Abstract
Background
Mental health disorders such as depression, anxiety, and stress are significant public health concerns, affecting 10–20% of adolescents globally. In Saudi Arabia and Malaysia, youth mental health issues are growing, yet Mental Health Literacy remains low. MHL encompasses recognizing mental disorders, seeking appropriate help, and understanding treatment options. Reusable Learning Objects (RLO), offer a promising solution to provide evidence-based education. However, studies on the effectiveness of RLO in different cultural settings are limited. This study employed a protocol of a cross-country comparison study aimed at evaluating the potential effectiveness of RLO in supporting Mental Health Literacy among youth in Saudi Arabia and Malaysia.
Methods
A quasi-experimental design was employed among youth aged 16–24 years in two cities, Riyadh, Saudi Arabia, and Kuala Lumpur, Malaysia. RLO was developed using the ASPIRE methodology, and a validated English and Arabic MHL questionnaire was used in the study. Participants were assigned to intervention and control groups. The intervention group engaged with RLOs, while the control group completed the questionnaire without RLO exposure. Data were collected at baseline and post-intervention. Wilcoxon signed-rank tests compared baseline and post-intervention scores within groups, while Mann–Whitney U tests compared post-intervention change scores between countries.
Results
Wilcoxon signed-rank analyses revealed significant improvements in MHL among participants in Saudi Arabia and Malaysia. In Saudi Arabia, improvements were observed across all domains, including a reduction in erroneous beliefs (p = .021). Mann–Whitney U tests showed that Malaysian participants achieved greater gains in mental health disorder knowledge (p < .001) and overall MHL (p = .002) compared to Saudi Arabian participants, with small-to-medium effect sizes. In Malaysia, large gains were found in mental health disorder knowledge, help-seeking/first aid skill, self-help strategies, and total MHL (p < .001), whereas changes in erroneous beliefs were not significant.
Conclusions
These findings highlight the promise of scalable, interactive RLOs for enhancing youth MHL in diverse cultural contexts, informing national digital mental health promotion strategies, school curricula integration, and policies to reduce stigma and improve early help-seeking in resource-constrained settings.
Keywords: Mental health literacy, Reusable learning objects, Youth, Digital health education
Background
Mental health problems, including depression, anxiety, and stress, affect millions of youth worldwide. Studies estimate that 10–20% of children and youth experience mental health issues, which can significantly impact their academic performance, social relationships, and overall well-being [1]. Despite the growing awareness of mental health concerns, a review conducted by Furnham and Swami [2], revealed that mental health literacy (MHL) remains low, particularly in developing countries, limiting youth’s ability to recognize symptoms and seek appropriate help.
In Malaysia, the prevalence of youth mental health issues has reached a concerning level, with increasing cases of stress, anxiety, and depression among youth [3]. The rise of digital technology may provide an opportunity to introduce innovative learning methods that could enhance MHL by making mental health education more accessible and engaging. Meanwhile, in Saudi Arabia, mental health issues among youth remain underreported and under-addressed due to cultural stigma and limited access to mental health education [4]. Research has shown that youth in Saudi Arabia with lower educational attainment are at a higher risk of experiencing disruptive behaviour disorders, mood disorders and substance use disorders, further emphasizing the need for early intervention [5, 6].
MHL among Malaysian youth is shaped by various factors, including sociodemographic influences and cultural considerations. Research has shown that higher MHL levels are associated with being female, older, a non-smoker and not experiencing loneliness, emphasizing the need for targeted policies and programs to address mental health issues among youth [7]. Additionally, expert perspectives from fields such as psychiatry, psychology and social work emphasize key MHL components, including the ability to recognize mental disorders, seek information, develop positive attitudes, and understand self-treatment and professional help. These findings underscore the importance of culturally relevant MHL initiatives tailored to the Malaysian context to improve mental health awareness and help-seeking behaviours among young people [8].
Despite shared global concerns over youth mental health, cross-country comparative evidence on digital interventions including Reusable Learning Object (RLO) remains limited. Saudi Arabia and Malaysia offer a theoretically grounded comparison due to the similarities of cultural, religious, and educational contexts, and the need for culturally adaptive e-promotion strategies. Riyadh and Kuala Lumpur are cosmopolitan cities but deep rooted in religious and cultural practices. The youth are embracing modernity at the same time bound by the traditional beliefs and culture thus it is timely to understand the changes that are occurring among the youth related to mental health issues.
This study employed a cross-country comparison design to assess the association of RLO and MHL level across two settings. By assessing youth’s engagement with RLO-based mental health education, this research will contribute to a better understanding of digital interventions in MHL promotion.
