Perception on Anxiety among Adolescents and Mental Health Professionals and Development of Comic Strip

Abstract

Background:

Adolescence is a phase of many physical and psychological developments. This stage is also vulnerable to the development of mental illness. Anxiety is one of the most prevalent disorders among adolescents, which mostly onsets before puberty. This study aimed to understand the perception on anxiety among adolescents and mental health professionals and develop a comic strip on anxiety.

Methods:

This qualitative study involved focus group discussions (FGDs) among mental health professionals and pre-university college students. The FGD data were analyzed through direct content analysis according to the predetermined broad themes.

Results:

Awareness regarding anxiety was poor among adolescents, and in certain situations they were found to be reluctant to seek professional help. The comic strip on anxiety was developed based on the findings of FGD based on the themes, general awareness, factors responsible, symptoms and coping, management, and barriers to seeking professional help.

Conclusions:

Keywords

Anxiety awareness adolescents mental health professionals comic strip

Key Messages:

Two FGDs were conducted with mental health professionals and adolescents to derive the themes for the development of comic strip. The themes include general awareness, factors responsible, symptoms and coping, management, and barriers to seeking professional help. A unique study to develop a comic strip on anxiety for adolescents as a health education strategy to create awareness on anxiety.

Adolescence is one of the most important phases of human development.¹ Many neural changes influenced by certain hormonal changes happen during this phase.^2,3 This stage is important for learning to manage emotions and relationships and is also vulnerable to developing many sexual and reproductive health problems, mental illness, and injuries.¹

Adult mental disorders have an onset early in the young age itself. And among these, anxiety and depression begin before puberty and continue to adulthood.⁴ Anxiety, at a moderate level, stimulates people to adapt to stressful situations. Anxiety is considered excessive or pathological when it arises in the absence of challenge or stress, particularly when it is out of proportion to the challenge or stress in duration or severity.⁵

Anxiety disorders are one of the most prevalent mental health problems among young people, with a 12-month prevalence rate of 24.9%.⁶ Most of the functional disorders are likely to develop before 25 years of age, particularly between 11 and 18 years of age.⁷ Anxiety not amounting to a psychiatric diagnosis could be situational or a symptom of another psychiatric disorder.⁸

By late adolescence or early adulthood, the pure form of anxiety disorder decreases, with an increase in disorders like substance use disorders and depression.⁹ A survey among psychiatrists experienced in treating anxiety disorders showed that 45% of patients suffered from symptoms of GAD (generalized anxiety disorder) for ≥2 years before they were correctly diagnosed.¹⁰

Only up to one-third to half of the population affected with anxiety disorders seek help. Interventions to improve help-seeking for depression, anxiety, and general psychological distress include improving mental health literacy, destigmatization, providing information about different services available for seeking professional help, cognitive behavioral therapy, and personalized feedback.¹¹

According to Gulliver et al., stigma affects help-seeking behavior negatively. Increasing mental health literacy, social support, and encouragement can reduce the stigma regarding professional help-seeking.¹²

A 2017 study emphasized the significance of comic books as a tool for health information, as they not just disseminate factual information but also promote “self-awareness, reassurance, empathy, companionship and a means to explore the impact of illness on family relationships.”¹³

Several studies have shown that students of all ages can use comics to gain knowledge across topics and make meaning.^14,15 A study evaluating the influence of a comic leaflet on preoperative anxiety among children showed that the information on surgical procedure and anesthesia provided in the form of a comic leaflet effectively reduced preoperative anxiety.¹⁶ Logistically, comics are low-tech, involve low cost, are easy to make, and are highly effective in improving mental health literacy.¹⁴

Hence, the present study aimed to understand the perception on anxiety among adolescents and mental health professionals and later develop a comic strip to create awareness about anxiety and its management.

Material and Methods

This qualitative study was conducted from December 2019 to May 2020. A total of 12 students (7 girls and 5 boys) of a pre-university college in Urban Bangalore, aged 15-17, who can read, write, and converse English, were included. They were enrolled using purposive sampling. Informed assent was obtained from all the students before the FGD. Consent form was obtained from the parents. Eight mental health experts who have worked for at least two years in the area of mental health and were willing to consent were included. These included one psychiatrist, two psychologists, two psychiatric social workers, one yoga therapist, and two public health experts. The study was approved by the Institute Ethics Committee under Behavioural Sciences Division, National Institute of Mental Health and Neurosciences, Bengaluru.

