The research team, led by Andreia Sofia Cristina and including Inês Franco de Almeida, Carlos Alberto Cruz Sequeira and Amorim Gabriel Santos Rosa, framed their work around the concept of mental health literacy, often abbreviated as MHL. Mental health literacy encompasses the knowledge and beliefs about mental disorders that aid their recognition, management and prevention. In practical terms, it means being able to identify symptoms in oneself and others, understanding what treatments exist and how effective they are, knowing how to access professional help, and holding attitudes that reduce stigma rather than reinforce it. When literacy is low, symptoms are misread as personal weakness, help is delayed or never sought, and treatable conditions are allowed to harden into chronic problems that corrode academic performance and well-being.

While general mental health literacy programmes already exist, the authors identified a specific deficiency: very few interventions have targeted anxiety explicitly, and fewer still have been co-created with the students they are meant to serve and then subjected to rigorous expert content validation. Anxiety is a particularly demanding target because it sits on a continuum that runs from the normal, even useful nervousness before an examination to clinical states that can be disabling. Distinguishing adaptive stress from something requiring professional attention is precisely the kind of judgement that literacy education is designed to support, and it is a judgement students repeatedly report struggling with.

The study adopted an exploratory, qualitative design guided by the PRODUCES framework, a structured approach to developing complex health promotion interventions, and unfolded in two sequential phases. The first phase placed students at the centre of the design process. Nineteen higher education students took part in focus groups in which they discussed their experiences, needs and views concerning anxiety and mental health literacy. This participatory starting point matters technically because interventions imposed from above frequently fail on acceptability: if the language, examples and delivery format do not resonate with the intended audience, engagement collapses regardless of the underlying evidence base. By listening first, the researchers grounded the programme in the lived reality of student life.

From these focus groups, the team distilled six core domains that shaped the initial architecture of the programme. Although the published abstract does not enumerate every domain in detail, the resulting design was built to promote recognition of anxiety symptoms, develop self-regulation skills, reduce stigma and encourage help-seeking behaviours. These four objectives map directly onto the canonical components of mental health literacy, but they are here tailored to the specific phenomenology of anxiety, which includes physical manifestations such as palpitations, tension and sleep disturbance that students often misattribute to purely somatic causes.

The second phase subjected this draft to a modified electronic Delphi study, a well-established consensus methodology in health services research. The e-Delphi technique works by circulating structured questionnaires to a panel of experts over successive rounds, collecting quantitative ratings and qualitative feedback, then refining the material between rounds until either consensus is achieved or the panel agrees that further iteration is unproductive. In this study, 18 experts participated in each of two rounds, evaluating the programme’s structure, content and implementation strategies. The Delphi approach is particularly valuable for content validation because it separates panellists, preventing the dominance of any single vocal opinion and allowing anonymity to elicit honest judgements about weaknesses as well as strengths.

The results of the expert evaluation revealed a high level of agreement on most components of the programme, which is a strong signal of content validity. At the same time, the panel identified concrete areas for revision. Experts suggested changes to the duration of individual sessions, to the overall structure of the programme, to the delivery format, to the digital support components and to the practical activities embedded in the sessions. This pattern of granular, actionable critique illustrates why content validation is more than a rubber stamp: it converts a promising draft into an instrument that practitioners can realistically deliver. Digital support, for instance, has become a near-essential element for interventions aimed at young adults, whose expectations of on-demand access differ sharply from earlier generations, and expert feedback here pushed the programme toward greater technological relevance.

One item resisted resolution. Across the two Delphi rounds, no consensus was reached on the proposed programme duration of eight weeks. The researchers have deliberately left this question open, planning to evaluate it during pilot testing rather than forcing agreement at the design stage. This is a methodologically defensible choice. The optimal dose of a psychoeducational intervention depends on factors such as session length, participant engagement, competing academic demands and the depth of skills practice, and these are best observed empirically. A programme that is too short may fail to consolidate self-regulation skills, while one that is too long risks attrition in a population already juggling coursework, examinations and employment.

