A film-based intervention (Intinn) to enhance adolescent mental health literacy and well-being: multi-methods evaluation study

John Goodwin (School of Nursing and Midwifery, University College Cork, Cork, Ireland)
Laura Behan (Health Information and Quality Authority, Cork, Ireland)
Mohamad M. Saab (School of Nursing and Midwifery, University College Cork, Cork, Ireland)
Niamh O’Brien (Maynooth University, Maynooth, Ireland)
Aine O’Donovan (School of Nursing and Midwifery, University College Cork, Cork, Ireland)
Andrew Hawkins (School of Nursing and Midwifery, University College Cork, Cork, Ireland)
Lloyd F. Philpott (School of Nursing and Midwifery, University College Cork, Cork, Ireland)
Alicia Connolly (School of Nursing and Midwifery, University College Cork, Cork, Ireland)
Ryan Goulding (School of Nursing and Midwifery, University College Cork, Cork, Ireland)
Fiona Clark (Cork International Film Festival, Cork, Ireland)
Deirdre O’Reilly (Cork International Film Festival, Cork, Ireland)
Corina Naughton (School of Nursing and Midwifery, University College Cork, Cork, Ireland)

Mental Health Review Journal

ISSN: 1361-9322

Article publication date: 4 December 2023

Issue publication date: 1 February 2024

875

Abstract

Purpose

Adolescent mental health is a global concern. There is an urgent need for creative, multimedia interventions reflecting adolescent culture to promote mental health literacy and well-being. This study aims to assess the impact of a film-based intervention on adolescent mental health literacy, well-being and resilience.

Design/methodology/approach

A pretest-posttest intervention with a multi-methods evaluation was used. A convenience sample of ten schools facilitated students aged 15–17 years to engage in an online intervention (film, post-film discussion, well-being Webinar). Participants completed surveys on well-being, resilience, stigma, mental health knowledge and help-seeking. Five teachers who facilitated the intervention participated in post-implementation interviews or provided a written submission. Analysis included paired-t-test and effect size calculation and thematic analysis.

Findings

Matched pretest-posttest data were available on 101 participants. There were significant increases in well-being, personal resilience and help-seeking attitudes for personal/emotional problems, and suicidal ideation. Participants’ free-text comments suggested the intervention was well-received, encouraging them to speak more openly about mental health. Teachers similarly endorsed the intervention, especially the focus on resilience.

Originality/value

Intinn shows promise in improving adolescents’ mental health literacy and well-being. Film-based interventions may encourage adolescents to seek professional help for their mental health, thus facilitating early intervention.

Keywords

Citation

Goodwin, J., Behan, L., Saab, M.M., O’Brien, N., O’Donovan, A., Hawkins, A., Philpott, L.F., Connolly, A., Goulding, R., Clark, F., O’Reilly, D. and Naughton, C. (2024), "A film-based intervention (Intinn) to enhance adolescent mental health literacy and well-being: multi-methods evaluation study", Mental Health Review Journal, Vol. 29 No. 1, pp. 48-63. https://doi.org/10.1108/MHRJ-05-2023-0027

Publisher

:

Emerald Publishing Limited

Copyright © 2023, John Goodwin, Laura Behan, Mohamad M. Saab, Niamh O’Brien, Aine O’Donovan, Andrew Hawkins, Lloyd F. Philpott, Alicia Connolly, Ryan Goulding, Fiona Clark, Deirdre O’Reilly and Corina Naughton.

License

Licensed re-use rights only


Introduction

Adolescent mental health is as a global concern (Benton et al., 2021; Davison et al., 2017). The peak onset of mental illness emerges during the neurodevelopmental phases in mid-to-late adolescence (Solmi et al., 2022). When mental health challenges go untreated in adolescence, they can persist into adulthood, leading to more severe issues, often preventing people from leading fulfiling lives (Kessler et al., 2007). Therefore, this developmental phase is an important time to target knowledge about mental health and promote access to mental health services (Kessler et al., 2007; Schizoph, 2011).

There is a need to develop age-appropriate targeted interventions (Goodwin et al., 2021). A useful and complementary construct to assist in developing such interventions is mental health literacy (MHL), defined as: “understanding how to obtain and maintain positive mental health, understanding mental disorders and their treatments, decreasing stigma related to mental disorders, and, enhancing help-seeking efficacy” (Kutcher et al., 2016b, p. 155). Adolescents often demonstrate poor MHL, with recent evidence suggesting that mental health education is not always sufficiently addressed within schools (Spencer et al., 2022). Poor MHL leads to limited help-seeking behaviours, which poses a challenge to successful early intervention (Goodwin et al., 2021; Sinclair and Holden, 2013).

