“There are still broken or fragmented systems”: Qualitative assessment of needs to strengthen adolescent mental health services in American Samoa

Abstract

Mental health challenges appear common among adolescents in American Samoa. There is a community-identified need to better understand the health burden and identify opportunities to strengthen the mental health system to better meet adolescent mental health needs. The goal of this qualitative study was to gather community stakeholders’ perceptions of common mental health problems among adolescents in American Samoa, identify existing services for adolescent mental health, and highlight strength-based opportunities to enhance care. Using the Fa’afaletui research framework semi-structured in-depth interviews (n=28) were conducted between October 2020 and February 2021 using Zoom. Key informants were adults living in American Samoa, sampled for diversity in profession, age, gender, education, and region of residence. Transcripts were coded in duplicate and analysed using deductive thematic analysis. Participants reported that suicide, depression, anxiety, and post-traumatic stress disorder are conditions of highest burden. Participants identified an impressive amount of infrastructure and community mobilization, but also limitations in these services in addressing adolescents’ health needs. Four themes arose related to the need to: (1) strengthen existing infrastructure; (2) reduce barriers to treatment access; (3) improve sustainability; and (4) encourage collaboration among leadership.

Policymakers should prioritize allocation of resources to strengthen infrastructure, public education, and stakeholder collaboration to improve adolescent mental health in American Samoa.

INTRODUCTION

In the United States (US), mental health disparities among Indigenous populations are thought to be rooted in a recent history of colonialism and long-standing inequities among social determinants of health, among other factors (King, Smith & Gracey, 2009; Tofaeono et al., 2020; Brave Heart et al., 2011). These mental health issues are of particular concern among adolescents, for whom suicide accounts for a greater proportion of deaths compared to adolescents in the general US population (Brave Heart et al., 2011; Pollock et al., 2018). Despite this, minimal research has been conducted on mental health among adolescent populations indigenous to US territories outside of the continental US.

American Samoa is an unincorporated US territory in the South Pacific with a population of nearly 50,000 people (US Census Bureau, 2020), 89% of whom identify as indigenous to Samoa (Central Intelligence Agency, 2023) and youth compose roughly one quarter of the population (American Samoa Department of Commerce, 2016). A recent systematic review suggests that American Samoan suicide rates are less than among other US Indigenous communities (Pollock et al., 2018). Given the strong cultural survivance among Samoans in the face of imperialism (Tofaeono et al., 2020), this community might provide lessons on resilience that could generalize to other Indigenous populations; other evidence, however, suggests that the mental health landscape is in need of assessment and action. The 2013 Youth Risk Behavior Survey (YRBS) indicated that 38% of American Samoan students in Grades 9–12 felt sad or hopeless almost every day for a two week period during the past year, and that 23% had made a suicide plan in the last year (US Centers for Disease Control, n.d.), compared to national estimates of 29.9% and 13.6% (Kann et al., 2014). A community-led survey of 1125 high school students in 2021 reported that one in three adolescents had seriously thought about suicide and nearly 30% endorsed having attempted to die by suicide in the past year (McCutchan-Tofaeono, 2022). This, as well as a recent cluster of youth suicide deaths (McCutchan-Tofaeono, 2022; Radio New Zealand, 2016), reinforces the need to further understand the burden of common mental health problems and identify community-developed approaches to manage psychiatric needs.

Building on a strong community desire for research on this topic, this study aimed to understand adolescent mental health through key informant perceptions of (1) the status of mental health problems among adolescents; (2) resources available to manage adolescent mental illness; and (3) current adolescent mental health system needs. This study offers a first attempt to systematically understand gaps in the adolescent mental health system and community-identified suggestions to address them.

METHODS

This study used a qualitative approach. We conducted semi-structured in-depth interviews with adult (>18 years) key informants (KIs) based in American Samoa between October 2020 and February 2021. We followed the Fa’afaletui methodological framework developed for research in Samoan communities (Goodyear-Smith & ‘Ofanoa, 2022; Tamasese et al., 2005), which emphasizes the importance of weaving together different perspectives to reach consensus (Goodyear-Smith & ‘Ofanoa, 2022). Ethical approval was obtained from the Yale University (#2000028354) and the American Samoa Department of Health (#00001249) Institutional Review Boards.