Research objectives:
To compare the baseline (pre) and post intervention MHL scores within each setting (Saudi Arabia and Malaysia).
To compare changes in mental health literacy outcomes between Saudi Arabia and Malaysia following RLO intervention.
Methods
Study design
This research employs a quasi-experimental, with a baseline and post-test evaluation of effectiveness of Reusable Learning Object (RLO) for mental health literacy (MHL) among youth. A cross-country comparison approach is used to compare findings between Riyadh, Saudi Arabia, and Kuala Lumpur, Malaysia. The study involved an intervention group using RLO-based learning and a control group. Post-test data were not collected from the control group due to the quasi-experimental design and ethical considerations, as participants in the control group were provided immediate access to the RLO upon completion of baseline data collection.
ASPIRE framework for RLO development
Reusable Learning Objects (RLOs) represent an innovative approach to education by offering digital resources that can be leveraged repeatedly, scaled, and distributed from a central online location to enhance teaching and learning. They come in different sizes, scopes, and levels of detail, ranging from brief instructional segments to a collection of resources designed to create a more comprehensive educational experience.
The ASPIRE framework [9, 10], a structured methodology for developing high-quality e-learning resources, provides a foundation for RLO development. ASPIRE consists of Aim, Storyboarding, Population, Implementation, Release and Evaluation, ensuring that Reusable Learning Objects (RLOs) are designed to be pedagogically robust, interactive, and adaptable to diverse educational settings. The ASPIRE framework (Fig. 1) is systematically applied in the creation and implementation of RLOs in this study:
Fig. 1.
ASPIRE framework and schematic diagram showing the developmental framework for the production and quality assurance of RLOs [9, 10]
Aim: The development process begins with defining the learning objectives and ensuring that the content aligns with mental health literacy goals. This phase establishes clear educational targets for the RLOs to enhance student understanding of mental health concepts.
Storyboarding: This phase allows educators, mental health experts, and e-learning specialists to collaboratively sketch and annotate the structure of the RLOs. The visual representation of content ensures clarity in instructional design before development begins.
Population: The content framework developed during the storyboarding stage is populated with detailed specifications for multimedia elements, activities, and assessments. A peer review process is conducted at this stage to validate content accuracy and pedagogical soundness.
Implementation: This phase involves the technical development of RLOs, focusing on assembling and refining the content to ensure clarity, accessibility and effective knowledge delivery.
Release: The finalized RLOs undergo a secondary peer review before being made accessible to learners. This ensures that the digital content meets quality standards for usability and effectiveness.
Evaluation: The effectiveness of RLOs on mental health literacy is measured through data collection and analysis, providing insights into resource effectiveness and areas for refinement.
Theoretical underpinnings: mental health literacy model
The development of RLO content is guided by Jorm’s Mental Health Literacy Model [11], and Campos et al. [12], which defines MHL as:
The ability to recognize specific mental disorders.
Help-seeking/first aid options and available resources.
Understanding of self-help strategies for mental well-being.
Awareness of risk factors and causes of mental health conditions.
Reduction of mental health stigma through education and awareness.
Campos et al. [12], constructed a short version questionnaire for adult (SVa) in 2022 and validated the questionnaire across the European and Asian countries. In addition, a follow-up validation for the Arabic version was performed by Zakaria et al. in 2025 [13] (Table 1).
Table 1.
Campos et al. [12] Mental Health Literacy dimensions and the 16 items that are used in this study
| Factor name | Items | |
|---|---|---|
| Dimension 1: | Mental Health Disorders (MHD) knowledge |
1. Mental disorders affect people’s thoughts 2. A person with schizophrenia may see and hear things that nobody else sees and hears 3. One of the symptoms of depression is the loss of interest or pleasure in most things 4. Highly stressful situations may cause mental disorders 5. Changes in brain function may lead to the onset of mental disorder 6. The symptoms’ length is one of the important criteria for the diagnosis of a mental disorder |
| Dimension 2: | Erroneous Beliefs |
7. Only adults have mental disorders 8. Mental disorders don’t affect people’s feelings 9. Mental disorders don’t affect people’s behavior/actions |
| Dimension 3: | Help-Seeking and First Aid Skills |
10. If I had a mental disorder, I would seek for a psychologist’s help 11. If someone close to me had a mental disorder, I would encourage her/him to see a psychiatrist 12. If I had a mental disorder, I would seek for a psychiatrist’s help. |
| Dimension 4: | Self-Help Strategies |
13. Sleeping well contributes to a good mental health 14. A balanced diet contributes to a good mental health 15. Physical exercise contributes to a good mental health 16. Doing something enjoyable contributes to a good mental health |
By using this questionnaire along with the RLO intervention, this study can measure the MHL level. Higher scores indicate better MHL across dimensions (after reverse scoring of erroneous belief items, which were negatively worded to assess misconceptions).