The final product is a structured yet adaptable programme of sessions aimed at prevention and early identification of anxiety among higher education students. Its adaptability is worth emphasising. In health promotion, a rigid protocol can be a liability in real-world settings where timetabling, group sizes and institutional cultures vary widely. A framework that specifies core content while allowing flexibility in format and pacing gives university counselling services, campus nurses and student support teams room to fit the intervention to their local context without diluting its validated components. Significantly, the programme is grounded in mental health nursing practice, positioning nurses, who are often embedded in university health services and skilled in both clinical assessment and health education, as central actors in campus mental health promotion rather than peripheral support staff.

With content validation complete, the programme now moves to the next stage of its evaluation pathway: pilot testing to assess feasibility, acceptability and preliminary effectiveness. Feasibility testing will determine whether the sessions can be delivered as designed within the constraints of academic calendars, whether students attend and complete the programme, and whether the unresolved question of total duration can be settled with empirical data. Acceptability testing will reveal whether the participatory foundation laid in the focus groups translates into genuine student engagement. Preliminary effectiveness measures will provide early signals of whether the programme actually improves symptom recognition, self-regulation capacity, stigma-related attitudes and help-seeking intentions. If those signals prove positive, the intervention could offer universities a practical, evidence-informed tool for addressing one of the most common and most under-treated mental health problems of student life, delivered by the professionals perhaps best placed to make a difference. For a field in which prevention has long been overshadowed by crisis response, a carefully co-created and expert-validated anxiety literacy programme represents a meaningful step forward.

Subject of Research: Development and content validation of an anxiety-specific mental health literacy programme for university students

Article Title: Development and content validation of an anxiety-specific mental health literacy promotion programme for higher education students

Article References: Cristina, A. S., de Almeida, I. F., Cruz Sequeira, C. A., & Santos Rosa, A. G. (2026). Development and content validation of an anxiety-specific mental health literacy promotion programme for higher education students. BMC Nursing, 25(1), Article 939. https://doi.org/10.1186/s12912-026-05395-0

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05395-0

Keywords: anxiety, mental health literacy, higher education students, e-Delphi, nursing, health promotion, programme development, stigma reduction, help-seeking, Portugal, participatory research, student mental health

The study, conducted as part of the international Study of Discrimination and Stigma Outcomes, known as INDIGO, adapted and pilot-tested contact-based anti-stigma interventions at three distinct levels of Nepal’s health system. The research team, led by Bhawana Subedi and colleagues including Kalpana Bhattarai, Brandon A. Kohrt, Claire Henderson, Graham Thornicroft, and Petra C. Gronholm, designed the pilot to answer a deceptively simple question: can a single anti-stigma program be tailored to work simultaneously for female community health volunteers, primary healthcare workers, and specialist psychiatric staff, and can its effects be sustained over time? The answer emerging from the data is a cautious but encouraging yes, with important caveats about the structural constraints that training alone cannot overcome.

The intervention targeted three groups of health workers in sequence. Nineteen female community health volunteers took part in the component known as INDIGO Local. Nine primary healthcare workers participated in the INDIGO Primary component. Nine psychiatrists and psychiatric nurses formed the INDIGO READ-MH group. In each case, the training package integrated social contact with people with lived experience, a technique with strong evidence behind it in stigma research. Rather than lecturing health workers about the wrongness of discriminatory attitudes, the program brought them into direct, structured interaction with individuals who have personally navigated mental health conditions and the health system, allowing stereotypes to be challenged through personal encounter rather than abstract instruction.

The researchers measured outcomes using validated instruments administered before training, immediately after training, and at follow-up points of three and six months. Among the community health volunteers in INDIGO Local, the mean knowledge score rose from 20.43 at pre-training, with a 95 percent confidence interval of 20.0 to 20.9, to 25.11 at six months, with a confidence interval of 23.83 to 26.17. That a knowledge gain of this magnitude persisted half a year after the training ended is one of the most striking findings of the pilot, since anti-stigma effects are often reported to fade quickly once the immediate enthusiasm of a workshop dissipates.