Sample and recruitment

KIs needed to speak English to participate (an official language and often used in healthcare delivery). KIs were identified through nominations from our partners at the Department of Health, Division of Behavioral Health Services. Additional participants were identified using snowball sampling. Participants were sampled for diversity in profession and role in the community. Using the Fa’afaletui framework, we sought diversity of perspectives from ‘the top of the mountain’, ‘the top of the tree’, and ‘the person in the canoe fishing’ (Table A1) (Goodyear-Smith & ‘Ofanoa, 2022). We also followed the MacDonald et al (2018) framework to maximize diversity among mental health professionals (roles and institutions) and community stakeholders (school staff, informal sources of help, criminal justice professionals, and religious leaders). As interviews progressed, the sampling frame evolved to maximize diversity among age, gender, region of residence, and level of education, allowing for broader community engagement. Once potential KIs were identified, they were contacted via email, phone, texting, and/or social media. We invited 56 individuals and four organizations to participate; 36 KIs (64%) expressed interest in participating. Eight KIs were unable to participate due to scheduling problems or were no longer needed after saturation was reached. The final sample consisted of 28 KIs.

Data gathering and analysis

Interviews were conducted in English over Zoom teleconferencing, or phone when Zoom was not possible. All interviews were conducted by the first author and lasted from 1.25 to 2.5 hours. Interviews used open-ended, non-directive questions, beginning with: “Can you tell me about your thoughts on the state of mental health among adolescents in American Samoa?” Conversations then focused on broad topics including common mental health problems, available resources, pathways to care, barriers and facilitators to care, and potential interventions (among others; Table A2). Our interview guide was iterative and evolved to ensure questions explored emerging themes more deeply. Interviews focused on factors related to common mental health problems including depressive, anxiety, substance use, suicidality, and trauma- and stressor-related psychiatric disorders (American Psychiatric Association, 2013). We defined adolescents as 13–17 years old. Interviews were transcribed verbatim using Temi software (www.temi.com). Transcripts were analysed using deductive thematic analysis, following guidelines suggested by Braun & Clark (2006). Analyses focused on semantic themes (Maguire & Delahunt, 2017). The codebook was generated via an iterative process among the coding team (EM, VB, JW, LH, and NH). Transcripts were double-coded, with the first author coding all transcripts. Themes were driven by the codebook and supported by iterative team review and discussion (Braun & Clark, 2006). We only presented topics for which we believe achieved adequate consensus. Quotes are provided in the manuscript text to support major themes with additional quotes in Table A3.

RESULTS

Included among the 28 KIs were 13 mental health professionals/lay counsellors and 15 stakeholders/community members (e.g. educators, non-governmental organization [NGO] representatives, and service administrators). As shown in Table A1, 28 KIs brought diversity of perspectives from ‘the top of the mountain’ (n=15; superscript ‘M’), ‘the top of the tree’ (n=9; superscript ‘T’), and ‘the person in the canoe fishing’ (n=4; superscript ‘C’). The vast majority of participants were of Samoan ethnicity. Other demographic characteristics are not described to protect participant confidentiality (necessary given the small, close knit community).

Two major themes emerged: one theme described the high burden of common adolescent mental health problems, while the second focused on gaps to improve the mental health care system for adolescents:

Theme 1: Mental health burden: “we’ve got a lot of teens who struggle”

KIs stated that adolescents seem to excel in their dedication to their faith, communities, and families. However, the majority reported that, under the surface, many adolescents struggle: “we have a serious mental health issue here” (KI #11^M). Specifically, suicidal ideation was perceived to be common:

“Last week we had [organization] come in… and they were doing presentations on suicide. And what surprised me was that one of their activities was they would have all the kids close their eyes and ask who has had suicidal thoughts… and more than I thought were raising their hands.” (KI #9^T)

KIs described a number of youth suicides during the study period: “I stopped counting, but I’m pretty sure there’s been more than 10 [suicide deaths] this year, all within this age group of high school students” (KI #9^T) and collectively expressed an urgent need to address the crisis, especially given that this small community is at high-risk for suicide contagion, or ‘copycat’ suicides.

KIs also described mood disorders, anxiety disorders, and trauma-related disorders (including high exposure to adverse childhood experiences, such as physical and sexual abuse) as common and in need of attention. KIs also reported that substance use and non-suicidal self-injury (such as cutting) were common coping mechanisms for mental distress. The majority reported that depression is of highest concern, and is an underlying cause of many suicides:

“Depression is very, very, real here…we’re supposed to be an Island people who live [in] the white sandy beaches and enjoy the nice tropical sun. The fact of the matter is we have just as many problems and issues that we face both socially and at home as anywhere else in the world. And so, depression is real and it’s everywhere.” (KI #7^M)

A small number of KIs also reported the burden of other diagnoses including conduct disorder, attention-deficit hyperactivity disorder, eating disorders, and bipolar disorder.