Implementation of RLOs in the study
The intervention involved embedding in a RLO into the mental health education resources for the intervention group. The RLO is accessible through an online platform, offering self-paced and interactive digital content focused on key aspects of mental health literacy.
Bilingual RLO in Saudi Arabia: https://acord.my/xerte/play.php?template_id=138#page1.
RLO in English used in Malaysia: https://acord.my/xerte/play.php? template_id=151#page1.
The mental health literacy questionnaire short version for adults by Campos et al. [12], is used as a key instrument to assess changes in MHL among youth following educational intervention using RLOs [12]. The first page of RLO begins with a baseline questionnaire as shown in Fig. 2 to assess youth’s baseline MHL before engaging with the RLO.
Fig. 2.
Baseline assessment/pre-test
Figure 3 outlines the introduction of the RLO, outlines the key learning outcomes and emphasizes the importance of enhancing MHL among youth.
Fig. 3.
Learning objectives overview
Figure 4 an example of the learning content designed to educate learners on neuroendocrine systems in relation to mental health disorders.
Fig. 4.
Introduction to the neuroendocrine system
Figure 5 shows parts of the RLO content aimed to explain common mental health erroneous thoughts and how to encourage a more accurate understanding of mental health issues.
Fig. 5.
Addressing erroneous beliefs
Study setting
The study was conducted around schools and colleges located in Riyadh, Saudi Arabia, and Kuala Lumpur, Malaysia. The locations were conveniently selected based on the willingness to participate and demographic similarities that align with the study objectives. Additionally, the selected settings have an existing structure for implementing e-learning initiatives, ensuring the feasibility of RLO-based interventions.
Study participants
Participants composed of youth aged 16–24 years old who are enrolled in the selected educational institutions are eligible to participate. The inclusion criteria for participation are: (1) access to the internet and basic digital literacy, (2) the ability to read and comprehend Arabic or English (for Saudi Arabia participants) and English (for Malaysian participants), and (3) obtaining parental or guardian consent when needed. Youth who did not meet the inclusion criteria or decline participation were excluded from the study.
Sample size
The sample size calculation was determined with reference to prior similar studies. Utilizing a power of 0.80 and an anticipated effect size of 0.5, as per Cohen [14], a minimum of 64 participants per group was required. To account for potential attrition or dropout (20%), the sample size was increased to approximately 80 participants per group, totalling 160 across both countries. Actual recruitment exceeded this threshold, with 82 participants in the intervention group from Saudi Arabia and 109 from Malaysia. The sample size calculation was conducted using the TTestIndPower function from the statsmodels library in Python, adhering to standard statistical guidelines [15].
Sampling method
Purposive sampling method was used to select educational institutions that align with the study’s demographic and feasibility criteria. Within each selected education setting, cluster sampling was applied to assign youth to either the intervention group (receiving RLO-based learning) or the control group This sampling approach ensures balanced representation across different socioeconomic and educational backgrounds.
Data collection
Data collection was carried out in three phases: baseline assessment (pre-test), intervention, and post-intervention assessment (post-test). The study procedure was structured to ensure consistency in data gathering across both intervention and control groups. The enrolment process began with visits to identify the available groups to participate in the study. During these sessions, prospective participants received an overview of the study’s objectives and procedures. The importance of confidentiality and voluntary participation was emphasized. Upon agreement to participate, the participants completed the baseline screening questions to assess eligibility and establish initial mental health literacy levels.
Quasi-experimental study conditions
Participants were assigned to one of two groups based on a non-randomized allocation approach. Youth from one cohort formed the intervention group, receiving RLO-based learning, while youth from cohort formed the control group, to answer only the baseline questions.
Intervention condition
Youth allocated to the intervention group first completed a baseline screening, which includes eligibility criteria, sociodemographic information, and the Mental Health Literacy (MHL) Questionnaire to assess their initial MHL level. Upon completion of the baseline survey, they were given immediate access to the developed RLO on mental health literacy. Participants were instructed to engage with the RLO modules and actively interact with the embedded activities. After completing the review of RLO, the investigator requested the participants to answer the MHL Questionnaire for post-intervention assessment.
