Journal Pre-proof

Understanding mental health and its determinants from the perspective

of adolescents: A qualitative study across diverse social settings in
Indonesia

Lisa Willenberg, Nisaa Wulan, Bernie Endyarni Medise, Yoga

Devaera, Aida Riyanti, Ansariadi Ansariadi, Tjhin Wiguna, Fransiska
Kaligis, Jane Fisher, Stanley Luchters, Aishah Jameel, Susan M.
Sawyer, Thach Tran, Elissa Kennedy, George C. Patton, Budi
Wiweko, Peter S. Azzopardi

PII: S1876-2018(20)30259-8
DOI: https://doi.org/10.1016/j.ajp.2020.102148
Reference: AJP 102148

To appear in: Asian Journal of Psychiatry

Received Date: 11 March 2020

Revised Date: 28 April 2020
Accepted Date: 30 April 2020

Please cite this article as: Willenberg L, Wulan N, Medise BE, Devaera Y, Riyanti A, Ansariadi
A, Wiguna T, Kaligis F, Fisher J, Luchters S, Jameel A, Sawyer SM, Tran T, Kennedy E, Patton
GC, Wiweko B, Azzopardi PS, Understanding mental health and its determinants from the
perspective of adolescents: A qualitative study across diverse social settings in Indonesia,
Asian Journal of Psychiatry (2020), doi: https://doi.org/10.1016/j.ajp.2020.102148
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Understanding mental health and its determinants from the perspective of adolescents:
A qualitative study across diverse social settings in Indonesia

Lisa Willenberg (1), Nisaa Wulan (1), Bernie Endyarni Medise (2), Yoga Devaera (2), Aida Riyanti
(3), Ansariadi Ansariadi (4), Tjhin Wiguna (5), Fransiska Kaligis (5), Jane Fisher (6), Stanley
Luchters (1,7), Aishah Jameel (1), Susan M Sawyer (8), Thach Tran (6), Elissa Kennedy (1), George
C Patton (8), Budi Wiweko* (9), Peter S Azzopardi* (1,8,10).

1. Global Adolescent Health Group, Maternal Child and Adolescent Health Program, Burnet Institute,
Melbourne, Australia
2. Department of Child Health, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

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3. Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Indonesia, Jakarta,
Indonesia
4. Department of Epidemiology, School of Public Health, Universitas Hasanuddin, Makassar,

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Indonesia
5. Department of Psychiatry, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
6. Global and Women’s Health Unit, School of Population and Preventive Medicine, Monash
University, Melbourne, Australia
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7. Chair, Department of Population Health, Aga Khan University, Nairobi, Kenya.
8. Centre for Adolescent Health, Royal Children’s Hospital, Melbourne; Murdoch Children’s
Research Institute, Melbourne; Department of Paediatrics, University of Melbourne, Australia.
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9. Research and Social Services, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
10. Aboriginal Health Equity Theme, South Australian Health and Medical Research Institute,
University of Adelaide.
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* Joint senior

Corresponding author: A/Prof Peter Azzopardi, Global adolescent health group, Maternal Child and
Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne 3004, Australia.
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peter.azzopardi@burnet.edu.au
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Highlights

 This is the first study to explore concepts and determinants of mental health
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amongst adolescents in Indonesia

 Mental health was recognised as a significant concern by adolescents in Indonesia.
 Concepts of mental health highlighted limited mental health literacy and
substantial stigma.
 Family connection, school pressures, and adverse exposures on social media were
identified as key determinants.
 This study provides a foundation for targeted responses to adolescent mental
health in Indonesia.
Abstract

Poor mental health is a leading contributor to the burden of disease experienced by

adolescents, including in resource constrained settings. However, little is known about how
adolescents in these countries conceptualise mental health and its determinants which is
essential to informing effective responses. This study aimed to explore how adolescents in
Indonesia (a populous and rapidly developing country) conceptualise mental health and what
they identify as important determinants. Eight focus group discussions (FGDs) were
conducted with 86 Indonesian adolescents (aged 16-18 years), sampled from schools and
community settings from Jakarta and South Sulawesi. FGDs were recorded, transcribed,

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translated and thematically analysed. Mental health was recognised as a significant concern
by adolescents in Indonesia. Good mental health was conceptualised as emotional wellbeing

