Increasing Mental Health Literacy and Peer Support Among Caregivers: An Electronic Painting and Peer Supportive (EPPS) Platform

During the 8-week period, caregivers are encouraged to draw paintings. There is no fixed frequency for making the paintings but they are recommended to draw at least one painting per week. Caregivers could draw the electronic paintings at any time when they are free. They could share the paintings with friends or peers in the group. 10-12 caregivers will be gathered as a small group for interaction supported by a supportive team member (e-chat). During this period, the supportive team members will announce a theme for drawing each week. Caregivers can self-assess their mental health status by using the validated scale, Depression, Anxiety and Stress Scale (DASS-8) which is installed in the EPPS system at Week 0, Week 8 and Week 12. At any time, they draw the painting, caregivers can self-assess their mood by completing PHQ-2. Caregivers can look for the available mental health support services (shown in the system) and seek help, if necessary. They would also approach the facilitators if they need help. On the other hand, the supportive team members will also monitor the mental health assessment scores and make referral to the professionals if necessary.

Study design. A randomized controlled trial with focus group interviews with caregivers and members of supportive team will be used to assess the efficacy of the EPPS system. Caregivers will be randomly assigned to intervention group (IG) and control group (CG). Caregivers in the IG will use all the features in the EPPS system for 8 weeks (at the same time, they will continue to receive the usual supportive service to caregivers in the NGOs) while the caregivers in the CG will use only the e-chat function in the EPPS system and receive usual care (the usual supportive service to caregivers in the NGOs). After 8 weeks, the caregivers in the CG will be given opportunities to use all the features in the EPPS system. All caregivers are invited to complete an online survey at Week 0 (before they use the system), Week 8 (immediately after the system use) and Week 12 (4 weeks after the system use). 30 to 40 caregivers will be invited to attend focus group interviews to indicate their comments and views on the use of the EPPS system after Week 8. Such qualitative data collection will be ceased when no new comments is received (data is saturated).

Outcome measures in the evaluation: Attitudes Toward Seeking Professional Psychological Help-Short Form (ATSPPH-SF) (primary outcome). It consists of 10 items measuring the propensity for seeking help for mental disorders. A 4-point Likert scale ranging from "0=disagree" to "3=agree" is used as the response options. Total score, ranging from 0 to 30, is calculated by summing up all the items - higher scores indicate higher propensity to seek help. There are two subscales (1) openness to seeking treatment and (2) need in seeking treatment in this instrument. Other outcome measures include: DASS-8, WHO-5 [9], Chinese version of Zarit Burden Interview (CZBI-short), Modified Medical Outcome Study Social Support Survey (mMOS-SS) and PHQ-2 [12]. The DASS-8 is the shortest version of the DASS-21. It is composed of three subscales: depression (three items, e.g., felt that I had nothing to look forward), anxiety (three items, e.g., felt close to panic), and stress (two items, e.g., was using a lot of my mental energy) (36, 38). The minimum score of the DASS-8 and its subscales is 0, while the maximum scores are 24, 9, 9, and 6, respectively. Cronbach alpha = 0.933, and its correlation with DASS-21 is 0.977.

The sample size required for evaluating the efficacy of the EPPS system (using RCT) is calculated with reference to ATSPPH-SF (primary outcome). In a previous study, 65 adults changed their help seeking behaviour (total score of ATSPPH-SF) after watching a short video, and the mean ATSPPH-SF score was 18.1 (SD = 4.3) at pre-test and 19.4 (SD = 3.8) at post-test. The effect size of this e-learning was 0.46. Using a conservative approach, we assume the learning from the AIMHS system has small effect size (=0.3). Using G*Power 3.1.9.4, we assume an effect size of 0.3 with 90% power, two-tailed 5% significance, and 1:1 allocation ratio, the estimated sample size required is 382 (191 per group). Assuming 55% attrition, we intend to recruit about 700 caregivers.