The results among primary healthcare workers were equally notable, particularly on measures of intended behavior and self-stigma. In the INDIGO Primary group, the intended behavior score increased from 16.67 at pre-training, with a confidence interval of 14.73 to 19.27, to 18.88 at post-training, with a confidence interval of 17.69 to 20.31. Perhaps more dramatically, the mean score on the Social Distance Scale, a widely used measure of the desire to keep distance from people with mental health conditions, fell from 39.26 to 20.62. A reduction of this size indicates a substantial softening of the avoidance instincts that often cause primary care workers to refer mental health patients elsewhere rather than engage with them directly. The study also recorded that the primary care personnel’s helpful behavior increased while harmful behavior decreased, a paired shift that speaks directly to the quality of care patients actually receive.

Among the specialist psychiatric staff in INDIGO READ-MH, the knowledge and Objective Structured Clinical Examination scores both improved. The knowledge mean score rose from 12.67 at baseline, with a confidence interval of 10.36 to 14.97, to 14.67 at post-training, with a confidence interval of 13.28 to 16.05. The OSRE mean score, which assesses clinical competency through simulated patient encounters, climbed from 2 at pre-training, with a confidence interval of 1.62 to 2.38, to 9 at post-training, with a confidence interval of 7.56 to 10.44. This leap in competency scores suggests that the training did more than adjust attitudes; it equipped clinicians with practical skills for communicating with and treating people experiencing mental health crises, skills that were demonstrably lacking before the intervention.

The study was not without its more complicated results. On the Anti-Stigma Toolkit for Assessment of Discrimination, or ASTAD, subscales, most domains increased at the three-month follow-up, but two subscales, motivation and work satisfaction, decreased at post-training. The researchers do not gloss over this pattern. It may reflect a sobering recalibration among specialist staff, who, having become more attuned to the realities of stigma and the gaps in their health system, found their sense of efficacy and job satisfaction tested. Alternatively, the immediate post-training period may simply capture a moment of fatigue after intensive coursework. Either way, the finding is a reminder that anti-stigma interventions do not operate in a vacuum and that emotional responses to training deserve attention in future iterations.

The qualitative strand of the study, drawing on interviews with 43 participants across all three levels of the health system, added depth and texture to the quantitative findings. Participants consistently described a positive attitudinal shift following the interventions, and the involvement of people with lived experience emerged as the single most emphasized element of the training. Health workers reported that hearing directly from individuals who had experienced mental health conditions dismantled assumptions in a way that no lecture or written module could. This aligns with a growing international consensus in stigma research that social contact is among the most powerful mechanisms for changing discriminatory attitudes, and it demonstrates that this mechanism can be successfully embedded in training packages adapted to the specific cultural and institutional context of Nepal.

Crucially, the providers themselves judged the training to be feasible and appropriate within the structure of Nepal’s health system. This assessment matters because interventions that look effective on paper often fail in practice when they demand resources, time, or institutional arrangements that a health system cannot supply. The multi-level design, reaching from community volunteers to specialist clinicians, reflects an understanding that stigma is not confined to any single professional group. A community volunteer who fears a person with psychosis will not refer them for care; a primary care worker who avoids mental health presentations will not provide first-line support; a psychiatrist who holds subtle discriminatory attitudes will not deliver person-centered treatment. Addressing all three levels simultaneously multiplies the potential impact of each individual training.