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and happiness. By contrast, poor mental health was predominantly described in terms of
substantial mental illness manifesting as behavioural and physical disturbance. Further, poor
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mental health only happened to ‘other’ people, with stigmatising views prevalent. Absent
from the discussions were common symptoms of poor mental health (stress, loneliness, poor
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sleep) and common mental disorders (eg depression, anxiety) or a conceptualisation that
reflected poor mental health to be a normal human experience. Discussions around
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determinants of poor mental health suggested that family connections (particularly with
parents), school pressures, and adverse exposures on social media were important drivers of
poor mental health, with religion also surfacing as an important determinant. In highlighting
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mental health as an important issue for Indonesian adolescents, this study provides a
foundation for targeted responses.
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Keywords: Mental health; depression; anxiety; determinants; qualitative; adolescents; Indonesia;

communities; schools; parents.
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1. Introduction

Mental disorders are a leading contributor to the burden of disease for adolescents globally

(Patton et al., 2016). Poor mental health has significant implications for adolescent

development and social role transitions, and is a determinant of risky substance use, early
pregnancy and school disengagement (WHO, 2017). Adolescent mental health also predicts

future adult health, and the health of the next generation (Patton et al., 2018). Yet despite this,

investments in adolescent mental health have been minimal (Li et al., 2018). One reason may

be the poor coverage and quality of mental health data (including qualitative data) for

adolescents, critical to informing priority areas for action (Erskine et al., 2017). Mental health

data are most lacking in resource constrained settings where the majority of the world’s

adolescents live.

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Indonesia is the fourth most populous country in the world and home to 68 million

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adolescents (Azzopardi et al., 2019). Rapid socioeconomic development has resulted in a

significant epidemiological transition, with mental disorders now modelled to be leading

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contributors to the disease burden in Indonesia (Mboi et al., 2018). This is particularly so for

adolescents where mental disorders are modelled to account for a quarter of non-fatal disease
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burden (Mokdad et al., 2016). Available primary data from the Global School Health Survey
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show that 7% of 16 – 17 year olds had seriously considered attempting suicide in the

preceding 12 months (WHO, 2015), with the national RISKESDAS survey finding that one

in ten Indonesian 15-24-year-olds have a non-specific emotional disorder (Indonesian

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Ministry of Health, 2018). These data highlight a need for a more nuanced understanding of

mental health amongst Indonesian adolescents.

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How adolescents conceptualise mental health is central to understanding their mental health

needs, but also to framing interventions that are responsive to them (Armstrong et al., 2000;

Backett-Milburn et al., 2003). For example, adolescents may not recognise or articulate the

symptoms of common mental disorders, an important consideration in designing quantitative

measures (Azzopardi et al., 2020) and framing community and health-system responses
(World Health Organization, 2016). Perceived determinants are also important. For example,

a qualitative study of Indonesian adults with unmet mental health needs identified

‘supernatural causes’ as a perceived determinant which is likely to be a powerful barrier to

accessing health services (Marthoenis et al., 2016). Stigma and other negative implications of

diagnosis are also determinants of health action; in some parts of Indonesia in the recent past,

people experiencing severe mental illness were physically restrained or confined (Minas and

Diatri, 2008).

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This study aimed to better understand mental health from the perspective of Indonesian

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adolescents, an important knowledge gap. It was framed around two main questions: How do

adolescents in Indonesia conceptualise mental health; and, what do Indonesian adolescents

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perceive to be important determinants of mental health?
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2. Methods

This qualitative study represents the formative phase of a mixed-methods project that has

been fully detailed elsewhere (Azzopardi et al., 2020). Methods relating to qualitative

analysis are presented in brief.

2.1. Populations

Two provinces were purposively selected to capture Indonesia’s geographic diversity: Jakarta

(urban mega-city) and South Sulawesi (inclusive of peri-urban and remote areas). We

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focussed on 16 – 18-year olds as this is the age when mental disorders typically manifest, and

also coincides with secondary school enrolment (an important sampling frame for the main

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study). Given the inter-relationships between social and educational transitions and

adolescent mental health, we engaged adolescents who were both in school and out of school.
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2.2. Design
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Focus group discussions (FGDs) were used to capture a broad range of perspectives and
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stimulate discussion amongst adolescents, although we did not seek specifically to understand

young peoples’ lived experiences of mental health. A semi-structured question guide was

developed, pilot-tested and refined to explore conceptualisation of mental health (Table 1).
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To explore perceived determinants, we used a visual-participatory method built around a

schematic of Bronfenbrenner’s socio-ecological framework, with participants marking in

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both perceived risks and protective factors at different levels. Levels were refined on piloting
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and included individual; peer; family; school; spirituality; media; and community. The first

two qualitative interviews were then observed, during which the conceptualisation of mental

health largely focussed on stress and depression. For consistency across FGDs, subsequent

discussions focussed around these constructs.