Control condition
Participants assigned to the control group first completed the baseline screening questions, which include eligibility criteria, sociodemographic information, and the Mental Health Literacy (MHL) questionnaire to assess their current mental health literacy. Following the baseline assessment, they were not given access to the RLO. All participants in the control group were only given access to the developed RLO After the survey is completed to ensure equitable learning opportunities.
Results
The data collection period took place from January 2025 to May 2025 across schools and universities in the two cities. Our research team managed to collect data from schools and universities with the average age of 21 years old in both settings.
The RLO was delivered as a self-paced, unsupervised web-based module completed in approximately 10–15 min. All 191 participants in the intervention group completed the entire module including pre- and post-assessments. The RLO comprised 13 interactive pages covering: (1) baseline assessment (pre-test), (2) introduction and learning objectives, (3) case vignette, (4–7) neuroendocrine mechanisms (HPA axis, dopamine function, and mental health connections), (8–9) symptom recognition and misconception correction, (10–11) self-help and help-seeking strategies, (12) conclusion, and (13) post-tests. Interactive elements included animations, hotspot diagrams, flash cards, and embedded quizzes [13] (Fig. 6).
Fig. 6.
Consort chart describing the details of participant flow
A total of 455 participants were initially assessed for eligibility and subsequently enrolled in the study without any exclusions. These participants were allocated into two distinct cohorts: an intervention group consisting of 191 individuals (82 from Saudi Arabia and 109 from Malaysia) and a control group of 264 individuals (173 from Saudi Arabia and 91 from Malaysia). For the intervention group, all 191 participants in the intervention group successfully completed the post-test. In contrast, the control group participants were provided access to the RLO, but no post-test data was collected from them. Consequently, the final post-test analysis exclusively evaluated the 191 participants from the intervention group, which accounted for all 82 participants from Saudi Arabia and between 107 and 109 participants from Malaysia, depending on the completeness of their individual responses.
Analyses were performed using IBM SPSS Statistics. Each dataset was checked for incomplete responses; participants were excluded from analysis for specific pretest or post-test items if data were missing. All analyses were nonparametric given violations of normality assumptions.
Wilcoxon signed-rank tests were used to evaluate pretest–post-test differences within Saudi Arabia and Malaysia intervention groups separately on the five outcome measures (mental health problem knowledge, erroneous beliefs about mental illness, help-seeking/first aid skills for mental illness, self-help strategies for mental illness, and total mental health literacy score). Mann–Whitney U tests were used to evaluate differences between Saudi Arabia and Malaysia intervention groups s in change scores (post-test score minus pretest score) on each outcome measure.
Bonferroni corrections were used for the five statistical tests conducted (α = 0.01). Effect sizes were computed using r = Z / √N and were considered small (0.10), medium (0.30), or large (0.50). Internal consistency estimates (Cronbach’s alpha) were calculated for the pretest and post-test survey data; post-test internal consistency coefficients are based only on participants in the intervention condition. The sociodemographic characteristics of participants in the Saudi Arabia intervention group are presented in Table 2.
Table 2.
Sociodemographic characteristics of the Saudi Arabia – Control and Intervention group
| Sociodemographic Variables | n (Control) | Valid (%) | n (Intervention) | Valid (%) |
|---|---|---|---|---|
| Gender | ||||
| Female | 104 | 60.1 | 61 | 74.4 |
| Male | 69 | 39.9 | 21 | 25.6 |
| Mean age (SD) | 20.02 | (2.31) | 21.39 | (3.46) |
| Educational Institution | ||||
| College/University | 148 | 84.4 | 72 | 87.8 |
| School | 25 | 15.6 | 10 | 12.2 |
The relatively low internal consistency of the Self-Help Strategies subscale in the post-test Malaysian sample (Cronbach’s α = 0.53) should be interpreted cautiously. The high mean scores and low variability suggest a ceiling effect, which likely reduced inter-item correlations and lowered alpha [16]. This is consistent with prior research showing that behavioural and coping-related mental health literacy domains often yield lower reliability because they capture multiple related behaviours rather than a single trait [17]. In addition, the subscale contains only four items, and shorter scales typically produce lower reliability estimates [18]. Thus, the low alpha likely reflects restricted variance and short scale length rather than poor item coherence.
A series of Wilcoxon signed-rank tests were conducted to examine pre–post changes in mental health literacy outcomes within Saudi Arabia and Malaysian participants. A Bonferroni correction was applied to control for Type I error across five comparisons (adjusted α = 0.01).