Procedure

One focus group discussion (FGD) was conducted among the eight mental health experts and another among the 12 college students in January 2020. Two distinct FGD guides were prepared by the first author for conducting FGD with mental health experts and students. The FGD guide for mental health experts focused on broad areas of anxiety and its prevalence among adolescents, factors influencing it, presenting symptoms, coping, barriers to help-seeking, and its management. The FGD guide for the students focused on awareness about mental health and anxiety, factors influencing, coping mechanism, attitude toward help-seeking, and identifying barriers to help-seeking. The FGDs were conducted by the moderator (the first author) using the FGD guide, and she took help from her batchmates to take notes and for audio recording. The comic strip was developed based on the findings of both the FGDs.

Analysis

Both the FGDs were audio-taped. The data collected were analyzed manually through direct content analysis, in which the transcript of the two groups were first examined separately. The frequency counts were noted and compiled according to the predetermined broad themes listed in the FGD guide. The predetermined broad themes included general awareness on mental health and anxiety, factors leading to anxiety, symptoms and coping, management of anxiety, and barriers to seeking professional help.

Results

There were a total of 12 students (7 girls and 5 boys) included for the FGD, and the average age of the students was 17 years. All of them were studying in second-year pre-university in a private college and were residents of an urban area. All the eight mental health experts involved in the study were working in private health facilities. The findings of the FGD’s among mental health experts and students based on themes and sub-themes presented in Table 1 are described below.

Table 1.

Summary Table of the Findings of the FGDs among Mental Health Experts and Students, Categorized Based on Themes and Sub-Themes.

Theme	Sub-Themes	Codes	Sub-Themes	Codes
Theme	Mental Health Experts (n = 8)	Codes	Students (n = 12)	Codes
General awareness	Improvement in help-seeking by increasing awareness	8	Importance of mental health for overall health	12
General awareness	Lack of support from parents in identifying the problem	5	Being mentally healthy can help concentrate better, think properly, and make better decisions	12
Factors leading to anxiety	Everyone has some element of anxiety	8	Exam stress, worries about the future, parental expectations	12
Factors leading to anxiety	Conflict with parents and lack of social life increases the risk of anxiety	4	Change of school leads to anxiety	1
Symptoms and coping	Symptoms include frigidity, restlessness, inability to focus, being withdrawn	8	Symptoms include constant worry, headaches, loss of balance, discomfort in the stomach	12
Symptoms and coping	Means of coping can be healthy or unhealthy	4	Means of coping include connecting with friends, relaxation techniques, talking to family members	8
Management of anxiety	Active support from parents to overcome anxiety	8	Need to seek help from mental health professional	5
Management of anxiety	Educational interventions help to deal with anxiety	4	Active support from parents and also spending time with them help in coping	12
Barriers to seeking help	Students are not comfortable reaching out to school counsellor due to concerns about confidentiality	8	Factors like stigma and lack of support from family	12
	Lack of support from parents	8	Lack of confidentiality and trust	5
	Lack of support from parents	8	Availability of mobile apps for information and help-seeking is sought, as no face-to-face interaction is needed	3

According to some (n = 6), it is important to consult a mental health professional when a mental health issue is out of control. Most students (n = 12) listed the following barriers to seeking professional help: stigma regarding mental health prevailing in society, the assumption that a good rapport may not be there between the person and the professional, and lack of support from the family. One of the excerpts mentioned says, “The factors like others may create rumour or call me mad, will stop me from not seeking help from professionals.” A few students (n = 3) thought professional aid would not be helpful. A few (n = 3) expressed the need for an app through which they can search for information concerning their personal problems and seek solutions, without any face-to-face interaction, so that anonymity will also be maintained.

The story script was derived based on the themes and sub-themes, with an intention to educate the adolescents on anxiety and its management.

The theme was set as “early identification and mitigation of anxiety of an adolescent boy,” and the subthemes identified were exam anxiety, stage fear, symptoms of anxiety (perspiration, shivering, and intrusive thoughts), help-seeking, the role of a mental health professional, management methods (medication, psychotherapy, and coping strategies like breathing techniques).

Development of the Comic Strip

The script for comic strip was finalized based on the themes and subthemes derived from both the FGDs. Considering the positive effect of relatability in health education materials, an adolescent boy (Gopu) was chosen as the protagonist for the comic.¹⁷ The comic strip was developed incorporating the themes and subthemes, with the help of a professional artist.¹⁸ The details of the content of the comic strip have been explained in Table 2. The comic strip was shown to two people who were not from mental health background whose inputs were incorporated to the final version

Table 2.

Description of Contents and Structure of the Comic Strip with Respect to Various Themes Derived.