2.3. Sampling and recruitment

In-school adolescents were sampled from state schools in South Sulawesi, and state, private

and religious schools in Jakarta. Community-based participants (not attending school in last

90 days) were sampled from internet cafes and social institutions in Jakarta and referred by a

community health worker in South Sulawesi.

2.4. Procedure

FGDs were conducted in September 2017. Eight FGDs were undertaken to accommodate the

study locations, settings and separate sexes. All FGDs in Jakarta were conducted at a

centrally located research institute, with FGDs in south Sulawesi conducted at a school. A

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minimum of 8 and a maximum of 12 adolescents were invited to participate in each FGD,

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facilitated by two Indonesian researchers of the same gender and province as participants.

FGDs were conducted in Bahasa Indonesia in Jakarta and in the local dialect in South
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Sulawesi. Each FGD was audio-recorded, with additional notes taken by one of the

facilitators.
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2.5. Analysis
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Audio recordings were transcribed verbatim in Bahasa Indonesia and then translated into

English, with 10% back-translated to check accuracy. Transcripts were read and re-read by
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two researchers independently to inform the initial coding frame (inductive approach), with

transcripts coded using NVivo11 and the coding framework refined as required. Quotes were
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recorded to illustrate key themes. Findings were validated with the field research teams, in-

country partners and review of audio recordings as required.

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2.6. Ethics

The study was approved by the Alfred Health Human Ethics Committee, Melbourne,

Australia (approval 114/17) and the Ethics Committee of the Faculty of Medicine,

Universitas Indonesia (approval 714/UN2.F1/ETIK/2017). Written consent was obtained

from guardians, with written and verbal assent provided by adolescent participants.
3. Results

Eighty-six adolescents participated in the study (Table 2). Key themes are presented below,

with select quotes identified by setting (“C” community, “S” school), gender (“f” female,

“m” male) and province (“J” Jakarta, “S” South Sulawesi). Omitted text in a quote is

indicated as ‘…’.

3.1. Conceptualisation of mental health

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Mental health was recognised as a significant issue for young people in Indonesia.

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I think mental illness is a big problem in Indonesia since being a teenager means that
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we can be unstable, we can be moody, we can change easily based on society. In
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addition, there are many problems that we face, [such as] family, education, financial

issues. It’s just too much for teenagers (SfS)

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3.1.1. Good mental health

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Good mental health was conceptualised as ‘happiness’ by some respondents. Other concepts

included personal control (of problems, emotions, stress and personal limits), and the ability
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to socialise and interact with others. Some respondents also related good mental health to

spirituality.
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Good mental health reflects happiness. (SfS)

Good mental health reflects good emotional control and good relationships and

interactions with others. (SfS)

 Not being too obsessive. For example, he likes to play ball, but he is not obsessed with
things related to balls. (CmJ)

..understand their limit. For example there is someone who can’t swim but tries to swim
in the sea. So good mental health is about understanding your limits. (SmJ)

Good mental health can be seen from a religious aspect, such as their spiritual

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relationship with their God. It can be seen from an emotional aspect as well.. that

they can control their emotions. It can also be seen from a physical aspect, where they

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are seen to be healthy physically and spiritually, and also have good interactions with

society. (SfS) -p
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3.1.2. Poor mental health

Poor mental health was conceptualised as having a significant impact on people’s lives, with
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some Jakarta-based participants using psychiatric terminology including “personality

disorder”, “post-traumatic stress disorder” and “suicide.” A strong theme to emerge was that
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poor mental health included the inability to cope with contemporary pressures, poor social

skills and fractured relationships.

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In my opinion, mental illness is when they cannot do their daily activities normally
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(SfS)

I think people with mental disorders like being alone and are very emotional. They

don’t like people in their surroundings. There are even people who dislike their own

parents. (SmJ)
Some males associated poor mental health with interpersonal violence, whilst females

associated it with self-harm.

