Conceptualisations of positive mental health and wellbeing among children and adolescents in low‐ and middle‐income countries: A systematic review and narrative synthesis

Abstract Background Mental illnesses are the leading causes of global disease burden. The impact is heightened in low‐ and middle‐income countries (LMICs) due to embryonic care systems and extant barriers to healthcare access. Understanding children and adolescents' conceptualisations of mental health wellbeing in these settings is important to optimize health prevention and promotion initiatives. Objective To systematically review and synthesize children and adolescents' conceptualisations and views of mental health and wellbeing in LMICs. Design Ten databases were systematically searched from inception to July 2020 and findings from included studies were synthesized. Results Twenty papers met eligibility criteria comprising qualitative, quantitative and mixed methods studies. Children and adolescents identified aspects of mental health and wellbeing, including positive affect and outlook and having sufficient personal resources to face daily challenges. Identified factors recognized the importance of activating both kin and lay networks in supporting and maintaining wellbeing. Conceptualisations of mental health and wellbeing were varied and influenced by culture, developmental stage and gender. Discussion and Conclusions Irrespective of environmental and sociocultural influences on concepts of wellbeing and mental health, children and adolescents in LMICs can conceptualise these constructs and identify how they pursue positive mental health and wellbeing important for developing age and culture‐appropriate community mental health strategies. Our review highlights the need to extend inquiry to wider developmental stages and both across and within specific populations in LMICs. Patient and Public Involvement Initial results were presented at stakeholder workshops, which included children, adolescents, parents and health professionals held in Indonesia in January 2019 to allow the opportunity for feedback.


| INTRODUCTION
Mental health problems constitute the leading cause of disability among children and adolescents globally, accounting for almost half the disease burden. 1 In childhood, they are linked with a myriad of social problems, such as substance misuse, academic failure and school drop-out giving rise to impaired physical and mental health later in life. 2,3 There is a growing imperative to prevent and protect children and adolescents from developing mental illnesses as well as to promote positive mental health and wellbeing, 4 particularly in lowand middle-income countries (LMICs) where intervention implementation is hampered by limited healthcare resources. 5 Research in school-based mental health has focussed largely on reducing stigma and improving negative attitudes to encourage appropriate help-seeking for mental health problems. As such, mental health literacy approaches have traditionally adopted a deficit approach. 6 Evidence from systematic reviews and meta-analyses shows that multicomponent mental health promotion interventions are effective, 7-9 particularly when adopting a positive mental health stance rather than focusing exclusively on illness prevention. 7,10 There is conflicting evidence, however, and a separate review suggests that these interventions are minimally efficacious and do not demonstrate sustained effects in school-going cohorts. 11 Operationalizing and standardizing specific target outcomes related to positive mental health and wellbeing poses a distinct challenge. 11 A range of relevant outcomes reflect the broad nature of the field and some are flawed due to ceiling effects in community-based populations. 11 Selecting multiple target outcomes for reviews increases the likelihood of achieving positive effects 10 and highlights the need for greater clarity in concepts and outcomes measured. Additionally, in varied geographical settings, these constructs are likely to be influenced by the sociocultural contexts in which they are perceived. Few studies attempt to measure the success of communitylevel promotion programmes to improve positive mental health and well-being from the perspective of children and adolescents. 11 There is increasing awareness that strengthening knowledge about what constitutes good mental health and how to maintain it may have a positive effect on overall wellbeing. 12 Arguably, the success of health-promoting initiatives is contingent on the extent to which interventions take into account an individual's own understanding and beliefs. 13   Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 16 The review protocol was developed and revised by the authors. The protocol is registered in PROSPERO (CRD42019122057 available from https://www.crd.york.ac.uk/ prospero/display_record.php?ID=CRD42019122057). tabases. An example search strategy is available from the author on request. Forward citation tracking was undertaken for included studies up to April 2020.

| Eligibility criteria
This review included original research that utilized primary data to examine the conceptualisations, views and perceptions of children and adolescents regarding positive mental health and wellbeing. Studies that had used qualitative, quantitative or mixed-method designs were included. Also, studies that reported on samples of children and adolescents in LMICs with a mean age under 18 were included. LMIC countries were defined by the Organization for Economic Cooperation and Development (OECD) Development Assistance Committee 2018-2020. Peer-reviewed journal articles and dissertations were included. Conference paper authors were contacted to include peerreviewed, full-text articles of studies where available. Non-English studies were included, and data were extracted by bilingual researchers affiliated with the study team. No date restrictions were used, and studies were not excluded based on the results of the quality assessment. Full inclusion/exclusion criteria can be found in Table 1.