KIs overwhelmingly expressed concern about underreporting of adolescent mental illness: “the state of mental health for adolescents here is a lot bigger than even the reports show” (KI #14^T), “this may be just the tip of the iceberg” (KI #7^M), and “I honestly feel like there’s more young people out there that experience a lot of these symptoms or are experiencing challenges with their mental health and wellness. It’s just under reported” (KI #17^M). There was consensus in this theme across Fa’afaletui perspectives.

Theme 2: Opportunities to strengthen existing infrastructure: “we still have a lot of roadblocks”

KIs explained that community-based mental health services are relatively new in the territory; despite this, participants reported an impressive variety of government and grassroots-initiated and -led mental health services across NGO and faith-based sectors (Table A4). However, participants described frustration with the existing infrastructure and provided several suggestions to better meet adolescent mental health needs. These suggestions covered four major themes (Table 1). Themes 2A and 2B were voiced from all three Fa’afaletui perspectives; themes 2C and 2D were voiced primarily from KIs with perspectives ‘from the top of the mountain’.

Table 1.

Needs for improvement in adolescent mental health services and proposed strategies to address identified needs, gathered from semi-structured qualitative interviews with key informants in American Samoa between 2020–2021.

Themes	Proposed strategies
2A. Need to strengthen existing infrastructure
➢ More mental health professionals	• Train high school counsellors to manage mild to moderate mental illness as first point of contact within health system
	• Recruit and employ more highly skilled mental health professionals
➢ Strengthen identification of cases	• Expand school-based screening programs
2B. Need to reduce barriers in treatment access
➢ Reduce barriers for help seeking behaviors	• Mental health curriculum to educate adolescents on signs and symptoms of mental distress • Consistent confidentiality training for providers • Increase public communication of availability and confidentiality of services
➢ Greater education among adult first-responders	• Increase mental health education including signs of adolescent mental distress, crisis de-escalation, and referral pathways for community members such as parents, educators, and faith-based leaders
2C. Need for sustainability in services
➢ Proactive and sustainable mental health policies and practice	• Implementation of sustained proactive polices focused on prevention, earlier identification, and earlier treatment
➢ Increased and sustainable funding	• Increased public awareness of the importance of mental health to engender the prioritization and reallocation of government health spending
2D. Need for collaboration within local leadership
➢ Coordination, integration and communication between stakeholders and providers	• Unite stakeholders (ex: government organizations, NGOs, faith-based organizations, and mental health clinicians) for knowledge sharing and collaboration
➢ Consistency in communication strategies and service provision	• Develop and disseminate standardized and consistent referral pathways for first-responders, public communication strategies, and oversight across programs and providers

Theme 2A: Need to strengthen existing infrastructure: “underdiagnosed and undertreated”

Many KIs stated that the current infrastructure is not sufficient to meet the mental health needs of adolescents. Collectively, KIs identified only four doctoral-level clinical psychologists/psychiatrists serving the entire territory, in addition to approximately 20 other mental health counsellors and clinicians with varying levels of training (e.g. master’s, undergraduate, or locally trained) and licensing (e.g. local versus national licenses). KIs credited this lack of human capacity to underfunding, but also reported challenges recruiting skilled providers:

“Funding is an issue, but at this time, with the vacancies we have, we just haven’t been able to fill them here. There are not enough people with these skills on Island, young people who graduated from college and technical, even if they majored in this field or field related to mental health or psychology or social work or anything in that spectrum, they’re getting jobs elsewhere. So we don’t have the capacity” (KI #17^M)

Furthermore, none of the licensed professionals in the territory specialize in adolescent mental health: “there is no specific service for children and adolescent mental health within the behavioral health…there is definitely something lacking there” (KI #1^M).

KIs cited the lack of capacity as an explanation for the under-detection of mental illness, particularly mild and moderate cases. To address this, participants called for expanded school-based screening programs: “the school system may need to be strengthened a bit in terms of detecting and referring” (KI #1^M), but expressed concern that, if more cases are identified, the existing infrastructure will further struggle to meet demand.