Sometimes we know somebody has a mental disorder because they like to hit others,

so we should be careful. (SmS)

Their behaviour is not usual. They do things that are not usual to do – suddenly

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crying alone, suddenly cutting. (SfJ)

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Three participants (from both provinces) explicitly described people with poor mental health
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as “crazy”, “insane”, and “weak”. Some participants also believed that it was possible to tell

the mental health status of an individual simply by looking at them, using terms such as
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“tattooed”, “malnourished”, “dirty”, “pale face”, “skinny”, “red eyes” and “not well
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groomed”.

3.2. Perceived determinants of poor adolescent mental health

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3.2.1. Individual level determinants

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Having “low self-esteem”, “lack of confidence” and engaging in anti-social behaviours were
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three of the major factors that were identified as individual risk factors for poor mental

health. Participants also identified lack of faith or spirituality, and engagement in mysticism

as determinants of poor mental health. Substance abuse (forbidden in Islam) was cited as a

determinant, as was poverty.

 They usually use drugs or other forbidden medicines that could lead to mental illness.

(SmS)

Maybe being poor leads to many thoughts and problems. (SfC)

Adolescents viewed various personality factors as protective, including being “optimistic”,

“hopeful” and “relaxed”, as well as being organised in their daily lives.

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.. depression is usually caused by a lot of activities and responsibilities such as

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homework and tests. We need good time management to be able to manage our

activities and duties so it won’t burden us (SmJ)

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A male participant from Jakarta believed that internalising emotions can lead to depression,
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which can be obviated by more open communication.
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We keep our distress and depression to ourselves, and it makes us suffer. So we

should build good communication. (JmS)

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Participants also identified a number of physical factors such as eating a “good and balanced
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diet”, “exercising routinely” and gaining “enough rest” as being protective against poor
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mental health.

3.2.2. Friends and peers

Bullying was consistently identified as a risk for poor mental health, with implications for

social interaction and school engagement. Many different outcomes were recognised,

including a number that were quite extreme.

I have a friend who is frequently bullied. It makes him rarely talk. (SmJ)

There are a lot of students who wish to [leave school] due to the pressure from their

surroundings… They may even try to make friends, but they only get bullied, isolated,

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or mocked. (SmJ)

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If someone gets bullied, she/he will keep it to her/himself. Then there will be a time
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when they cannot cope with it anymore, and finally they will become a psychopath.

(SmJ)
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Adolescents widely perceived the nature of relationships with friends and peers to be

important determinants of mental health, with relationships that were respectful, trusting and

tolerant perceived to be protective.

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Friends who always encourage us to do good things, are always there for us, always
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listen to us, can be trusted, and always give us advice. (SmJ)

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3.2.3. Family determinants

Family emerged as an important determinant of mental health.

Mental disorder in adolescence is first caused by family, then by surroundings or

 social life. (SmJ)

Parental pressure, particularly around educational performance and future endeavours,

emerged as an important risk.

...pressure from parents. It can cause someone to be sad and emotional. (SmJ)

Someone wants to be a singer, but her/his parents demand them to be a doctor. It

makes them feel pressured and may cause disturbances. (SmJ)

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Young people also identified lack of parental support as a risk.

Parents being super busy, no time for their children, no time for family. Parents don’t

care about their children. (SfS)

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Their parents are divorced so they feel abandoned. (CmJ)
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Relationships with family and parents that were supportive, understanding and provided

guidance whilst still enabling freedom, were identified as strongly protective. A common
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theme that emerged was the need for open communication between parents and children.
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Having more communication and spending time together with family may decrease
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depression and anxiety risk among adolescents. (SmJ)

I think to avoid mental disorder starts from the family. The family should let the

children express themselves and be less demanding, because parents’ role is only to
 guide and direct the children. Decisions should be made by the children. So they must

be given freedom and less pressure. (SmJ)

3.2.4. School-level determinants

Participants felt that the pressure placed on them by schools had a significant impact on their

mental health. They believed that teachers who were “too firm”, “stern”, “strict”, “cruel”,

“unfair” or “demanding” adversely impacted their mental health. The school curriculum was

also identified as a risk.