| Screening
Returned records from database searches were combined, duplicates removed using Endnote software, and remaining references imported to the Covidence tool (https://www.covidence.org/). Two reviewers independently screened the title and abstracts of each study for relevance during the first stage of screening. Full texts of potentially relevant articles and those which did not contain sufficient information at the level of title and abstract were obtained and doublescreened by two reviewers. Disagreements regarding inclusion or exclusion that did not achieve consensus were resolved by a third reviewer not involved in the original decision. The authors met regularly throughout the review process to discuss the process of screening and resolve any difficulties or challenges in the process.
Reasons for exclusion at the level of the full text are documented in the PRISMA diagram 16 (please see Figure 1).

| Data extraction
We extracted data using electronic forms created in Microsoft Excel expressly for the purpose of organizing data from selected studies.
We piloted extraction using 10 studies across the review team to ensure field titles and descriptors were interpreted and extracted consistently allowing further iterations before extracting all data.
Data extraction and quality assessments were conducted simultaneously by the study team (L. R., H. B. and R. P.).
Primary data were extracted from quantitative, qualitative and mixed methods studies relating to the review questions simultaneously. Data relating to study conduct were also extracted including publication, country, and setting (community, school-based, clinical), study design, primary aim, metholodological approaches employed and other relevant contextual information.

| Quality assessment
We anticipated a wide range of methodologies in this review signalling the need for a mixed methods appraisal approach and quality assessment of included studies was undertaken using the Mixed Methods Appraisal Tool (MMAT). 17 We used the criteria corresponding to qualitative, quantitative descriptive and mixed methods designs based on the studies selected for review. Scores were expressed as a percentage of possible items divided by affirmative items. Each study was then classified as weak (≤50%), moderate-weak (51%-65%), moderate-strong (66%-79%) or strong (≥80%) based on a methodological scoring system. 18 Quality was individually assessed by reviewers with 10% checked for accuracy. Any disagreements were resolved by discussion among reviewers. No records were excluded based on quality alone, but the quality assessment was used to inform the narrative synthesis of included studies.

| Data analysis and synthesis
Due to the heterogeneity of included study designs and outcome measures, a narrative synthesis was used to synthesize data, which was guided by the Economic and Social Research Council (ESRC) guidance on the conduct of narrative synthesis. 19 This was RENWICK ET AL. | 63 undertaken collaboratively between authors (L. R., H. B. and R. P.) and the resultant presentation of results was discussed among the wider study team. We used thematic analysis to map data to our three research questions deductively, arranging evidence with similar lines of evidence to ensure reliability. We then conducted analysis inductively to systematically generate theory about wellbeing and mental health in response to each question ensuring that each piece of information was relevant to the synthesis. Quantitative and qualitative data were synthesized simultaneously, and we used textual description, grouping and tabulation methods for preliminary synthesis and to explore patterns across studies. Included studies were tabulated in terms of study characteristics and extracted data. Initial inductive coding was undertaken at the point of extraction to characterize data in relation to descriptive categories. Differences in identified categories in relation to the country of origin, age and gender of included participants and other relevant contextual information were considered next. Finally, the draft synthesis was considered in light of the quality appraisal results (see below).

| Study characteristics
A PRISMA study flow diagram in Figure 1  Participants in this review had a mean age of 16.6 (range:  and the majority were adolescent and young person populations.
Four studies included children under the age of 10 alongside adolescents. 20,[25][26][27] Apart from three studies, [28][29][30] two of which reported on the same sample, all studies drew their sample from T A B L E 1 Inclusion and exclusion criteria

Category Inclusion Exclusion
Population of interest • Views, attitudes and perceptions of under 18-year old's towards mental health, emotional well-being and treatment-seeking for mental health problems (where children and young people are employed the mean age of the sample will be less than 18 years old). • Data collected within a low-/middle-income country (as defined by OECD's DAC list for 2018-2020).
• Data obtained representing the views of CYP, parents, teachers or other professionals where individual CYP data cannot be extracted. • Data collected in high-income countries employing ethnic minorities originating from low-/middle-income countries (as defined by OECD's DAC list for 2018 to 2020). • Studies where the primary research question is about developmental disorders.

Study types and designs
• Primary data from observational studies, cross-sectional data, surveys, other nonexperimental quantitative research, and qualitative and mixed methods studies were included.
• Not primary data.
• Data from reviews.
Health outcomes and outputs of interest