At the same time, the study is candid about the limits of what attitude change can achieve. Even as providers reported more positive perceptions of people with mental health conditions, they identified persistent structural barriers to effective mental health care, including insufficient availability of medicines, limited human resources, and the absence of separate counseling rooms where confidential conversations could take place. These findings underscore a central tension in global mental health work: changing hearts and minds is necessary but not sufficient if the material infrastructure of care remains inadequate. A health worker who now wants to help a patient with depression may still be unable to prescribe an essential medication or find a private space for a counseling session. The researchers’ mixed-methods approach captures this tension precisely, pairing statistical evidence of improvement with qualitative testimony about the conditions under which that improvement must be translated into patient care.

As a pilot feasibility study, the INDIGO Nepal work does not claim to demonstrate population-level impact, and the modest sample sizes at each level mean the confidence intervals around some estimates are wide. But the pilot achieves what a well-designed feasibility study should: it shows that the intervention can be delivered, that participants find it acceptable, that outcome measures move in the expected direction, and that effects on knowledge at least can persist for months. The involvement of people with lived experience, the element participants valued most highly, stands out as both an ethical imperative and a practical engine of change. If subsequent controlled trials confirm these findings at scale, the model developed in Nepal could offer a template for other low- and middle-income countries grappling with the same entanglement of stigma, scarce resources, and unmet mental health need, demonstrating that the people who have lived through mental health conditions are not merely beneficiaries of reform but its most persuasive advocates.

Subject of Research: Multi-level mental health stigma reduction interventions in Nepal's healthcare system involving people with lived experience

Article Title: Multi-level mental health-related stigma interventions in healthcare systems through the involvement of people with lived experiences: Mixed-methods pilot findings from international study of discrimination and stigma outcomes (INDIGO) study in Nepal

Article References: Subedi, B., Bhattarai, K., Kohrt, B. A., Henderson, C., Brohan, E., Thornicroft, G., Bakolis, I., Semrau, M., Votruba, N., Gronholm, P. C., Ouali, U., & Gurung, D. (2026). Multi-level mental health-related stigma interventions in healthcare systems through the involvement of people with lived experiences: Mixed-methods pilot findings from international study of discrimination and stigma outcomes (INDIGO) study in Nepal. PLOS Mental Health, 3(9), e0000638. https://doi.org/10.1371/journal.pmen.0000638

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000638

Keywords: mental health stigma, Nepal, INDIGO study, contact-based intervention, lived experience, community health volunteers, primary healthcare workers, psychiatrists, PLOS Mental Health, stigma reduction, health system, mixed methods

The clinical problem the project targets is well recognized in pediatric practice. Children with implanted or long-term medical devices frequently experience anxiety, stigma, and social isolation, particularly in school and community settings where looking different from classmates can feel overwhelming. The American Academy of Pediatrics emphasizes child-centered, trauma-informed approaches that promote resilience and normalize chronic illness experiences, and therapeutic play has long been recognized as a developmentally appropriate strategy to reduce fear and improve coping among children with complex medical needs. What has been missing, the Mayo Clinic team notes, are interventions that specifically address body image and device-related self-consciousness — the part of a child’s experience tied to feeling “different” because of a medical device.

Anders Jenson, M.D., a PGY-2 pediatric resident at Mayo Clinic, explained the distinction at the heart of the project. “Therapeutic play has long been used to ease children’s medical fears, but this advocacy project specifically targets the body-image and self-consciousness piece, the part of a child’s experience tied to feeling ‘different’ because of a medical device,” Jenson said. “It’s a small, easily replicated idea with a real emotional payoff for kids with medical devices.” The bears, in other words, are not generic comfort objects; each one is deliberately outfitted with the same category of device its young recipient lives with, creating a one-to-one mirror between toy and patient.

The technical construction of the bears is a story in itself, and one that reveals how the program doubles as a training exercise. The program was resident-initiated and resident-run. Funding came through an internal Mayo Clinic grant of just $2,200, which was used to procure approximately 200 teddy bears. Pacemaker and tracheostomy models were provided generously by medical device manufacturers, keeping equipment costs low. Gastrostomy tubes, which would otherwise be expensive or difficult to source in toy-appropriate form, were simulated with inflation valves of beach balls — an everyday material that mimics the external profile of a feeding tube button. The devices were then sutured into the stuffed animals using suture materials donated by the Mayo Clinic Emergency Department.

