Comparative study on school-based mental health literacy in three Asian countries | Tropical Medicine and Health

This study used deductive content analysis to examine both policies and basic education curricula related to school-based mental health literacy in three Asian countries—the Philippines, Indonesia, and Japan—which have successfully enacted and implemented mental health laws or policies addressing the needs of both adults and school-aged children. These three countries, each with their own unique socio-cultural environment, including their approach to education, offer a rich tapestry of strategies and methodologies for addressing mental health literacy. Table 1 shows a comparison of the characteristics of the target countries. This study analyzed school-based mental health literacy policies and basic education curricula from the Philippines, Indonesia, and Japan using deductive content analysis. Policies were examined with the policy triangle framework and global mental health policies, while the basic education curricula were analyzed based on prior studies. The collected documents of this study analyzed both policies and basic education curricula that were adapted to the deductive content analysis methods. Policies were analyzed using the policy triangle framework [23] and mapped using the review points [10]. Basic education curricula were analyzed using the definition of mental health literacy [7].

Progress of the National Center for Global Health and Medicine (NCGM) project on mental health

The NCGM project, launched in 2017, initially focused on mental health training for educators, health workers, and physicians in Japan and the Philippines [24]. In 2020, it expanded to address mental health promotion challenges through collaboration with the University of the Philippines Manila [25]. By 2022, the “School Mental Health Project for Children and Adolescents Post-COVID-19 Pandemic” advance school mental health initiatives, particularly in developmental disorders. In 2023, the project became a tri-nation collaboration, including Indonesia. In 2024, the project convened a meeting to standardize school mental health literacy education across Southeast Asian countries.

Data collection

The policy document review identified recommendations for policy options for school-based mental health literacy by conducting a comparative analysis among Asian countries with similar populations. These included the Philippines, Indonesia, and Japan. The curriculum review was conducted to describe the national curricula on mental health literacy education in the selected countries. This study acknowledged potential limitations, such as incomplete access to policy documents or curricula, which may have resulted in gaps in the analysis. To address these issues, efforts were made to obtain comprehensive data by consulting official government sources, education departments, and publicly available databases.

The collection and review of documents was conducted through three meetings in November 2023, February 2024, and June 2024. These meetings were organized by the Department of Child and Adolescent Psychiatry of Kohnodai Hospital, National Center for Global Health and Medicine in Japan. NCGM has contributed to the promotion of mental health among children and adolescents through the Program for International Promotion of Japan’s Healthcare Technologies and Services. An overview of the NCGM project is provided below. After collection, all data were analyzed to compare findings across the three Asian countries, including policies and curriculum.

Policy document review

The policy document review was conducted to identify the legal and policy foundation that shapes school-based mental health literacy. Documents may be used as part of a systematic evaluation within a study, and they may take a variety of forms [26]. This study collected policies and curricula on mental health literacy based on the common framework among the three countries and analyzed the policies (the Philippines, 22; Indonesia, 9; and Japan, 6) and curricula that were constructed by the Ministry/Department of Education in each country. The policies were extracted from the collected documents using a stepwise process as follows:

1. (1)

   Policy collection

The collection of policies was carried out according to the following keywords: (school health OR health promoting school) AND (mental health) AND (law* OR policy* OR regulation*). This was followed by Google searches with regional settings applied, using the same search terms along with the country name (e.g., ‘search terms’ and Japan). Official government websites and inputs from local mental health experts were also utilized to search for pertinent policies. The keywords were used to search for relevant policies in the local language such as in Japanese for Japan and Bahasa Indonesia for Indonesia. In the Philippines, the policies were searched in English. Data were extracted from school health/mental health policies released between 2000 and 2023.

1. (2)

   Translation and policy screening

The collected policies from Japan and Indonesia were translated into English from the local language using a translation function (DeepL Translator) to maintain the accuracy and quality of translation. After collecting the policies, the researchers used a translation function to interpret their contents, and this confirmed the accuracy among the researchers. Relevant policy documents on mental health were collected and classified into the framework and were extracted according to policy definitions stated by the Centers for Disease Control and Prevention (CDC) [27]. The collected policies were screened and the type of documents based on the policy definition by CDC including a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions throughout the policy screening.

1. (3)

   Summary of the collected policies

The titles of the collected policies related to school-based mental health literacy among three Asian countries are summarized in Table 2. Also, the details of collected policies in each country are summarized in Table 3 (Philippines), Table 4 (Indonesia), and Table 5 (Japan).