| Quality appraisal
The quality of studies was varied and scores on the MMAT ranged from 0% to 100%. All but one of the qualitative studies achieved a score of 80%-100%, indicating these studies were of high quality.
Fewer quantitative studies achieved high scores within their category of assessment with half showing a risk of measurement and response bias. The quality of mixed methods studies was also varied and few of the mixed methods designs addressed issues of divergence between the findings from quantitative and qualitative methodologies, nor did they adequately identify the explanatory or exploratory nature of the chosen design. We extracted qualitative data from mixed methods studies; with the exception of one study [22] none of the available studies provided quantitative data relating to the research questions.
The few cross-sectional studies that were included were examined for their contribution to the synthesis to determine the weight of evidence from these sources. Quality appraisals are detailed in Table 3.
To evaluate the robustness of our synthesis, we examined the  • good mood (smiling, being cheerful and polite and being worry-free), • positive thinking (good attitude towards one's self, focussing on the positive aspects of others and of situations) and • good social relationships (being friends with others and ability to manage problems • happiness, • personal control (of problems, emotions, stress and personal limits), • ability to socialize and interact with others, • spirituality Signs of poor mental health include: • inability to cope with contemporary pressures, interpretations. Removing the results from low-quality studies (n = 3) did not influence the synthesis and the removal of both weak and moderately weak quality studies (n = 6) demonstrated some bearing on the quantity of evidence that supported the synthesis. As such the synthesis findings were drawn mainly from interpreting and integrating the findings from well-conducted and reported qualitative studies. These are presented in Table 4. Optimism and positivity were also considered to mean how one relates to oneself, having a good attitude towards oneself 33 31,[33][34][35] were further emphasized as key indicators of being mentally healthy. Quantitative data supported this viewing functioning in a narrower sense, confined to academic performance. In this latter study, mental health concepts were obtained from 1168 Brazilian adolescents. These were sampled purposively from different socioeconomic sectors, using an adapted measure and ranking potential components of well-being by importance. 21 Self-agency emerged as a pertinent constituent of mental health and wellbeing, comprising multiple facets, including personal attributes and competency for making decisions, having a central purpose to guide life decisions and being given the responsibility to make one's own decisions. Evidence drawn from both qualitative and quantitative studies illustrated that having the necessary personal attributes to make one's own choices leading to competent decisionmaking and being granted the freedom to do so by others signified the key elements of autonomous behaviour. Quantitative survey data from 1635 Mexican adolescents sampled purposively showed both future plans and having a purpose in life were key factors characterizing psychological wellbeing. 22 Quantitative data from South African students randomly sampled from rural areas showed that intrinsic life goals were significantly positively correlated with psychological wellbeing. 24 Having the freedom and ability to make one's own choices about own actions and enterprise 22,31,35 were highly valued among respondents in a large cohort of adolescents in Brazil.