That suturing step is where medical education enters the picture. Medical students were recruited to assist with implanting the medical devices into the bears, giving them a low-stakes environment in which to practice and refine their suturing technique. According to the authors, this additional practice helps medical students and residents become more confident in their abilities, and the work can double as a peer-education tool among trainees. The project also serves as a recruitment opportunity for the field of pediatrics: students get a hands-on, meaningful introduction to pediatric care without the pressures of a clinical environment, and they are exposed to a distinctive component of the specialty — the use of developmentally appropriate care and education for young patients.

Once completed, the stuffed animals with implants were distributed to patients with the corresponding medical device on the pediatric hospital service. The benefits, the authors report, flow in several directions at once. For the child, receiving a bear that visibly shares their own equipment fosters normalization and may reduce device-related anxiety. For families, the bears become a practical rehearsal tool: parents and children can use them to practice care steps the child needs, such as tracheostomy suctioning or gastrostomy tube feeds, before or alongside performing those steps on the child. The abstract notes that the stuffed animals can be used during teaching sessions, facilitating improved understanding of the child’s own devices and increased willingness to engage in their care.

The social reach of the intervention extends beyond the patient’s bedside. Because the bears make devices visible and approachable, they can be used to increase awareness of medical devices among a child’s peers, supporting peer education and reducing stigma by introducing the device through toys and play. For a school-age child who dreads questions or stares about a feeding tube or tracheostomy, a classroom moment built around a teddy bear offers a gentler entry point than any lecture. The bears can also serve as a hands-on recruitment tool that introduces medical students to pediatrics through what the authors describe as a low-pressure, high-impact, meaningful project.

For Jenson, the project carries a personal dimension. “As someone with a medical device myself, I remember how isolating it could feel growing up surrounded by those without one,” Jenson said. “I hope these teddy bears help children to feel more comfortable and confident with their medical devices, knowing that they are not alone in their journey.” That lived perspective shapes the program’s core premise: that the emotional burden of pediatric medical devices is not only about pain or procedure, but about identity — about a child’s sense of whether their equipment makes them strange or simply makes them themselves.

The Teddy Bear Clinic Advocacy Project is presented by its authors as a low-cost, scalable intervention that leverages therapeutic play to promote resilience, normalize implanted medical devices, and reduce stigma among children with complex medical needs. The economics are part of the argument: with roughly 200 bears procured for $2,200, donated manufacturer models, beach-ball valves standing in for feeding tubes, and suture material supplied by the emergency department, the program demonstrates that meaningful psychosocial support does not require expensive technology. By combining advocacy, education, and creative partnership with device makers, the initiative offers what the authors call a replicable model for pediatric institutions seeking to advance child-centered, trauma-informed care.

Jenson is scheduled to present the research in the poster hall at the conference on Saturday, Oct. 3, and will be among highlighted abstract authors giving brief presentations and taking questions during a “Soundbite Session” on Sunday, Oct. 4, in the conference center Press Room. The research received external funding from Kid’s Cup Rochester. Whether the model spreads to other institutions remains to be seen, but its central claim is already resonating with clinicians who treat children with complex medical needs: sometimes the most effective therapeutic technology in a pediatric hospital room is a teddy bear wearing the same device as the child holding it.

Subject of Research: A therapeutic play intervention using teddy bears fitted with medical devices to normalize pediatric medical devices and reduce device-related anxiety and stigma in children.

Article Title: Teddy bears with medical devices help normalize them for children

Article References: Teddy bears with medical devices help normalize them for children. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: pediatrics, medical devices, therapeutic play, teddy bear clinic, Mayo Clinic, gastrostomy tube, tracheostomy, pacemaker, medical anxiety, stigma reduction, child health, medical education