Several authors (Hampson et al., 2018; McMahon et al., 2017; O’Connor et al., 2018) report that the formal education system is an ideal platform to improve awareness and understanding around mental health challenges. They recommended that people should be introduced to concepts relevant to mental health from an early age. Furthermore, adolescents have suggested that more mental health education within schools would be beneficial to them (McMahon et al., 2017; Spencer et al., 2022). Given the risk of developing mental illness during adolescence, there is a need to develop interventions that are acceptable to this population (World Health Organisation, 2021).

Interventions that aim to increase MHL assist in the promotion of mental health knowledge, the reduction of mental health stigma, improved mental health help-seeking attitudes and early identification of mental illnesses (Kutcher et al., 2016a). It is imperative to address well-being among the adolescent population, strengthening their capacity to regulate emotions and build resilience (Mathias et al., 2018; World Health Organisation, 2021), an important factor in enhancing adolescents’ ability to cope with everyday stresses (Fenwick-Smith et al., 2018), and one which can maintain well-being in the face of adversity (Liu et al., 2021).

Evidence has shown that diverse types of mental health/well-being interventions can be effectively delivered in non-clinical based settings, such as schools, to address psychological symptoms before they become more severe (Benton et al., 2021; Gonsalves et al., 2021). Although there are numerous interventions available to implement in schools, there is variable evidence of acceptability or effectiveness (Das et al., 2016); however, creative, arts-based interventions for adolescents may be beneficial (Goodwin et al., 2021; Goodwin and Behan, 2023; Janoušková et al., 2017). In a systematic review, Goodwin et al. (2021) found that film-based interventions have the potential to enhance MHL, well-being and resilience in adolescents. Moreover, Janoušková et al. (2017) reported that such interventions can positively impact on adolescent mental health stigma. There is a need to better understand “if and how” film-based interventions work among adolescent audiences.

This study aimed to assess the use of a film-based intervention in enhancing MHL, well-being and resilience in adolescents. The objectives were to examine the acceptability of the intervention and its delivery method and to gauge the level of interest to participate in the intervention and its evaluation. The delivery of the intervention and the response from student and teacher participants are the subject of this paper.

Methods

Design

The design used a pretest-posttest intervention with multi-methods evaluation.

Ethics

Ethical approval was granted by the University’s Social Research Ethics Committee (log: 2020–006). Written consent/assent was obtained from participants.

Intervention

A description of the Intinn elements is provided in Figure 1. Owing to the growing issue of suicide among young people and the call to address this topic in schools (McMahon et al., 2017; Walsh et al., 2023), the feature film used as part of Intinn was “I Used to Live Here”. The 82-min film, written and directed by Frank Berry, centres around the impact of suicide on two young people and their community and is situated in a working-class area of a large urban centre (Figure 1). It should be noted that “I Used to Live Here” was chosen by the researchers as the feature film component of the Intinn intervention, but was not initially developed to be part of an intervention package.

The intervention was tested among secondary (high) school students in “transition” (fourth) year (TY). TY is an optional (non-exam) year where students remain in school but are provided with opportunities to engage in community activities and work experience, and where an emphasis is placed on personal and social development, including mental health. As TY students follow a much less structured curriculum, there was “space” to accommodate the screening of Intinn (approximately 202 mins).

Intinn was first piloted in 2018/2019 as a face-to-face event. Due to the COVID-19 pandemic, Intinn was converted into a digital intervention hosted on a password protected digital platform (Eventive), piloted in 2020 and rolled out nationally in 2021. Schools were informed in advance that, to avail of the Intinn intervention, they were required to partake in the evaluation. No schools withdrew from the study evaluation following receipt of access to the Intinn digital platform. Teachers facilitated screening of the online Intinn intervention while students were physically present in class during a normal school day. The participating students and teacher watched the material together in class. Teachers had no other role in delivering the intervention. Once the intervention was accessed on the digital platform, they had three days to complete all elements.

Participants

Study participants were TY students who participated in the Intinn intervention and teachers who facilitated these. Schools were recruited through previous (in-person) Intinn sessions (n = 8) and from a publicly available online database of secondary schools (n = 730). Each of the schools (n = 738) was contacted via email.

The final sample consisted of ten schools. Based on the ten schools participating, we estimated there were approximately 600 students eligible to participate.

Data collection

Prior to Intinn, teachers emailed student participants a study information pack, comprising a study participant information leaflet, links to an online assent form for student participants to complete and an online consent form for parents/guardians to complete.

Student participants were asked to complete a structured online questionnaire, comprising five validated instruments measuring well-being, resilience, stigma, mental health knowledge and help-seeking, as well as demographic data. Two weeks later, students were asked to complete the post-test survey, which included additional open-ended questions about their experiences and suggestions for intervention improvements.