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The curriculum is unclear. It is always changing... Makes us confused. (SfJ)

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Beyond bullying, sexual harassment also emerged as a risk factor for poor mental health.
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Bullying and sexual harassment in school…can lead to depression. (SfS)
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Participants recognised schools as important settings to ensure mental health. Most protective

factors suggested by adolescents centred on characteristics of teachers, who they felt needed
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to be “patient”, “humorous”, “fun” and “not too demanding”. Some structural changes to

schools were also suggested, including the availability of counselling on campus.

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The teaching system should be optimal, not demanding too much, making clear rules

and helping students who are struggling. (SfS)

Focus not only on academic skills but non-academic skills as well. (SfS)
 Reducing lessons. Starting from half-past six until four o’clock. Also reducing the

tuition fee and providing fee assistance. (SfJ)

3.2.5. Spirituality and religiosity

Mysticism and disconnection from religion were identified as important risk factors for

mental health.

One of my neighbours has a mental illness because he deals with mystical things.

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(SmS)

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Mental disorder attacks the spiritual realm, so it depends on our closeness to God.

(SmJ)
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In relation to religion, people with mental disorders are those who are far from
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religion. When they get into trouble, they will get even further from religion. (SmJ)

A number of participants also felt that prayer and worship could be protective of anxiety and
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depression.
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If he meets the spirit, it makes him happy, so it won’t be as easy to get depressed.
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(CmJ)

... Allah does not burden a soul beyond what it can bear. When you feel anxious or

worry, just remember Allah every time, then you will be peaceful. (SfS)
3.2.6. Media and Social media

The majority of participants identified media (television, movies and social media) as a risk

factor for poor mental health. Many spoke about the need to be mindful about the amount of

time spent on electronic devices.

They should limit their time with all gadgets because spending most time with gadgets

will have a negative impact on health. (CfS)

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A consistent finding in discussion about social media was the ease of social media as a

platform for cyberbullying.

3.2.7. Community
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Identified risk factors included conflict (examples included war, brawling, fighting, coercion
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and massacre), lack of tolerance of religion, unemployment, corruption, badly regulated

governments, poor relationships with neighbours, and failure to adapt to social change.
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Uneven infrastructure such as the roads and uneven facilities such as the water. Yes,

the water is so dirty, it makes people stressed. (SfS)

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Protective factors included building good relationships with neighbours and communities that

were ‘tolerant’, ‘hospitable’, and ‘respectful’. Participants also spoke about the value of

actively participating at community events, including volunteering. The application of good

laws and a government that served with integrity and without corruption were also

mentioned.
4. Discussion

Mental health was recognised as a significant concern by these Indonesian adolescents. Good

mental health was conceptualised as emotional wellbeing and happiness, but in contrast, poor

mental health was predominantly described in terms of serious or severe mental illness

manifesting as emotional, behavioural and physical disturbance. Further, young people

believed that poor mental health only happened to ‘other’ people, with stigmatising views

prevalent. Absent from the discussions were features of common mental disorders such as

depression and anxiety (eg low mood, worries, poor sleep, loneliness) or an understanding

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that reflected poor mental health was both common and a normal aspect of being.

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Discussions around the determinants of poor mental health highlighted the challenge of

family connection (particularly that with parents), school pressures, and adverse exposures on
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social media to be important drivers of poor mental health, with religion also surfacing as an

important determinant.
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The conceptualisation of mental health by young people in this study is quite distinct from

adolescents in high income settings. A study of Swedish young people identified mental
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health as an emotional experience that was part of the human condition (Johansson et al.,

2007). A study of adolescents from the UK found mental health to embody different

emotions, thoughts and behaviours, with these young people articulating a ‘continuum of
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difficulties’ that ranged from minor worries or concerns to more severe distress (Roose et al.,
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2003). Adolescents in the UK also defined mental health problems to be ‘really hard to see’,

quite distinct from this study where participants felt it was possible to identify mental illness

from physical appearance, behaviours or traits. These differences in conceptualisation are

important, as it suggests that measures or initiatives developed for adolescents in high income

settings may not be effective for adolescents in Indonesia.

Many of the determinants identified by Indonesian adolescents in this study have been

reported in observational studies. These include: low self-esteem (Kaur et al., 2014), bullying

and social isolation (Arseneault et al., 2009; Lereya et al., 2015; Ott et al., 2011), family

separation and poor attachment (Johansson et al., 2007; Otsuka et al., 2020; Ott et al., 2011;

Wille et al., 2008), and academic stress (Kwak and Ickovics, 2019; Nguyen et al., 2013).

