Efficacy of a Mental Health Game-Board Intervention for Adolescents in Remote Areas: Reducing Stigma and Encouraging Peer Engagement

4.1. Stigma Reduction and “peer” Health-seeking Behavior

Analysis from the pre and post-test results of the stigma, perception, knowledge, and attitude toward the board game exposure questionnaire in Table 1. showed that only two variables showed significant differences, with all scores increasing. The first variable that exhibited a notable difference was related to the stigma and fear surrounding mental illness and those who suffer from mental disorders.

The findings in Table 1. were congruent with the Student's perception after exposure to the board game (Table 2). The perception of taking Professional and counselor help in mental health problems are the two components with the lowest proportion of strongly agree and agree answers. On the other hand, the perception of seeking peer help and engagement with peers had a higher proportion of strongly agree and agree on answers rather than the professional and counselor help in addressing mental health issues. These findings stated the advantage of the carpe diem board game in enhancing peer roles in adolescent mental health problems. Using board games, which facilitate simultaneous face-to-face interaction, could bring more engagement and emotional involvement between subjects.

Social stigma was the fourth-highest-ranked barrier to help-seeking behavior in mental health problems [26]. Adolescents who face such stigma related to mental health issues may face negative consequences, including a reduced likelihood of seeking help and a lower quality of life. Various factors, including gender, can impact how adolescents perceive such stigma, as mentioned by the participant below:

“……… several factors influence depression itself, and it could be from family, society, the school environment, maybe like bullying; maybe it's also because he has his friends who he thinks can help him, but in reality, the sharing just makes his problems increase.” (M-17)

Findings from the content analysis in Table 3 showed that The Carpe Diem tends to reduce the stigma through a collaborative experience in facing many scenarios provided during the gameplay. Stigma and fear towards mental illness and individuals with mental disorders significantly differ in pre and post-test scores. These findings showed the possibility of the game-board intervention in reducing stigma. Stigma often consists of three components: stereotypes, which refer to negative preconceived notions about a specific individual or group; prejudice, which entails the presence of negative emotional responses; and discrimination, or the actions taken in response to it. Stigmas' primary consequence is deterring persons from pursuing treatment for mental health concerns [27, 28].

According to the previous research, gamification has been identified as a potential strategy for minimizing obstacles to participant engagement in interventions. It includes addressing participants' defensiveness and alleviating their suffering with destigmatizing as the outcome [29]. This board game also allows direct social contact with people with mental illness at the individual level at a similar time, and this direct interaction could decrease the stigma among players. This mechanism could explain why the stigma decreased in this study after the game-board exposure [30].

I learned that everyone is at risk of mental illness, and the causes and ways to deal with it are also different. When we run out of + cards, we will think that help from other people is also very important (F-17)

One contributing factor to stigma is the level of Mental Health Literacy (MHL) among individuals, which encompasses identifying mental health illnesses and knowing the appropriate avenues for seeking treatment [27]. Many children and adolescents experience mental health challenges that can impede their growth and overall well-being. Regrettably, most young people with mental illness do not actively seek or receive appropriate mental health services, a reluctance that can be attributed to the social stigma surrounding mental health issues [31].

From the health-seeking behavior post-exposure questionnaire results and the theme that emerged from the qualitative data (Table 3), most participants have a good mental health perception of seeking help with the most outstanding readiness: the willingness for friends or peer help. The health-seeking behavior findings are congruent with the pre-post test score Beliefs and perspectives on the existence and environmental cause of mental disorders, which significantly increase after the game-board exposure. Thus, a board game was reported to prevent illness-prone behaviors in young people effectively [32]. These points were mentioned by several participants, as represented in the quotes below:

Yes, this game made me think that no matter how great and capable I am, it turns out I still need other people to ask for help (M-17)

Because if there is stress and problems at home, they will come to share, share, and sometimes cry together. (F-16)

Using gamification techniques in board games can improve players' cognitive knowledge and generate a transformative shift in their attitudes and perspectives on a specific subject [32, 33]. Increased literacy increased awareness of this situation, resulting in a paradigm shift toward health-seeking behavior. Among other 'outside' people, peers or friends were the most preferred to be consulted in adolescent mental health difficulties. The involvement of peers with varying mental health statuses in board-game engagement could explain how peer preference outperformed other health-seeking activity preferences. Multiple studies demonstrating the benefit of peer support in reducing anxiety, decreasing effects, and increasing self-esteem in young people with mental illnesses could explain this conclusion [34].