In addition, ten teachers were invited to partake in individual interviews or submit a written response. Following informed consent, semi-structured interviews were conducted via Microsoft Teams. Interviews lasted between 25 and 85 min.

Instruments

Participant well-being was measured using the Warwick–Edinburgh mental well-being scale (WEMWBS) (Tennant et al., 2007), a 14-item instrument with a five-point Likert scale (1 = “none of the time” and 5 = “all of the time”). Scores from each item are added to obtain an overall score for well-being (14 minimum; 70 maximum value). Those with scores between 41 and 45 are considered as high risk for psychological distress and increased risk of depression (Tennant et al., 2007). We used these scores as cut-off points within our sample. Cronbach’s alpha for the WEMWBS indicated excellent internal consistency (0.93).

The Child and Youth Resilience Measure-Revised (CYRM-R) was used to measure resilience (Jefferies et al., 2019). This instrument contains 17 items to calculate an overall resilience score as well as two subscales [personal resilience (ten items), and caregiver/relational resilience (seven items)]. Cronbach’s alpha for the CYRM-R showed excellent internal consistency (0.93). There are some tentative thresholds for overall scale scores that set out the following categories: low resilience: <61, moderate resilience: 61–69, high resilience: 70–75 and exceptional resilience: ≥76 (Jefferies et al., 2019).

The Peer Mental Health Stigmatisation Scale was used to assess mental health stigma (McKeague et al., 2015). This 24-item instrument has four subscales, each of which has a summative score: stigma awareness, stigma agreement and overall stigma. Cronbach’s alpha indicated excellent internal consistency (stigma awareness = 0.86, stigma agreement = 0.86 and overall stigma = 0.85).

The mental health knowledge schedule (MAKS) was used to assess mental health knowledge (Evans-Lacko et al., 2010). This scale contains 12 items divided into six statements. Cronbach’s alpha for the MAKS had poor internal consistency (0.36).

The general help seeking questionnaire (GHSQ) was used to assess help-seeking intentions for different sources (Wilson et al., 2005). The instrument contains two subscales assessing help-seeking intentions for personal or emotional problems and suicidal ideation. Each question contains items which measure help-seeking intentions using a seven-point Likert scale, 1 being “extremely unlikely” to 7 being “extremely likely” resulting in a summative score. Cronbach’s alpha for the GHSQ had good internal consistency (0.88).

A demographics questionnaire was also included. Questions on gender, age, year in school and location (county) of school were included.

Data analysis

Descriptive statistical analysis was used to examine the demographic variables and the distribution of pre- and post-test data. Proportions and percentages are reported for categorical data and means and standard deviation for continuous data. Statistical differences between pre- and post-test data were compared using paired sample t-tests, with p ≤ 0.05 considered statistically significant. Bonferroni correction was used to adjust for multiple testing and indicated that p < 0.004 should be considered a statistically significant difference. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 26.0 (SPSS Inc., Chicago, IL, USA).

Using reflexive thematic analysis (Braun and Clarke, 2019), qualitative data from individual interviews with (and the written submission from) teachers and students’ open-ended survey questions were coded by two researchers independently (AH; AC) and were cross-checked for accuracy by one researcher (JG). Themes were identified and refined by AH, AC and JG. Data source triangulation was then performed by one researcher (NOB) and cross-checked by another (MMS), where data from students and teachers were explored for convergence, complementarity and dissonance (Carter, 2014).

Results

From the ten schools, there were 120 completed questionnaires of which 101 could be matched with a baseline questionnaire. Most participants were female (80.2%) and aged 16 years (74.2%). At least five counties were represented (Table 1).

Participant mental health indicators

There was a statistically significant positive increase in post-test scores for participants’ well-being, the personal resilience subscale, and attitudes towards help-seeking for personal and emotional problems and help-seeking for suicidal ideation compared to baseline values (Table 2); however, it should be noted that effect sizes were small. Following Bonferroni correction for multiple testing, only well-being remained statistically significant; the effect size was 2.86, indicating a small effect.

In terms of the WEMWBS well-being cut-off values, at baseline, 22 participants (21.8%) had a score between 0 and 40 and were considered high risk of major depression, and 19 (18.8%) had a score between 41 and 45, indicating “high risk” of psychological distress. Post-test, there was a small reduction: 17 (16.8%) participants had a score ≤40 and 15 (14.9%) had a score between 41 and 45. There were no significant changes in the other outcome measures: total resilience, stigma or mental health knowledge.

Results from students and teachers’ qualitative responses

All students provided written responses to the open-ended questions. Of the ten teachers who facilitated intervention delivery, four were interviewed and one returned a written response.