There were, however, some important concepts to emerge from the perspective of young

people that may help focus the target of preventative interventions. The first was the

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importance of engagement with parents (quite distinct from family separation), with young

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people suggesting that communication with parents and a sense of connection were protective

of mental health. The second related to school pressures, which extended beyond pressure to
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perform, and included the school environment, curriculum and teaching style. Bullying

emerged as a key theme across both school and digital settings.

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An additional key determinant was religion and spirituality. Indonesia is a majority Islam

country, and there is a large body of research highlighting the positive impacts of religion and

spirituality on mental health (Hovey et al., 2014; Regnerus, 2003; Weber and Pargament,
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2014). An Indonesian study of adolescents found that engagement with prayer and fasting

was protective against depressive symptoms (Purwono and French, 2016), with a global
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systematic review finding that adolescents who reported higher engagement in religion were
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more likely to have better mental health (Wong et al., 2006). However, some young people in

this study conceptualised mental disorder to arise from a failure of prayer or connection with

God. This attributes the cause of mental disorder to be a religious failure and may serve as a

barrier to accessing health services.

A strength of this study was the diverse sampling frame from school- and community-based

adolescents from urban and remote areas. While some differences across the samples

emerged (for example, Jakarta-based adolescents were more likely to use medical

terminology around conceptualisation of mental health), overall the samples were remarkably

similar. A further strength was the use of relatively unstructured FGDs that enabled young

people to explore mental health and its determinants in their own words. The visual-

participatory method of mapping determinants that was used in this study appeared

particularly successful in eliciting young people’s perspectives around determinants. While

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this study utilised focus group discussions in the hope that it would foster open and

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uninhibited discussion, the stigma associated with mental disorders in Indonesia may have

elicited biased responses, even though we were explicit that we did not wish to discuss any
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individual’s lived experience of mental disorder. Future studies may be strengthened by the

addition of individual in-depth interviews.

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This study’s findings provide the basis for a number of potential targets for mental health

intervention (Box 1). An important focus is the promotion of a better understanding of

common mental health problems amongst adolescents, that will also play a key role in
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essential efforts to reduce stigma (Sharma and Seshadri, 2020; Utz et al., 2019). Multi-

sectoral approaches involving the education, health and community sectors (including
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religious organisations) appear essential. In particular, schools provide an opportunity to

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build mental health literacy in students; they can also be intrinsically mental health promoting

institutions. This is consistent with the Health Promoting Schools framework that, led by the

World Health Organisation and UNESCO has called for “every school to be a health

promoting school”(WHO, 2020). School-based interventions for adolescent mental health

have commonly been implemented in high income settings (Das et al., 2016); however there
is a particular opportunity in Indonesia given that the health of students is a priority of the

Government of Indonesia (Indonesia’s Coordinating Ministry for Human Development and

Cultural Affairs, 2018), and there are examples of other health-promoting activities within

schools (Brooks et al., 2019; Mahendradhata et al., 2017). Examples of effective school-

based interventions are also increasingly available in the Asia-Pacific (Shinde et al., 2018).

Treatment of mental illness is also an important component of a public health response.

Efforts are underway to increase the adolescent friendliness of health services in Indonesia

(Nair et al., 2015), including building the competencies of health care providers to respond to

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adolescent mental health. For these services to be accessible and effective, investments are

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required to build community support for adolescent mental health, with Universal Health

Coverage extended to include these essential services (Agustina et al., 2019).

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This study highlights that mental health is an important issue for Indonesian adolescents.
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These data underscore the value of involving young people in research about them and offers
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an informed foundation for targeted response. Efforts must now focus on measuring the

community burden of mental disorder and designing and implementing effective public