Themes	Contents Covered in the Comic Strip
General awareness	Gopu starts having anxiety in multiple situations such as exams, stage fear, etc. He still ignores it as there is lack of awareness.
Identification of anxiety and the various factors causing it	Gopu’s mother identifies that he is having a hard time facing his fears. She suggests seeking help from a mental health professional.
Symptoms and coping	The mental health professional helps Gopu to practice some coping mechanisms to deal with his fear, and this resulted in reduction of symptoms.
Management of anxiety	Gopu starts to feel much happier and relaxed after starting regular psychotherapy sessions and other coping mechanisms like yoga, having a pet, and breathing techniques.
Barriers to help-seeking	Gopu knew he needed help, but still, he did not seek help from any of the support systems available to him, such as his friends, teachers, parents, etc.

Discussion

We found that even though young people are aware that physical and mental health are equally important and interrelated, they still have an ambiguous concept of mental health. Study by Ogorchukwu et al. conducted among adolescents aged 15-19 years supports the same.²⁰ Young people also understand the importance of consulting a counsellor or a mental health professional in case anybody has some mental health issues. According to mental health experts, very few are reluctant to seek help. Dardas et al. showed that while 67% of adolescents preferred psychotherapy if they had any emotional crisis, 65% opined that they would not seek help from a psychologist in case of emotional problems.²¹ The comic strip in this study is an attempt to create awareness on anxiety for early identification and to emphasize the importance of seeking professional help.

We found that factors influencing young people to develop anxiety could be broadly divided into individual vulnerability and external factors. Individual vulnerability includes factors such as low self-esteem, perfectionist traits, self-criticality, and extreme thinking. External factors include the nature of parenting; like overprotective parenting, critical parenting, and communication challenges at home; lesser social interaction; academic stress, and marital discord between parents. Bhatia et al.⁹ and Thabrew et al.²² suggest some additional factors for anxiety among children, such as family dynamics, type of parenting, loss of control over one’s circumstances, and peer pressure.

Adolescents cope with anxiety in both healthy and unhealthy manners. Reuben et al. explain trusting relationships where people can reach out to cope better.²³ In the present study, participants gave special focus to healthy coping mechanisms like yoga, meditation, and having a pet, which were incorporated as a part of the comic strip.¹⁸

The present study indicates that lack of confidentiality and credibility issues resulted in not seeking professional help for anxiety. Adolescents are looking out for better relationships with parents and peers to reach out in case of mental health issues. Financial concerns, stigma, the assumption that they can’t develop a good rapport with the professional, and lack of support from parents or peers are the other barriers. Similar barriers to help-seeking were found by Gulliver et al., where the barriers identified were stigma and embarrassment, poor mental health literacy, concern about the help provider, inaccessibility to the service, and self-reliance.¹²

The importance of raising awareness on anxiety and its management among adolescents is attempted in this study by developing a comic strip. A similar attempt has been made by Kapanee et al. in developing a picture book on mental health for adolescents.¹⁵ This method of health education can also help in destigmatizing mental health and promoting help-seeking behavior.

Implications and Future Recommendations

There is a critical need to develop awareness about anxiety and its management among adolescents. The development of a comic strip on anxiety can be useful in improving mental health literacy among adolescents and in sensitizing them to various mental health issues. Further studies are recommended to evaluate the effectiveness of the comic strip in improving awareness among adolescents with regard to anxiety and its management. Such resources can be made available for students through online and social media campaigns.

Limitations

The study focused only on adolescents of a particular age range and all residing in urban Bengaluru, thereby making it difficult to generalize its findings. Therefore, in future studies, the scope can be expanded by including different genders, age groups, and settings—private schools, government schools, etc. Only one round of FGDs could be conducted for mental health experts and students, due to short study duration and lack of permission from the college. This resulted in small sample size, reducing the scope of conducting a detailed study. In the future, the study should include multiple detailed FGDs to explore further. The validation of the comic strip and also the feasibility assessment could not be done due to short study duration and the onset of the COVID-19 pandemic in March 2020. Future studies can be further strengthened by validating the comic strip and conducting a feasibility assessment on its effectiveness. No experts specialized in child and adolescent mental health were included in the FGD group of mental health professionals, making it a major limiting factor in the study. Any future studies planned in this area should include experts specialized in child and adolescent psychiatry and psychology.

Conclusion

Adolescents perceived mental health as very important for their overall health. The adolescents did not know that they were going through anxiety, but they noticed that they had some mental health issues and wanted to get out of it. The factors that resulted in anxiety were academic pressure, exam stress, and parental expectations. The barriers for not seeking professional help included lack of support from parents and family, lack of confidentiality, stigma, financial concerns, and fear of rumors. One of the important strategies to overcome these barriers is health education, and the development of a comic strip on anxiety based on the findings of FGD such as, the importance of professional help-seeking, healthy coping strategies, and overcoming barriers was a unique attempt to improve awareness.

Supplemental Material

Supplemental material for this article is available online.

Supplemental Material

Supplemental material for this article is available online.

Footnotes

Acknowledgements

We thank the college management. We also thank the illustrator for his contributions.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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