The following three themes were identified from students’ open-ended responses and teacher interviews/written response:

  1. experiences with mental health and well-being programmes in schools;

  2. the power of film in raising awareness and promoting open discussion around mental health; and

  3. barriers to engagement and recommendations for programme enhancement.

Experiences with mental health and well-being programmes in schools

Teachers commented that students frequently experience mental health challenges but do not often discuss this with others. It was suggested that this issue was further exacerbated in the wake of the COVID-19 pandemic:

I think with the year that was in it, it’s possibly tougher […] I just think everything’s more heightened now and there’s a lot more anxiety (Teacher Participant [TP]1).

Teachers acknowledged that there is an effort within schools to promote students’ mental health and well-being. However, they commented that stigma served as a barrier to appropriately addressing the mental health needs of students. Teachers felt they lacked the skills to address such issues. Consequently, they felt under pressure when attempting to address the mental health needs of their students:

In schools at the minute we’re all doing our best within SPHE [Social, Personal and Health Education] and other subjects to try and promote wellbeing, but there is still, I suppose a bit of a stigma (TP4).

You can’t fix everyone; I think that was my biggest issue as a teacher, I’m trying to fix broken people all the time, and there’s only a limit to what you can do (TP2).

In the past, in response to increased levels of mental distress among students, teachers commented that they welcomed the introduction of mental health and well-being programmes in the classroom. Individuals who delivered these past programmes explored students’ thoughts and feelings, encouraging them to disclose their experiences of mental distress. However, teachers were critical about the content of these programmes, describing them as heavily focused on “mindfulness”, and that they were impractical, invasive, and did not address the mental health needs of young people in a meaningful way. Moreover, once these programmes were completed, students were left in a vulnerable position and teachers felt they were left to manage the “fallout”:

I know mindfulness is bandied about as a tool, solves everything, but it doesn’t solve everything, it helps you, calms you, and it helps with certain things, but it doesn’t provide enough resilience when somebody is actually beating the crap out of you at home, you know, oh be mindful, so, that’s the kind of programme I’m talking about (TP2).

Consequently, teachers stated that they have been seeking an alternative and practical approach which addresses the complexity of mental health among students:

I think actually discussing the really hard-hitting stuff that maybe schools and the teachers aren’t equipped to do themselves (TP2).

The power of film in raising awareness and promoting open discussion around mental health

Unlike previous interventions which involved directly and openly addressing students’ experiences of mental health, the film-based approach of Intinn facilitated students to work through complex adolescent problems in an indirect, unconscious manner, which was perceived by teachers as cathartic. Teachers noted that young people enjoy film, meaning its use as an intervention format was appropriate to communicate information about mental health. Students and teachers commented on the “realistic” nature of the film, including the portrayal of characters and their personal circumstances. Owing to the central characters’ ages, their stories resonated with students who were able to form mental connections with the main characters:

I feel like a lot of teenagers are struggling with mental health problems and the film could help a lot of people or be relatable (Student Participant [SP] 17).

My students loved the screening of the movie and found it very relatable, true to life […] Relatable, authentic, contemporary – they are the words that spring to mind (TWS).

Kids identify with movies […] they love them, they watch them, they absorb them (TP2).

Students commented on Intinn’s invaluable contribution in enhancing self-awareness around their own mental health. Through reflecting on the programme and identifying with the characters in the film, they were given an opportunity to consider how they might react in a similar situation. This process of reflection highlighted the importance of seeking help:

I learned more about mental health, and I tuned in more to my own mental health (SP56).

I think it was incredibly eye opening and made me think deeper into certain things and how I would act in similar situations (SP54).

I found it very beneficial as I learnt lots about mental health and asking for help when you’re struggling (SP89).

The different elements of the intervention were perceived to help increase students’ understanding of the ongoing stigmatisation of mental health, suicide, mental health terminology and the prevalence of mental distress. Intinn was perceived by teachers and students to promote self-awareness and to foster empathy and compassion. Through reflecting on the programme and identifying with the characters in the film, students were given an opportunity to consider how they might react in a similar situation, support people struggling with mental health challenges and appreciate the effect of social circumstances that contribute to mental distress:

I feel like a lot of teenagers are struggling with mental health problems and the film could help a lot of people or be relatable (SP17).

I think discussing stigma was especially beneficial because it’s still a prevalent problem around mental health (SP92).

It made me realise that you never really know what people are going through (SP9).