health responses.
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Table 1: Question guide for conceptualisation of mental health
Mental Health
Question
What do you think of when you hear the word
‘mental health’?
What types of behaviours and emotional states do
you associate with people who have good mental
health?
What do you think of when you hear the term ‘poor
mental health/mentally unwell’?
What types of behaviours and emotional states do
you associate with people who have poor mental
health/are mentally unwell?
Do you think poor mental health is an issue for
adolescents in Indonesia? Why/why not?
What kinds of attitudes/behaviours do you think
people have towards individuals with poor mental
health?
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What do you think influences these
attitudes/behaviours?
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Probes
What do you think it means to be mentally well/ have
good mental health?
Why do you think being mentally well is important?
How do people who are mentally well behave?
What do people who are mentally well look like?
How would you describe poor mental health?
What terms have you heard other people use to
describe poor mental health?
How do people with poor mental health behave?
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What do people who are mentally unwell look like?
How would you know if someone you knew had poor
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mental health?
In what ways do you think poor mental health
impacts physical health?
In what ways do you think poor mental health
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impacts on relationships between people – e.g.
family, friends/peers, colleagues?
In what ways do you think poor mental health would
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impact schooling/education, free time employment?
Are there any cultural or religious beliefs that
influence these attitudes/behaviours?
Are people with poor mental health accepted by the
community? Do they face any stigma or
discrimination?
How do you think this stigma/discrimination impacts
on them?
Table 2: Participant characteristics
This table shows the demographic characteristics of respondents. Where shown, percentages
are expressed for columns (provinces).
Jakarta South Sulawesi Total
(n=45) (n=41) (n=86)

Gender, girls n (%) 21 (46.7) 20 (48.8) 41 (47.7)

Age (median, IQR) 17 (16 - 18) 17 (16 - 18) 17 (16 -18)
School type n (%) 24 (53.3) 24 (58.5) 48 (55.8)
- Private 8(33.3) -
- Public 8(33.3) 24 (33.3)
- Religious 8(33.3) -

Community setting n (%) 21 (46.7) 17 (41.5) 38 (44.2)

-
- Internet café 3(14.3)

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- Social institution 18(85.7)
17 (41.5)
- Community cadre -

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 f
Box 1: Key qualitative findings and potential implications for response

Mental health is a significant concern
for adolescents in Indonesia
Conceptualisation
oo
Implications for public mental health interventions
Adolescent mental health is a priority area for action.
Young people should be involved in designing, implementing and evaluating responses.

pr
Limited recognition of common There is a need for interventions that build mental health literacy
symptoms of poor mental health

e-
Stigma around poor mental health In addition to building mental health literacy, messaging (through media, schools, community, health
services and peer educators) could focus on 1) normalising mental illness and 2) communicating what
supports, resources and services are available and 3) the potential for recovery.

Pr
Family connection Interventions targeting parents that build awareness, understanding and emotional support for adolescent
mental health, and fosters healthy relationships and communication with their family.

School pressure Interventions targeting schools and teachers that aim to strengthen schools as health promoting
l institutions, including setting curriculums that are developmentally appropriate and environments that are
na
pro-social. Opportunities to embed mental health interventions within schools should be explored.
Determinants

Spirituality and religiosity Leaders of religious groups (particularly Islam) should be engaged in building mental health literacy,
addressing stigma, and dispelling beliefs that mental illness is a curse.
ur

Adverse social media Legislation that limits harmful exposures (i.e. minimum age for accessing social media). Guidance and
education (targeting young people, teachers, parents) around potential risks of social media (cyber-
bullying, body image, sleep) and how to mitigate these.
Jo

The potential benefits of social media (especially for adolescents disengaged from education) should also
be explored.
End materials

Authors' contributions

This study was led by PSA, SL and BW, with the investigator team including LW, YD, BM,
AR, AA, SS, TW, FK, JF, TT and NW. LW, PSA and NW drafted this manuscript with
contribution and approval from all authors. All authors have read and approved the manuscript.

Disclosure statement- Conflict of interest and funding

The authors report no conflicts of interest

Ethics approval and consent to participate

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Ethical approval was provided by the Alfred Hospital Ethics Committee in Australia and
Universitas Indonesia in Jakarta.

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Funding source and role
This study was commissioned and funded by the Health Cluster of the Australian Indonesia
Centre. The funding body did not have any impact on the collection, analysis, or interpretation
of data or on the writing of this this manuscript.

Financial Disclosure
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The authors declare no relevant financial interests.
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Acknowledgments

We would like to thank the young people who participated in this research project and
acknowledge the partnership and support from school and community partners.
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Figure 1 summarises key determinants (protective and risk) for poor adolescent mental

health, which are described in further detail below.

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