Other suggestions to address the current lack of resources included task-shifting, such as training high school counsellors to act as initial points of contact for the health system. KIs expressed concern about current mental health support for students within schools, as, “there is no individual in any of the schools on Island that has the capacity, the knowledge, the awareness, the skills to be able to address and help a student who has mental health issues” (KI #17^M). Many KIs suggested specialized training for counsellors to screen for mental illness, manage mild and moderate cases, and to establish referral pathways to specialized care:

“If we can get at least one person who’s trained in mental health specific needs, then they could be the ones at the frontline with this wellness team. If the wellness team hears about somebody who might be troubled and might need some more assistance, there would be somebody onsite or in the schools that can help to kind of delineate, ‘Wait does this need to be something that’s then referred over to more specialized care? Or is this something that we can work with and address in the team?’” (KI #10^M)

Theme 2B: Need to reduce barriers in treatment access: “we are all not informed”

There was consensus among KIs that multiple barriers exist that prevent adolescents from accessing available treatment services. Participants believed that many adolescents are unaware of the signs and symptoms of mental distress, as “people think it’s just…normal behaviour” (KI #3^T). KIs suggested that a school-based mental health curriculum could not only teach adolescents to recognize signs and symptoms, but could also “empower them to be able to create a safety plan” (KI #10^M). Several KIs also expressed concerns that “[adolescents are] trying to reach out, but they don’t know who to reach out to” (KI #11^M). For instance:

“I often talk about this with our classes: ‘When someone falls down at school and breaks their leg, who do you call?’, and you’re like, ‘the ambulance’, they know. ‘But if you have something that’s bothering you emotionally, who do you call?’ Everybody just kind of looks around, and ‘I don’t know’” (KI #13^M)

Teachers themselves expressed a desire for increased mental health training, especially tools to support them when working with adolescents traumatized from peers’ deaths by suicide:

“The elephant in the room is that we are just, we are all not informed…we had walked on eggshells…Once those suicides started…we were not prepared to sit down and have conversations…I’m talking about being able to help [adolescents] knowing how to cope with the loss. Like there were students who had seen, like had to bring [down] students who had committed suicide. They were there at the scene bringing these other students down from the rope. And so how was I supposed to know how to help these students…?” (KI #12^T)

Further, KIs stated that few adolescents take initiative to seek mental health treatment. Confidentiality was cited as a concern: “I swear, nowhere have I had more questions about confidentiality than here in Samoa, and it makes sense because it’s a small place…and so that question of ‘Where does my information or material go? Who do you know? Who are you going to tell?’” (KI #10^M). Building on this, participants emphasized the need for confidentiality training among providers and the importance of communicating confidentiality commitments to adolescents to encourage help-seeking.

Building on Fa’a-Samoa, the ‘Samoan way of life’ (KI #15^M), and the role of a whole community in raising a child, KIs suggested engaging the entire village and broader community in addressing barriers to treatment. This could include training parents, faith-based leaders, chief’s council, police officers, and other community members as first-responders:

“We can’t just be expecting to have these PowerPoints or these presentations specifically for adolescents. The cry is not just for adolescents. This is…such a passive approach. The better approach is to have a community response where parents are part of the conversation. Teachers are also part of this…the development has to come across the board, not just where the problem is.” (KI #25^T)

KIs specifically expressed the need to train first-responders to identify signs of adolescent distress, since “the last few suicides, the comment has been, ‘…They’re always such a happy person and I can’t believe that he committed suicide...’ So obviously this person is going through something and nobody can identify it” (KI #4^M). Participants also expressed the need for first-responder training to de-escalate crises: “if people are not trained in this field of mental health to say the right thing and do the thing that’s appropriate, and it could be escalating the reaction of people” (KI #16^M). One KI echoed these concerns, in that, the status quo is to not intervene:

“The most recent suicide, the kid even posted it on Facebook, that I’m going to kill myself, how he’s going to do it, and what you think?, and nobody responded to that. Nobody said, ‘Are you okay? Let’s talk or let’s meet.’…I think it’s because we don’t know how to respond to it, or we’re too afraid to respond to it that you might say the wrong thing.” (KI #24^T)

KIs suggested that family members could be uniquely positioned to recognize behavioral changes and may be an important target for education: “I would work on…helping parents identify, know of these different behaviours, depressing behaviours, anxiety behaviours and dramatic behaviour…to warn them before the kid slowly drifts into that kind of mental depression state” (KI #26^M).

Theme 2C: Need for sustainability in service provision: “services will taper off”

Several KIs expressed the need for sustained and proactive mental health policies. Although KIs described prioritization of mental health in response to the increase in recent suicide deaths, they expressed concern that this political response is reactionary and were sceptical that it would be sustained:

“I think we’re still in the area of being largely reactive to things that happen in the community, and so once there was an up in deaths by suicide here in Samoa, then there was a huge response. Everybody was coming out, there were more messages being heard on the radio about you are not alone and to call the crisis line…but now that things are starting to settle, mental health will then again be on the back burner and only come out when something else happens.” (KI #10^M)

KIs also indicated frustration at the lack of political action regarding suicide prevention: “I feel that most of the time we do a lip service kind of thing. You know, we talk about things that we need to do, but there’s no actual action, you know, no actual implementation of any kind of plan to carry it out” (KI #26^M). As for the reason behind this lack of political action, participants expressed that “mental health is not regarded as a high priority in this community” (KI #26^M). KIs also expressed challenges in securing sustainable and adequate funding for mental health.