Teachers commented that, once the film was over, students seemed more comfortable engaging in discussions around mental health among themselves and with teachers. The intervention also encouraged students to consider their future well-being and to speak to others about their own mental health difficulties. Once students had reflected on the themes addressed within the film, teachers noted that they were much better prepared to engage in the Webinar. Although it was acknowledged that some of the content discussed throughout the webinar was “tough” or provocative, it was felt that the film prepared students to engage with this content more comfortably. The focus on resilience was commended, as teachers felt this was something that needs to be developed in young people:

This [Intinn] was one of the first things that I can definitely ever think of that would directly mention and refer to suicide (TP4)

so, you know, any programs like this that come on and that help with you know, developing children resilience because that’s what it’s all about (TP2).

The Webinar that followed the film was perceived to help facilitate a deeper insight into themes addressed in the film and equip students with personal coping skills, such as breathing exercises:

I thought the most beneficial part of Intinn was the webinar we were showed (SP47).

I found really interesting the video that followed the film, in particular the breathing exercises and the section about bullying, it made me look at things from a different point of view (SP74).

In addition, unlike previous programmes where teachers were left to follow up with students who disclosed their experiences of mental health, Intinn provided comprehensive details around help-seeking pathways for vulnerable young people. For all the above reasons, participants were enthusiastic about delivering Intinn again to next years’ students:

They enjoyed the webinar […] and they got involved in the class group discussions […] this brought all their learning/understanding out in discussion format in the classroom (TWS).

If you were doing it as a yearly thing or biannually, or whatever […] I think It’s important that we do have the hard discussion every year over and over again because eventually that will make a difference, I think […] I’d love to do it again with transition years next year I think it was really beneficial (TP1).

Overall, student respondents were positive about Intinn, describing it as “really enjoyable” and “a great experience”. Similarly, teachers embraced Intinn and felt that the intervention successfully addressed important topics that teachers themselves felt ill-equipped to deal with:

It was really enjoyable! (SP29)

I personally really enjoyed it (SP92)

It was a great experience to take part in (SP6)

Barriers to engagement and recommendations for programme enhancement

Despite the many positives, students identified some barriers to engagement and teachers reported some challenges they faced in facilitating the intervention. For instance, some students commented on the film itself, while others found it challenging to follow the narrative and understand the dialogue. It was also suggested that the film was too long, and it was difficult to maintain concentration for its entire duration:

I could not understand the actors (SP71).

Maybe it would be easier to keep the short attention span of teenagers if the film was shorter (SP65).

Teachers commented on the tension between competing priorities regarding the importance of introducing mental health and well-being programmes into schools and the time required to deliver the standard curriculum. Consequently, they had a concern that there was not enough time to accommodate mental health content during school hours:

There’s kind of general promotion all the time, but one of the biggest issues is and every school, that is, it’s so busy that like trying to find time, am, to run things isn’t always possible (TP1).

Although teachers enjoyed the post-screening Q&A section, this was the section of the programme where it was observed students were least engaged. One student made specific reference to this being their least favourite part of Intinn:

I didn’t benefit much from the Q&A (SP47).

Owing to this element of the intervention being perceived as the least engaging, teachers suggested merging the Webinar and discussion sections. It was suggested that this would help to maintain students’ concentration and engagement:

As an adult I found the post-screening interviews interesting; however, this was where I found my students least engaged. Maybe a format of mixing that section and the webinar together to enable students to build on the actors ideas/discussions along with their own thoughts and reflections? (TWS)

The COVID-19 pandemic also had an impact on the intervention. It was suggested that the virtual format Intinn adopted may have worked well in the past; however, owing to being over-saturated with screen-time in the context of online learning, a further requirement to engage in virtual learning was challenging:

I think lockdown had a huge effect on the actual programme, as it did in a lot of programmes (TP2).

They’re just very “over-Zoomed” this year so on a regular year I think they would have been engaged more with the, uh, discussion part, but they’re just used to seeing a lot of people talking at them online (TP4).

We have found that by the end of this year, [students] have had so much screen-time this year, that their concentration levels […] since online learning after Christmas, their concentration levels have dropped (TP3).

Discussion

The objectives of this study were to examine the acceptability of the intervention and its delivery method and to gauge the level of interest to participate in the intervention and its evaluation. To assess the impact of the Intinn intervention on participants’ MHL and well-being, as well as the level of interest in the study we used quantitative (i.e. structured online questionnaire) and qualitative methods (i.e. open-ended questions and individual interviews). Overall, there was considerable congruence between quantitative and qualitative findings. For example, findings from the questionnaire indicate that following engagement with the intervention, participants showed significant increases (albeit with small effect sizes) in well-being, personal resilience and attitudes towards help-seeking for personal/emotional problems and suicidal ideation. These findings were echoed in open-ended and interview responses. In addition to confirming quantitative findings, qualitative findings provided more in-depth accounts of participants’ experiences and helped better understand the study context. For instance, the impact of the COVID-19 pandemic on intervention delivery and on mental health/anxiety featured strongly in qualitative findings yet it was not explored in the questionnaire. Another example relates to participants’ views of the intervention and subsequent Webinar and how those fit into the social, personal and health education curriculum.

