Feasibility, Acceptability, and Effectiveness of a Coping and Resilience Intervention in Adolescents in the Post-COVID-19 Era

Background: The global impact of the COVID-19 pandemic on adolescent well-being necessitated targeted interventions to address increased mental health challenges. This study emphasized the significance to develop a school-based mental health intervention grounded on a previously tested adolescent resilience model. A comprehensive evaluation protocol was applied to assess its feasibility, acceptability, and effectiveness.

Objectives:
Study 1. The study was aimed to assess the psychometric properties of Pediatric Quality of Life Inventory (PedsQL™) Youth Version Generic Core 4.0 for evaluating health-related quality of life (HRQOL) among Indonesian adolescents exposed to COVID-19 risk. The investigation specifically examined gender-based differences within these groups.

Study 2. The primary aim was to assess the feasibility and acceptability of Coping and Resilience Intervention in Adolescents (CERIA) among adolescents aged 12-18 in public junior high schools in Yogyakarta, Indonesia. Secondary objectives included evaluating the effectiveness of CERIA on outcomes such as PTSD symptoms, defensive coping, courageous coping, social support, resilience, and HRQOL at one week before, one week after, and one month after the intervention.

Methods:
Study 1. A cross-sectional investigation conducted in May 2022, engaged Indonesian adolescents from two junior high schools in Yogyakarta. The Indonesian version of the PedsQL™ were administered. Confirmatory factor analysis (CFA) was applied and model fit was evaluated through various indices, including chi-square to the degree of freedom ratio (χ²/df), root-mean-square error of approximation (RMSEA), goodness of fit index (GFI), comparative fit index (CFI), Tucker-Lewis index (TLI), and standardized root mean square residual (SRMR). Additionally, multiple group CFA (MG-CFA) was employed, assessing configural, metric, scalar, and full invariance, along with reliability measures.

Study 2. A two-arm parallel group, double-blind (participants and outcome assessors) quasi-experimental trial design was employed, involving 122 adolescents divided into control group (n= 60) and experimental group (n= 62) and validated instruments to measure relevant constructs. The intervention group underwent six-weekly 45- to 60-minute sessions, while an active control group was included. Quantitative data collection took place one week before, one week after, and one month after the intervention. Qualitative data were gathered through a focus group interview conducted upon the completion of the intervention. The effectiveness of the intervention was assessed using Generalized Estimating Equation. This CERIA intervention study has been registered on ClinicalTrials.gov.

Results:
Study 1. The PedsQL™ exhibited a four-factor structure (physical, emotional, social, and school) confirmed by CFA, demonstrating excellent model fit (χ²/df= 3.545, RMSEA= 0.065, GFI= 0.904, CFI= 0.913, TLI= 0.900, SRMR= 0.050). Gender-based invariance testing for both scales produced positive results. Additionally, Cronbach’s alpha and composite reliability values indicated robust internal consistency and reliability across constructs.

Study 2. Feasibility variables, including participants’ recruitment time, recruitment rate, retention rate, attrition rate, compliance with intervention, and compliance and completeness of evaluation measures at three time points, were successfully executed. Expert panel review, participants’ perspective, and interventionist perspective results affirmed the appropriateness and acceptability of CERIA. The results of the study indicated that the CERIA had a significant positive impact on various mental health outcomes among adolescents. In comparison to the control group, the experimental group exhibited a notable reduction in PTSD symptoms at 1-week and 1-month follow-ups. Defensive coping scores decreased significantly, while courageous coping, social support, resilience, and HRQOL showed substantial improvements in the experimental group compared to the control group.

Adjusting for baseline score of PTSD symptoms, age, and gender did not alter the observed positive effects of CERIA on PTSD symptoms. The changes in defensive coping, courageous coping, social support, resilience, and HRQOL remained consistent even after accounting for baseline scores of each outcome and the demographic variables. These findings emphasized the robust and lasting impact of CERIA in enhancing various aspects of mental well-being among adolescents. The study added valuable insights to the literature on effective school-based mental health interventions, providing evidence of the feasibility, acceptability, and efficacy of CERIA in the post-COVID-19 era.

Conclusions: The study’s results reinforce the credibility and efficacy of PedsQL™ as a robust measurement tool for adolescents, particularly within the challenging circumstances of the COVID-19 pandemic. Additionally, we advocate for the practical implementation of CERIA as an effective and suitable school-based intervention to address the post-pandemic mental health needs among adolescents. This approach not only aligns with its core theory but also offers valuable insights into intervention strategies.

Significance/Contributions to the Field: The validation of the PedsQL™ as a reliable and applicable tool for assessing HRQOL in adolescents can contribute the understanding of adolescents’ mental health in the face of traumatic event. The endorsement of the practical implementation of CERIA post-COVID-19 adds an additional layer of significance, offering a potential avenue for intervention alignment to support adolescent mental health in the aftermath of global crises. The CERIA protocol has already demonstrated its feasibility, acceptability, and effectiveness among Indonesian adolescents. Therefore, it can be refined and applied to more Indonesian schools in the future.