Theme 2D: Need for collaboration between stakeholders: “everybody’s doing their own thing”

While KIs identified many dedicated community stakeholders who work to improve adolescent mental health, many KIs expressed concern over the lack of collaboration among stakeholders:

“I would like to see some kind of organized, consolidated collaboration by both churches, NGOs, and the government because there’s just a lot of fragmentation right now and it’s hard to quantify how effective these programs are because they’re doing their own thing in their own backyards. And no one wants to share, or reach out to other groups to collaborate because they fear that those people are going to take their federal funding, their grant funding, [and] don’t want to share their data… so everybody needs to come together and work together.” (KI #7^M)

KIs expressed the need for unity between stakeholders in service provision and community messaging. KIs also expressed the need to standardize training, accreditation, and oversight of lay mental health counsellors, as well as the need for standardized referral pathways and clear communication of these pathways to first responders: “there’s nothing set in stone that dictates that all children with certain risk factors are to have a mental health assessment. It’s often left up to persons along the pathway to make that determination” (KI #01) and : “…there wasn’t really clear protocol on what happens when someone is suicidal [in schools]...” (KI #6^M).

DISCUSSION

This study offers a first attempt to systematically understand current gaps in the adolescent mental health treatment system and stakeholder suggestions to address them. The high prevalence of adolescent mental health disorders reported by KIs aligns with prevalence estimates provided by available data (US Centers for Disease Control, n.d.; McCutchan-Tofaeono, 2022). Our findings further bolster this evidence that adolescent mental health is a major health concern in American Samoa.

To address adolescent mental health concerns, participants suggested the need for mental health task-shifting and gatekeeper training programs. Along these lines, programs implemented in other settings could provide guidance for possible interventions in American Samoa. One recent review suggests several initiatives for adolescent suicide prevention, including restricting access to lethal means, school-based awareness and skill-training (e.g., Signs of Suicide), and gatekeeper training programs (e.g., Youth Mental Health First Aid) (Kelly et al., 2011; Wasserman et al., 2021). Though there has been little evaluation of such programs in low- and middle-income settings, one lay-counsellor delivered mental health program among schools in India showed substantial benefits for health-related outcomes (Shinde et al., 2018). The Mental Health Gap Action Program (World Health Organization, 2016) also provides specific training for lay healthcare workers to administer basic mental health treatment in low-resource settings and shows promise in training and practice effectiveness (Keynejad, Spagnolo & Thornicroft, 2021).

The current work has several strengths and limitations. As this is a qualitative study, there are issues with generalizability given that the sample was small and purposefully recruited. These findings came from adult perspectives and should continue to be validated among adolescents, though we feel adolescents would have minimal insight towards system-level issues. These findings were also generated during the COVID-19 pandemic and very recently after a cluster of suicides, which may have heightened awareness and emotion about these issues. Strengths, however, include the many Samoan voices involved in this work in the design, data collection, analysis, and interpretation of findings. This work also garnered a substantial amount of data from 28 participants, which maximized diversity of perspectives across a variety of relevant axes and allowed us to reach saturation on many themes.

CONCLUSION AND RELEVANCE FOR CLINICAL PRACTICE

There is a need to strengthen and expand mental health infrastructure for adolescents in American Samoa, where youth compose roughly one quarter of the population. These results suggest the need for collaboration between community leaders and increased public education of available services to improve Samoan mental health.

Mental health nurses and other clinical professionals working in this context should be mindful of the high burden of youth mental health challenges and, if possible, take action to promote mental health. Within this existing infrastructure, specific actions for mental health nursing professionals could include: (1) integration of mental health screening practices for adolescents in a clinical setting; (2) initiatiating interdisciplinary collaboration with local stakeholders to provide a unified response; (3) assisting local efforts to advocate for sustainable infrastructure (for example, through grant-writing support); and (4) supporting territorial-wide educational efforts to improve mental health literacy to reduce barriers to care. Given the need, clinical training institutions in American Samoa could also consider developing a specialist track for mental health nursing.

DO YOU NEED MENTAL HEALTH SUPPORT?

If you are struggling with your mental health, please call the +988 Suicide and Mental Health Helpline to be connected with a mental health counsellor in American Samoa or call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).