In terms of the acceptability of the delivery method of the intervention, both students and teachers referred to it as both relatable and realistic. It was deemed an appropriate means of addressing real and pressing matters. A commonly reported barrier to implementing school-based interventions is poor student engagement (O’Reilly et al., 2018). Intinn was effective in engaging students around their mental health and well-being, as evidenced by a positive shift in MHL indicators as well as from qualitative comments. In addition, the film activated self-reflection as students began to consider times when help-seeking might be necessary as provoked by the lead characters of the film. Teachers involved in facilitating the intervention suggested that students’ previous experience, familiarity with, and general love of film made the intervention format more accessible and acceptable. The film portrayal of an adolescent character in an Irish context increased the authenticity and relatability of a sensitive topic further drawing in its audience. Watching films about relatable characters dealing with mental health issues provides viewers with an opportunity to reflect on their own internal struggles, inviting them to reflect on how they might act in a comparable situation (Roe, 2020). Films also can elicit difficult emotions yet provide the space for viewers to create a deeper understanding of themselves (Eppler and Hutchings, 2020). In this intervention, rather than directly confronting challenging topics, students discussed these in the context of the film, creating distance between them and the subject matter, thus enabling them to speak more openly about suicide.

Despite the reported successes of the film as an intervention, the students found it difficult to sustain interest for its full duration. This may have impacted the student’s interest in remaining focused during the post-film Q&A session. Future interventions should consider shorter films to sustain attention throughout the intervention.

The data indicate a statistically significant increase in well-being in participants following engagement with Intinn. Maintaining well-being is an important protective factor for mental health (World Health Organisation, 2021). Several studies have reported that school-based interventions that improve well-being often have a limited impact, with no one intervention consistently found to improve well-being in young people (Kuosmanen et al., 2019; O’Connor et al., 2018). Given the positive results from Intinn, there may be benefits in using film-based interventions as part of multicomponent strategies to enhance well-being during the adolescent period.

Related to well-being is the concept of resilience, an important protective factor for mental health and well-being (Mathias et al., 2018). Wu et al. (2018) found that higher levels of resilience were linked to fewer mental health-related problems and enhanced well-being. However, the lack of evidence-based interventions developed to enhance resilience is well-recognised (Dray et al., 2017; Goodwin et al., 2021). The current study suggests, there is potential for the film and Webinar/workshop format to improve personal resilience levels among adolescents.

Another improvement observed following the intervention was in attitudes towards help-seeking for both personal/emotional problems and suicidal ideation. Post-test, participants were better able to recognise the importance of seeking help and talking to people about their feelings. Help-seeking is a crucial protective factor for mental health and well-being in adolescents (Conceição et al., 2022). Several studies have found that, when access to treatment is delayed, adolescents are more likely to experience compromised mental health and well-being (Semovski et al., 2022). A systematic review by Goodwin et al. (2021) highlighted that a didactic/instructional approach may be useful in improving help-seeking attitudes. Intinn’s Webinar specifically addressed how to access help-seeking resources. An important consideration in any adolescent-focused mental health intervention is the inclusion of practical information related to help-seeking (Spencer et al., 2022), ideally tailored to local services as well as national online/telephone supports (McGorry et al., 2022).

While a decrease in stigma and increase in mental health knowledge was observed post-intervention, these were not statistically significant in the quantitative findings. However, in the qualitative findings it was expressed that a reduction of mental health stigma emerged as the film content was provocative and prompted the students to engage in dialogue around challenging mental health subjects such as suicide. Regarding mental health knowledge, the fact that the survey examined general mental health knowledge, including depression and schizophrenia, likely impacted on findings, given that the film and Webinar focussed on suicide. In relation to stigma, despite a non-significant change in quantitative scores, qualitative feedback indicated that the programme enhanced students’ understanding of stigma. It has been recommended that interventions to reduce mental health stigma should be introduced in school (Bulanda et al., 2014). Given the qualitative feedback from both students and teachers, there may be promise in using film-based interventions to reduce stigma; however, research using larger sample sizes is warranted.

