components’) that can help young people to feel good, keep them mentally stable and promote positive mental health in young people.
Improving social connection and relationship: For most of the young people, increasing social connections and improving social relationships (i.e., strengthening healthy relationships with family members) was highlighted as the most important AI. According to young people, youth in Pakistan live in a collectivistic culture that values family cohesion, solidarity, cooperation and good social relations, therefore social cohesion can positively impact the mental health of young people. Also, due to increased social isolation and loneliness because of pandemic and COVID-19 pandemic, the need for more positive social interaction was highlighted as an integral component to promote positive wellbeing. One young person (24, Male) from Pakistan said: “I think that social relationships will be very high on my list as social relationships are very important, especially from a Pakistani perspective where our society and our family units are more cohesive, there's a greater degree of co-dependence and that might seem like a hindrance, at times, but in times of crisis like if you can leverage your social networks, people will mobilize to help you if they know that you need help and if they understand the importance of what you're saying. “
Improved management of emotions. Participants highlighted that management of emotions was important given the socialisation of emotion in India and Pakistan. According to one participant (Female, 16; Pakistan): Young people should learn skills to manage their emotions. They don’t know how to regulate their emotions and express them because, in our society, expressing emotions is considered wrong, which is also a cause of depression and anxiety. Our society portrays that strongmen or boys don’t cry, their feelings can’t be hurt, and these are all wrong things. People should understand that apart from being men or boys, they are humans, they have emotions, and they can express them. If someone shows their emotions, people degrade him so much that he starts to think that he did something wrong."
According to another participant (18, Female; India):
"We never talk about what our emotions are and how we feel. We don't know how to manage things (emotions). If I was taught how to cope with stress and that stress is normal, then I wouldn't have had panic attacks."
Better stress response by relaxation. Many young people regarded relaxation techniques as simple, easy and effective and highlighted to be taught in schools to promote positive wellbeing in young people.
"Relaxation techniques should also be implemented; these techniques should be done especially in schools, universities, and colleges. I think private schools are now focusing on these. They should take the initiative to focus on these more.” (Female, 22; Pakistan)
Some Indian respondents mentioned better stress response by relaxation as an available resource which is an integral characteristic of an AI:
"I think an important characteristic of an active ingredient is its availability. If it's something like relaxation or sleep, if you're doing a job where you don't have time to relax or sleep, then what are you going to do? So that's important. I think it doesn't have to be something that you need to buy." (Female, 21; India)
Access to urban green spaces. Young people highlighted that, in South Asian culture, female adolescents have far less access to green spaces compared to male adolescents. Access to green spaces is a novel and important component that is underutilized currently; however, can be considered crucial for the prevention of mental health problems in adolescents.
Along with these, green spaces and neighbourhood cohesion are very important for prevention because I have personally felt that the mind feels fresh while seeing the greenery or natural environment; we get a sense of recess or feel easy, even though working in a close room feels like a depressive environment to me, and I get a fresher feeling by seeing the sunlight of the day. (Male, 21; Pakistan)
Although I really want to go to the park every evening and enjoy green spaces, you know that females cannot go outside alone because of security reasons. Parents are afraid of sending us alone without a brother (Female, 21; Pakistan).
Least likable AIs
Active ingredients that aligned with the way that young people understand their mental health were more likely to be perceived as relevant (such as social relationships and improved management of emotions), while AIs that did not work for them in the past or they were not aware of were consistently rated as the least preferred (such as anti-depressants and cash transfers). Young people spoke about personal experience as the dominant factor in guiding their decisions about which Active Ingredients were likely to be most helpful for them. Personal experience was either their own experience of what had worked or not worked for them in the past or the experiences of close friends and family members who suffered from mental health problems.
Missing components in the current AIs list
Role of family and parenting
Family-based and parenting components were described as an important missing AIs by young people in both countries. It was emphasised that parenting and family-focused programs are particularly important in the South Asian culture. Maintaining healthy boundaries and developing effective communication with parents and other family members was considered important to positively influence mental health of young people.
A 21-year-old female from Northern India highlighted that the importance of parenting and family interventions:
"The effects of parenting on youth are profound- especially in the context of India, because our lives are so intertwined with them. [Young people] need help figuring out how to create healthy relationships with [their families] or to learn how to create boundaries. [They] need to create boundaries, not just with their parents but with everyone, especially with Indians, because our culture is so friendly and interdependent, that we don’t know how to draw the line. This is really, really important—learning how to say no, respecting your own capabilities and limits, and knowing where to stop.” (Female, 21; India)
Multiple pathways were highlighted through which family and parenting interventions may influence mental health of young people, including reducing risk factors such as parent mental health problems and child maltreatment, increasing protective factors such as attachment and positive parenting skills, supporting implementation through increasing engagement in interventions, and increasing the strength of intervention effects.
"Improving parent-child relationship. I think those should definitely be added because parents are your very first interaction with the world. You grow up with them. And you should be able to share whatever you can with them, I think, especially in our culture; in a Desi culture, parents usually don’t involve their children and communicate with them. But I do believe that, after a certain period of time, you do come to an understanding (with them), but I feel understanding should be built earlier, and one should definitely be able to communicate with them (parents) openly in every matter." (Female, 22; Pakistan)
Respecting personal space/Safe Spaces
In both countries, young people mentioned the importance of feeling safe. They emphasized the need for both a physically safe environment as well as safe spaces to discuss difficult issues. While the former was described as partly reflected in the Neighbourhood Cohesion AI, safe spaces were seen as an important AI in their own right. The importance of safe spaces was reiterated by young people. "I don’t live in a kind of neighbourhood where I can just go for a walk outside, so I think this issue is important for, especially, women’s mental health." (Female, 20; Pakistan)
"When you're Indian and you're living at home with a lot of people (extended family). They are an important part of your day-to-day activities and your environment. A lot of your activities are influenced by your parents or extended family. I think Indian families are much more involved in their kids’ lives." (Female, 20; India)
In addition to physical safety, young people in our consultations described interpersonal safety as an essential precursor to willingness to disclose mental health difficulties and seek help. Safety was emphasized as a key characteristic of effective mental health services for young PWLE, especially in Pakistan where young people spoke about a mistrust of medical professionals and a preference for peer-delivered models of psychosocial support. Fluid personal boundaries in collectivist Asian countries was reported to be an important risk factor to mental illness among young people. Respecting young people’s personal space was considered essential to create safe space for them.