The personality and characteristics of the peers involved can significantly impact the effectiveness of using the board game as a medium for peer support among adolescents with mental health issues. The qualitative analysis (Table 3) revealed that peer involvement could foster a cooperative nature and teamwork, help people realize the importance of social support, teach problem-solving skills, and stimulate supportive behavior. The board game can help them identify and start interactions with peers who experience similar problems. This peer interaction could also foster the experience of behavioral modeling and social learning in many studies [24, 35, 36].

4.2. Further Improvement of the “Carpe Diem”

A few adjustments need to be made to enhance the effectiveness of the game Carpe Diem and ensure that it fulfills its intended purposes. From the quantitative phase result of the pre-post test result in Table 1, the Carpe Diem board game tends to stimulate the change in subject perception toward stigma and general mental health awareness. Still, it needs improvement in mimicry role-playing the actual mental health problems in the local context. It includes perception regarding the risk factors, treatment or health-seeking behavior, how to deal with mental illness people, and the prognosis of the mental disorders.

Three significant improvements can be implemented based on the qualitative findings, as defined in Table 3. Firstly, integrating the game into the formal curriculum would provide a structured and educational context. Secondly, modifying the game rules to align with real-life situations would enhance its authenticity and practicality. The game development should capture the specific local context environmental determinants, including family dynamics, socioeconomic status, peer relationships, and exposure to adverse life events. Dysfunctional family environments, financial stressors, peer pressure, social relationships, and traumatic experiences have been demonstrated to contribute to the emergence of mental health challenges significantly [37, 38]. The board game has to fulfill the socio-dynamic and local context of mental health problem determinants, as mentioned by our participants below:

So, my parents had separated, and then when my mother remarried, it was like, Mom, you don't love me anymore; why did you have to remarry? But as time went on, I couldn't accept the depression, so what was the point of crying all the time? In the end, yeah, leave it alone (F-17)

For example, at home, our parents are angry, we think that our parents hate us, so we keep it in our minds and our hearts, that makes us have more and more burdens on ourselves, then outside our friends are like bullies, well that's basically where we keep the problems, so in the end they want more, he wants more, wants to be alone, quickly gives up, doesn't want to hang out with people that's what I know about the characteristics of depressed people (F-16)

Psychological factors, such as self-esteem, coping strategies, and emotional regulation skills, also play a pivotal role. Adolescents with inadequate coping mechanisms and difficulties in expressing and managing emotions are more susceptible to developing mental health disorders [39]. In conclusion, the intricate interplay of biological, environmental, and psychological factors collectively shapes the landscape of adolescent mental health problems. A comprehensive understanding of these determinants is imperative for formulating targeted interventions and preventative strategies using the board game Carpe Diem.

Thirdly, increasing the game's motivational impact could be achieved through repeated visual exposure to motivational stimuli, such as written quotes on the back of the cards that players need to emphasize verbally. Lastly, improving player engagement with the game's underlying message would be beneficial rather than solely focusing on winning. These last two enhancements are crucial since they are directly linked to the board game's objective [40].

4.3. Strengths and Limitations

The current research possessed some notable strengths. To the best of our understanding, this board game is a pioneering effort in the mental health field, and it is being used as a game-based education strategy, as it has been specifically designed to cater to the unique societal diversity found in Indonesia. Moreover, it possesses the potential for adaptation to other regions or countries with their distinct sociocultural contexts. In this study, we specifically focused on examining the potential benefits and areas for enhancement of a board game. Our investigation involved 45 adolescent participants residing in remote/periphery regions of the east part of Indonesia in a participatory design approach. This study makes a valuable contribution to the existing literature by examining the efficacy of incorporating games in mental health literacy, specifically the use of a board game, into the formal curriculum of secondary-level schools. The findings suggest that this approach can effectively enhance destigmatization by increasing awareness and encouraging adolescents with mental health problems to seek and or become peer helpers. Furthermore, the study highlights the potential of non-traditional psychoeducation methods, such as board games, in addressing mental health concerns within the formal school setting. These findings hold promise for the long-term sustainability of adolescent mental health interventions.

There were some limitations in this study. The sample of this study in the quantitative phase used the cluster of senior high schools and did not represent the whole age range of the adolescent population; therefore, during the qualitative phase, we used maximum variation sampling to select a sample that reflects the socioeconomic characteristics of adolescents in remote/periphery areas. Another strength of the study was the use of mixed methods, which contributed to an in-depth comprehension of how the proposed game was evaluated from a broader and more profound perspective in assessing and improving the board game for mental health in adolescents. Further studies that include junior high school adolescents and non-formal high school students will enhance the findings and insight regarding the variables of this study in the future.