The main problem identified by teachers was a lack of time to deliver Intinn as they were committed to teaching content set by the curriculum. This is commonly reported in school mental health intervention research (Punukollu et al., 2020; Willis et al., 2019). It is well-established that teachers are under-resourced and ill-prepared when it comes to addressing the mental health needs of students, and they require appropriate mental health interventions in their schools (Shelemy et al., 2019; Ní Chorcora and Swords, 2022). However, Willis et al. (2019) states that teachers can feel torn between delivering the curriculum while simultaneously caring for the well-being of their students. Given that teachers do not always feel adequately supported in implementing relevant mental health programmes (Punukollu et al., 2020; Willis et al., 2019), there is a need to increase resources and time allocated to mental health to address deficits in the current education systems.

Limitations

Qualitative feedback from students was limited to post-test open text responses. Future research in this area should strive to use interview methods, which would facilitate the nuance and complexity of adolescents’ experiences to be captured (Mishna et al., 2022). A low number of male participants were included. However, it should be noted that low male participation in mental health research is in keeping with other published studies (Goodwin et al., 2022; Kazlauskaite and Fife, 2021). Moreover, the intervention was trialled only with TY students, who typically represent a younger cohort, with higher educational aspirations and higher socioeconomic backgrounds (Smyth et al., 2004). As such, future research should include a more diversified range of students. Due to COVID-19, it was not possible for Intinn to be delivered in-person. Instead, the intervention was delivered online. Due to the curriculum already being taught in this manner, many students had “screen fatigue”, a phenomenon well-reported in the wake of the pandemic (Singh and Balhara, 2021). The prospect of engaging with another virtual intervention may have affected Intinn’s impact. Finally, effect sizes were small, and the change in scores for several outcomes (well-being, resilience and attitudes towards help-seeking), although significant, were not “clinically significant”. Future research in this area should aim to recruit larger sample sizes.

Conclusion

The three-part film-based intervention (Intinn) examined in this study shows promise in improving adolescents’ MHL, resilience and well-being in school settings, and may encourage young people to seek professional help for their mental health. There is a need for greater innovation and more novel approaches to engaging young people in mental health education. Art and film-based interventions, such as Intinn, are feasible to incorporate into busy school curricula and were well received by students and teachers. There is a need for further development and refinement of the intervention (e.g. shorter film/Webinar, more blended approach to incorporate student activity and in-person discussion). Future research should aim to recruit larger sample sizes with a greater gender representation: the evaluation of Intinn effectiveness requires a cluster randomised or pragmatic trial design with specific strategies to include males and non-binary genders, and populations outside of Ireland to build its evidence base and generalisability. Ideally, Intinn should be delivered during periods where student learning is primarily school-based rather than online, as extended “screen fatigue” may affect its implementation and effectiveness. Incorporating interventions such as Intinn into busy school curricula requires at least a 12-month pre-planning phase and include greater supports for teachers. If this format is proven effective, other mental health topics such as schizophrenia or depression could be addressed using art and film-based approaches. Intinn was the product of a creative collaboration between an arts-based organisation and mental health professionals. It is an innovative approach to address sensitive topics such as suicide among adolescents. The data from this study will inform future intervention refinement and trial design.

Figures

Intervention description: Intinn

Figure 1

Intervention description: Intinn

Demographics (n = 101)

Attribute n (%)
Gender Female: 81 (80.2)
Male: 13 (12.9)
Other: 3 (3.0)
Prefer not to say: 4 (4.0)
Age 15: 12 (12.9)
16: 76 (75.2)
17: 13 (12.9)
County of school Cork: 30 (29.7) 
Dublin: 11 (10.9)
Kerry: 25 (24.8)
Sligo: 31 (30.7)
Other: 4 (4.0)

Source: By authors

Comparison in primary and secondary outcome measures

Measure Pre-intervention Post-intervention Paired t-test p-value Effect size
Mean SD Mean SD
WEMWBSa 48.59 11.12 50.74 11.09 −2.86 0.004* 0.29
CYRM-Rb Total resilience 71.53 11.67 73.50 8.75 −1.78 0.076 −0.08
Personal resilience 41.73 6.98 42.99 5.42 −2.03 0.043* 0.20
Caregiver resilience 29.80 5.29 30.51 4.07 −1.24 0.215 0.12
PMHSSc
Stigma awareness
25.07 6.66 24.53 7.06 0.81 0.418 0.08
Stigma agreement 16.01 4.48 15.49 6.20 −1.63 0.103 0.16
Overall stigma 41.08 7.84 40.02 10.76 −1.65 0.098 0.16
MAKSd 22.44 2.76 22.55 3.44 −0.35 0.770 0.04
Recognition 23.13 2.93 22.96 2.41 −1.23 0.219 0.12
GHSQe Personal and emotional problems 39.93 10.23 42.06 8.73 −2.45 0.016* −0.24
GHSQ suicidal ideation 40.16 10.11 42.11 10.64 −2.26 0.026* −0.23
Notes:

aWarwick–Edinburgh Mental Well-being Scale (WEMWBS); bChild and Youth Resilience Measure-Revised (CYRM-R); cPeer Mental Health Stigmatisation (PMHSS); dMental Health Knowledge Schedule (MAKS); eGeneral Help-seeking Questionnaire (GHSQ); *p < 0.05; Bonferroni correct p < 0.004

Source: By authors

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Acknowledgements

The authors wish to thank Creative Ireland and The Arts Council for their ongoing support of Intinn.