| Conceptualisation of mental health and wellbeing
Survey data demonstrated that having personal control of life choices 21 is an essential aspect of mental health explicated by in-depth qualitative interviews extending control to having command of one's problems, emotions, stress and personal limits. 35 Personal attributes for self-agency included maintaining balance for good decisionmaking linked with well-being, 34 being principled and showing moral awareness, behaving normally 21 and being 'sober-minded' in judgements. 34 There were consistent findings that mental health was a significant concern and demonstrated clearly in qualitative analyses among samples of Indonesian, Vietnamese and Chinese adolescents 30,32,35 and Indian adolescents advocating the need for school-based mental health services. 36 This was corroborated by quantitative data from Brazilian adolescents with the majority espousing the importance of mental health. 21 Conversely, one study demonstrated adolescents in Kenya recognized that understanding of positive mental health was limited. 34 Evidence from qualitative analyses consistently indicated that adolescent perspectives of mental health were often conflated with negative emotions and mental ill-health and adolescents sometimes used others with mental illnesses as a frame of reference to describe their own views and perspectives of health states. 25,30,32,35 There was also some discrepancy about whether adolescents believed that to attain wellbeing, mental illnesses must be absent. Leveraging social support a Weak ≤ 50%, moderate-weak = 51%-65%, moderate-strong = 66%-79%, or strong ≥ 80%.
For example, qualitative inquiry of Kenyan adolescents views of mental health and illness showed they believed one could possess attributes of good mental health while having a diagnosed mental illness. 34 Quantitative data indicated the opposite and adolescents indicated that reliance on mental health professionals was contrary to attaining good mental health. 21 3.4 | Risk and protective factors for mental health and wellbeing Family conflict and disagreements, particularly about education and romantic relationships were considerable wellbeing stressors. 32,36 Pleasure-seeking was an identified risk factor among these children and adolescents, specifically becoming over-involved in hedonistic pursuits could lead to delinquent behaviours like following media personalities, gaming, internet use and cigarette smoking.
Young people also reported awareness of generally increasing negative emotions and distortions in their sense of self during adolescent years as a specific threat to their wellbeing. 34 Academic pressure is viewed as a consistent and considerable source of stress among adolescents in qualitative analyses. With the exception of younger groups, 28 students overwhelmingly reported academic overload, especially with homework, being unable to complete work and projects on time and exam pressure. 26,29,[34][35][36] Anxiety about securing a job once education was completed was particularly salient among older adolescents. 36 Students also reported strictness, especially among teachers, reportedly fearing teachers' reactions to them, the effect on their confidence, ability to express themselves and ill-treatment negatively affecting their reputation among peers. 31,35 Unfairness and cruelty were words associated with how teachers treated students. 35 Gender differences were evident in qualitative data reporting specific factors affecting females wellbeing. There were relatively fewer data on males views and perspectives. One study constructively illuminated the complexities of specific socioeconomic environments but the analysis was limited to 37 females in one setting in India without comparison with males. 28   were aspects significantly impinging mental health. 35 Antisocial behaviour is a specific concern threatening adolescents safety, including theft and gun crime. 26,29 3.5 | Self-help strategies Reported self-help interventions incorporated both individual strategies and leveraging support from lay networks. One study looked at the relationship between such strategies and mental health outcomes and found that mental health behaviour was not a significant predictor of positive or negative affect. 24 The majority described selfhelp strategies and nonprofessional support sources alongside beliefs about the effectiveness of these.
Several self-help strategies were considered important to managing positive mental health and promoting wellbeing; the most identified strategy was using distraction from stressful situations by engaging in valued activities. Activities identified included music, 26,29,33,38 exercise and sports, 23 26,29 Friends were considered particularly useful through their role in the facilitation of distraction from stressful situations by encouraging the valued activity described above. 27 However, all identified sources of support were also considered to be potential sources of stress (see Section 3.4) highlighting the complexity of relationships with lay support networks for this group. 26 In reporting preferences for self-help strategies, differences relating to gender and age were limited in included studies. No differences were found between genders in stress response and selfhelp choices to promote wellbeing in a qualitative analysis. 27  The Lancet Commission on child health and wellbeing identifies that mental health problems are becoming dominant among this age group and substantial investment in prevention approaches is required. 45 In LMICs, a particular focus on mental health literacy is recommended while broadening mental health literacy concepts to include positive mental health, which enhances the salience and applicability of this concept to this population group. 6 A coherent discourse emerged that children and adolescents were able to conceptualize mental health attributes that transcend deficit-based mental health concepts, the key to developing asset-driven mental health promotion programmes and optimizing population-level prevention and promotion interventions. Nonetheless, there are significant gaps in knowledge and research arising from this review.
Encouragingly, the empirical evidence we included is relatively recent and increasing methodological quality demonstrating mental health and wellbeing research is gaining momentum. Still, evidence is concentrated on lower grade evidentiary research and while this provides a helpful exploration of child and adolescent perspectives and views, this synthesis is best regarded as indicative rather than definitive.
Substantial further research is required to develop and optimize culture-specific population-level prevention and promotion interventions. This synthesis represents research from just a few LMICs and is not representative of all children and adolescents in those countries or settings within countries. There were no studies from the least developed nations highlighting a significant gap in understanding of wellbeing perspectives to inform public health initiatives.
Self-help strategies were also under-researched and some concentrated on useful strategies for one specific problem and minimal evidence to support themes identified as a whole. Exploring the range of mental health behaviours that enhance mental health, their relationship to mental health constituents and wellbeing is needed.
Including an exploration of individual beliefs about the effectiveness of these strategies and potential ways to develop or enhance these for improving wellbeing would also be beneficial. One study demonstrated that stress management and health-supporting behaviours were linked with wellbeing 24 but empirical evidence in this area to support public health interventions is notably absent. Importantly, we found preliminary evidence of age differences in health beliefs, understanding of risk and protective factors and self-help strategies for mental health and wellbeing. Adolescent development takes place within the context of family, peer, school and community environments that are underpinned by broader cultural influences that shape their views and perspectives. 45 Further research is needed to understand wellbeing and mental health perspectives throughout all phases of childhood and adolescence, including the various context settings for individual psychological growth and a need for research that informs universal, yet targeted developmentally appropriate interventions.

| Strengths and limitations
Children's and adolescents' understanding of how to obtain and maintain good mental health is understudied in both low-and highincome settings 47,48 and there are significant gaps in the literature to contrast in different contexts. We did not exclude any study based on the quality, which may affect our interpretations; however, we employed robust systematic review methods, ensuring the integrity of the synthesis. We did not use an exhaustive list of search terms related to the phenomenon of mental health and wellbeing though we recognize that terms are used interchangeably in some circumstances and lack clarity and shared understanding such that research in this area can be difficult to synthesize. Our broad approach taken in our search strategy mitigates this to some degree. Nonetheless, the synthesis is dependent on existing evidence and as stated, there are significant gaps in research in these areas across LMICs. A further gap exists across demographic groups within the country. All but two studies researched school-going populations and while these are important sites for delivering effective health promotion interventions, 9,10,14