Personal space is like the space you need to breathe and the space you need to exist. It is a major thing … because in our Pakistani society, we are like a collectivist culture, so everyone needs to know everything about you. Even if it's your parents, siblings, or friends, everyone makes you feel like you owe everyone an explanation. People need to realize that sometimes it is better to spare another person. (Female, 22; Pakistan)
Religion and spirituality. Religion and spirituality were highlighted as a potentially important Active Ingredients that is currently missing in the AIs list. It was recognised that religion could act as both a facilitator and barrier for improved mental health outcomes in young people. Over-reliance on religion as a source of mental health support was also highlighted to be due to stigma and fear of being judged in seeking professional mental health support in South Asian culture:
"I told my teacher I am on medication and I am having a lot of problems." I was told it is a negative trap that if you follow religious practices, everything will be fine; you don’t need services. When people, elders, and teachers give such a strong negative response and forbid you, then it becomes a hindrance to overcome mental health problems." (Female, 15; Pakistan)
Given the pervasiveness of religion in the context of South Asian subcontinent, young people also felt it important to consider how religion and spirituality might be harnessed to promote youth mental health.
“I think religious factors could also be used as a positive influence. In our country, there are so many people who are uneducated and rely completely on religious education. So, considering this, you can use religion as a positive influencer, like in the case of suicide. One should not commit suicide, as it is haram (forbidden in Islam) and shouldn't be committed.” (Female, 22; Pakistan)
Mental health literacy and stigma reduction. Mental health literacy was another important active ingredient raised by many of the young people that is currently missing from the AIs list. Across both countries, agency was linked to both mental health literacy (i.e., knowing what mental health difficulties are and how to seek support) as well as willingness to be vulnerable.
"One thing that is not on the list now that I think (important) is information, just by being informed about what mental health is, you know when to reach out for help when things are not going well in your life. That I think is something that’s missing in our society generally." (Female, 20; India)
Young people also raised the issue of misinformation around mental health symptoms and the importance of being able to distinguish between healthy emotional responses and signs of mental illness:
"I guess now people have awareness about it through social media and other platforms; we see posts about it, and mostly people know about it. Now there is so much information out there that people confuse their emotions with mental illness." (Female, 15; Pakistan)
Role of school. Young people emphasised the importance of schools as a setting for the delivery of mental health supports across the spectrum of mental health promotion, prevention to clinical interventions. A need for easily accessible mental health services in schools and educational settings was raised as a priority by all young people.
"I honestly don't think that schools pay enough attention to children's mental health, at least mine. It's a great school; we have a school counsellor as well, but I think when it comes to anxiety, depression, or any such thing that a student might be facing, they just shut it out. and I think that our age group needs somebody to reach out to us. someone we can communicate with." (Female, 16; India).
In Pakistan young people particularly emphasized the importance of school-based approaches particularly in the context of family and academic pressures, and to raise awareness of promoting mental health awareness and stigma reduction among the families and school authorities.
Cultural considerations of implementing active ingredients in South Asia
Across our interviews, young people frequently highlighted the importance of the family environment as a key contextual factor influencing youth mental health. Family pressures were perceived as one of the primary stressors for young people, and a lack of family awareness about mental health issues was described as invalidating and undermining mental health supports.
“I think there is a need to address it because of generation gap communication gap is increasing. Parents are saying that if you do such things, you will become a better human, but for children, these things may not matter. So, ultimately, children feel that their parents don’t understand them.” (Female, 23; Pakistan)
The role of family awareness and support was also linked to stigma around mental illness, which was identified as a major barrier to help-seeking and provision of mental health care. Many young people highlighted the issue of mental health stigma, particularly within their families and school environments as a key barrier in accessing mental health services. Interventions to normalize mental health difficulties and reduce stigma were considered crucial for effective implementation of mental health interventions.
Demographic factors also play a unique role within the cultures we explored in this study. In our data, gender was identified to play as an important role both in the sorts of stressors young people are exposed to, and the types of solutions and services that are likely to be accessible to male and female young people in India and Pakistan:
"Boys can go out any time. [Girls] can’t go out at any time of the day or be with their friends and talk about things. For them, they have to stay at home, and they can go out with their parents or guardians. What helps me when I am feeling anxious and want to go out and get some fresh air or do some activity, but I have to be with Mama and wait for her to be free? If I were abroad, I could go on my own, but here I can’t go alone for a walk or get some fresh air because it’s not safe. So, this is a big problem that you can’t even go to the parks, etcetera." (Female, 15; Pakistan)
Additionally, according to young people in Pakistan sources of anxiety, depression and stress in younger adolescents (aged 14 to 18 years) are comparatively different from older adolescents (aged 19 to 24). Younger adolescents are more likely to experience stress, anxiety and depression due to academic pressure whereas, the older adolescents, who are in the period of transition from school to work, tend to experience distress due to problems related to finances and employment. Therefore, implementation of AIs will require careful consideration regarding age of young people.