Funding: ESB Energy for Generations Fund

19-EI-059

Rethink Ireland

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Conflict of interest: The lead author was paid to facilitate the Webinar section of Intinn.

Corresponding author

John Goodwin is the corresponding author and can be contacted at: john.goodwin@ucc.ie

About the authors

John Goodwin is based at the School of Nursing and Midwifery, University College Cork, Cork, Ireland. He is a lecturer in mental health nursing and programme lead for the undergraduate mental health nursing programme at the School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland. His research interests include mental health help-seeking, media depictions of mental illness, public perceptions of mental health care environments, the use of the arts and creativity in mental health, young people’s mental health and mental health stigma.

Laura Behan is based at the Health Information and Quality Authority, Cork, Ireland. She is a Senior Researcher at Health Information and Quality Authority, Unit 1301, City Gate, Cork, T12 Y2XT, Ireland. Laura holds a Master’s degree in public health and PhD in social sciences. Her research interests are health-related quality of life, patient perspectives of services and health and social care regulation.

Mohamad M. Saab is based at the School of Nursing and Midwifery, University College Cork, Cork, Ireland. He is a Senior Lecturer and Director of Graduate Studies at the School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland. He has expertise in various research methodologies including: systematic reviews, intervention development and testing, qualitative research and theoretical framework development.

Niamh O’Brien is based at the Maynooth University, Maynooth, Ireland. She is an Assistant Professor of Education at Froebel Department of Primary and Early Childhood Education, Maynooth University, School of Education, North Campus Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland. Her research aims to investigate well-being and positive mental health intervention cross all levels of education, from primary level to higher-level education. Niamh’s work seeks to understand mental health intervention design and impactful well-being practices among students, teachers and student–teachers.

Aine O’Donovan is based at the School of Nursing and Midwifery, University College Cork, Cork, Ireland. Aine O’Donovan is a Senior Lecturer in mental health in the School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland. Aine’s research interests focus on young people’s mental health, with a specific interest in positive mental health, depression, self-harm and e-health.

Andrew Hawkins is based at the School of Nursing and Midwifery, University College Cork, Cork, Ireland. Andrew Hawkins is a student mental health nurse in the School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland.

Lloyd F. Philpott is based at the School of Nursing and Midwifery, University College Cork, Cork, Ireland. He is a Lecturer in Public Health Nursing and Coordinator of the Postgraduate Diploma in Public Health Nursing, School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland. His primary area of research is paternal perinatal mental health. His contribution to the field of paternal perinatal mental health and the impact of his research for the advancement of knowledge, policy and clinical practice have been acknowledged by clinicians, academics and policymakers.

Alicia Connolly is based at the School of Nursing and Midwifery, University College Cork, Cork, Ireland. Alicia Connolly is a Research Assistant at the School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland.

Ryan Goulding is based at the School of Nursing and Midwifery, University College Cork, Cork, Ireland. Ryan Goulding is a Lecturer in mental health nursing, School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54. Ryan has a specific interest in the transgender and gender diverse population and initiatives aimed at improving the experience of this grouping in accessing health care.

Fiona Clark is based at the Cork International Film Festival, Cork, Ireland. She is the Festival Director and CEO of Cork International Film Festival, Castle Chambers, 6 Castle Street, Cork, T12 T25W. Fiona holds a BA in English and Drama from Bristol University; she serves on the board of Business to Arts and is a member of the European Film Academy. Cork International Film Festival is Ireland’s first and largest film festival.

Deirdre O’Reilly is based at the Cork International Film Festival, Cork, Ireland. She is a Marketing and Communications Manager at Cork International Film Festival, Castle Chambers, 6 Castle Street, Cork, T12 T25W. She has a wealth of proven experience in traditional and digital arts marketing, brand development, partnership management and public relations.

Corina Naughton is based at the School of Nursing and Midwifery, University College Cork, Cork, Ireland. She is a Professor of Clinical Nursing in Older Person’s Health care at the School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland. Her current research projects include a non-randomised feasibility study of a dementia communication intervention for pre-registration nurses; a pilot study of a regional education-career pathway to improve retention and competency in early career gerontologic nurses; and nurse-led quality improvement to increase nutrition intake in older adults during hospitalisation.

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