Curriculum review

School curricula related to mental health literacy were extracted in each country and were reviewed which targeted school-aged children who are from elementary schools to high schools. The Philippines, Indonesia, and Japan employ distinct national curricula to address educational goals. The Philippines has implemented the K-12 curriculum, a comprehensive framework covering Kindergarten to Grade 12 emphasizing core competencies, career readiness, and specialized senior high school tracks for holistic development. In Indonesia, the curriculum fosters thematic learning, incorporating science, technology, engineering, arts, and mathematics (STEAM). The “2013 School Curriculum (Kurikulum 2013 Sekolah)” focuses on competency-based learning, integrating character education, STEAM, and critical thinking, with accessible guidelines for uniform implementation. The total number of curricula was indicated in the curriculum review of the Methods section as follows: Philippines: Elementary School (20), Junior High School (12), Senior High School (4) (Table 9); Indonesia: Primary schools (3), Middle Schools (2), Senior High Schools (3) (Table 10); Japan: Elementary School (5), Junior High School (7), High School (9) (Table 11).

1. (1)

   Curriculum collection

The K-12 curricula in Japan and Indonesia which are written in their respective local dialects and the curriculum of the Philippines, which was in English, were collected for this study.

1. (2)

   Curriculum screening

The reviewed curriculum was extracted by referring to the guidelines for K-12 curricula in the Philippines, Indonesia, and Japan.

Data analysis

The data collected were analyzed separately for both the policies and the curricula using a deductive content analysis approach [28, 29]. The policies in the three Asian countries were analyzed using two matrices. The first matrix (Table 6) examined policy content and actors using the policy triangle framework [23]. The extracted policies were examined through two policy-making elements, specifically the actors and content (Table 6), according to the policy triangle framework of (i) processes, (ii) actors, (iii) content, and (iv) context [23].

The second matrix (Table 7) assessed the policy context in terms of the “Summary of key points of global mental health guidelines and manuals of UN agencies” [10] in comparison with global recommendations. The curriculum analysis was performed deductively following the definition of mental health literacy by Jorm in 2012 [7] and summarized in Table 8. With regard to the consultation between the researchers and stakeholders, contributed to extracting the findings and identifying the policy contents such as differences or commonalities, and brushing up the process of the reviews during the meetings throughout the project.

Policy content analysis

Walt and Gilson stated in 1994 that understanding the process of health policy reform enables policymakers and researchers to plan more effectively for its implementation (Fig. 1). This framework allows for an in-depth understanding of the factors in the policy triangle by illustrating how they are interrelated. The triangle framework illustrates four dimensions and the linkages between them that should be considered when conducting policy analysis. In this study, two dimensions such as “content” and “actors” were applied to examine policy content and who implements it in each country. The content pertains to the substance of the policy proposal and the actors who are fundamental in formulating the policy and during policy implementation. The researchers reviewed the policies in each country (Tables 3, 4, 5) and clarified the “actors” and “contents” that are related to school-based mental health literacy (shown in Table 6) [30, 31].

A model for health policy analysis [23]

Policy mapping analysis

Table 7 was developed to assess the context of key national policies related to school-based mental health. The policies were assessed according to an adapted version of the “Summary of key points of global UN agencies’ “mental health guidelines and manuals” by Margaretta et al. in 2023 [10], which was compared with the global recommendations. The global policy reviews identified several commonalities among UN global policy documents on school mental health, such as the promotion of comprehensive school health and collaboration between schools, government, families, and communities, and this was summarized a total of 21 items that were used to assess the comprehensiveness of national policies relevant to school-based mental health (Table 7). The reviewers (co-authors) in each country consulted with their colleagues from government agencies or other experts and responded with changes through a consultative process [30, 31]. Information was abstracted from the identified policies in each country in Table 3 (Philippines), Table 4 (Indonesia), and Table 5 (Japan), relating to each of the 21 items. Policies were ranked (“Yes”, “Partial”, and “No”) based on how comprehensively they addressed each of the items in school-based mental health policies and manuals.

Curriculum content analysis

The extracted curricula were analyzed deductively by referring to the definition of mental health literacy stated by Jorm in 2012 [7] and summarized in Table 8. Because the definition of mental health literacy curricula was not decided officially, thus, this study referred to the previous study in Japan by Ojio et al. in 2019 [22] to adapt the other countries such as the Philippines and Indonesia. This previous study indicated that the contents of the course of study in Japan were related to the concept of mental health literacy stated by Jorm et al., 1997 [1] and Kutcher et al., 2016 [32] following: (1) mechanisms of mental illness, prevalence, onset age, risk factors, and treatability, (2) typical symptoms of mental health problems and illnesses, (3) self-help strategies for prevention of and recovery from mental illness, (4) enhancing help-seeking and helping behavior and (5) decreasing mental health-related stigma. Deductive content analysis is applied when the structure of the analysis is operationalized based on prior knowledge [28, 29]. Accordingly, the curriculum was classified in consideration of the definition (concept) of mental health literacy stated by Jorm in 2012 [7] that were synthesized in Table 8, and it was reflected originality of this study to identify several challenges of this definition. Curriculum content analysis information was abstracted from the identified curricula in each country in Table 9 (Philippines), Table 10 (Indonesia), and Table 11 (Japan).