Among Malaysian participants, significant improvements were observed in mental health disorder knowledge (Z = -5.82, p < .001, r = .56), help-seeking/first aid skills (Z = -6.45, p < .001, r = .62), self-help strategies (Z = -5.16, p < .001, r = .49), and total mental health literacy (Z = -5.95, p < .001, r = .58), all reflecting large effect sizes. No significant change was found for erroneous beliefs (Z = -0.96, p = .335, r = .09).
Similarly, among Saudi participants, significant improvements were observed in mental health problem knowledge (Z = -5.58, p < .001, r = .62), help-seeking/first aid skills (Z = -3.31, p < .001, r = .37), self-help strategies (Z = -3.00, p = .003, r = .33), and total mental health literacy (Z = -3.75, p < .001, r = .41). However, changes in erroneous beliefs were not statistically significant after Bonferroni correction (Z = -2.30, p = .021, r = .25).
Overall, both Saudi Arabian and Malaysian participants demonstrated significant improvements across most mental health literacy domains, with generally large effects observed in Malaysia and medium-to-large effects in Saudi Arabia. Improvements in erroneous beliefs were not statistically robust after correction in either group.
Mann–Whitney U tests were conducted to compare changes in mental health literacy outcomes between Malaysia and Saudi Arabia. Significant differences were observed for mental health disorder knowledge, U = 3557.50, Z = -2.25, p = .024, r = .16, with Saudi participants demonstrating greater improvement than Malaysian participants. Significant differences were also found for First Aid knowledge, U = 3314.00, Z = -3.24, p = .001, r = .23, and erroneous beliefs, U = 3675.00, Z = -2.36, p = .018, r = .17, with Malaysian participants showing greater improvement in both domains. However, no significant differences were found for self-help strategies, U = 3971.00, Z = -1.45, p = .148, r = .10, or total mental health literacy, U = 3945.50, Z = -1.19, p = .235, r = .09. Overall, effect sizes were small, indicating modest differences between countries (Table 3).
Table 3.
Sociodemographic characteristics of the Malaysia – Control and Intervention group
| Sociodemographic Variables | n (Control) | Valid (%) | n (Intervention) | Valid (%) |
|---|---|---|---|---|
| Gender | ||||
| Female | 56 | 61.5 | 81 | 74.3 |
| Male | 35 | 38.5 | 28 | 25.7 |
| Mean age (SD) | 20.69 | (1.82) | 20.73 | (0.968) |
| Educational Institution | ||||
| College/University | 83 | 91.2 | 109 | 100.0 |
| School | 8 | 8.8 | 0 |
Discussion
This study aims to examine associations between Reusable Learning Object (RLO) in and mental health literacy (MHL) among youth in Saudi Arabia and Malaysia. The integration of RLOs as an e-learning intervention represents a shift from traditional mental health promotion toward a more interactive and engaging approach. By comparing the outcomes between an intervention group using RLOs and a control group that did not receive information via RLO, this study seeks to provide empirical evidence regarding the potential of RLO to give awareness mental health literacy among youth. Moreover, RLO, modular, interactive digital resources, provide a scalable, culturally adaptable tool to boost MHL among youth, addressing low recognition of symptoms, stigma, and delayed help-seeking in diverse contexts like Saudi Arabia and Malaysia. On the other hand, RLOs align with policies requiring social-emotional learning (SEL) and mental health education in schools/universities. They offer universal, low-intensity content on stress management, emotional regulation, and help-seeking, integral into curricula or orientation programs. Digital interventions like those in school protocols demonstrate feasibility in diverse settings, reducing academic stress and improving SEL skills. Policies could incentivize RLO adoption to meet well-being standards, support educators with training, and address workforce shortages. In addition, RLOs offer a scalable, low-cost solution for improving youth mental health literacy. Once developed, they can be reused, translated, and culturally adapted across platforms. In countries like Saudi Arabia and Malaysia with similar cultural and religious beliefs, they help overcome barriers such as geography, stigma, and limited professionals by providing anonymous, on-demand access. Though internet access remains a challenge, offline options and youth co-design can enhance reach. Overall, RLOs represent a sustainable and cost-effective approach, with ongoing studies expected to confirm their long-term impact [13].
Comparison with prior literature
Both datasets in Saudi Arabia and Malaysia were subject to reliability testing and both analyses indicated the instrument used [12] proved to be reliable. To answer the first Research Objective, which is to compare the baseline and post intervention MHL scores within each setting, analysis was performed within each intervention group. For Saudi Arabia youth participants, there are changes in mental health literacy in most of the dimensions in MHLq-SVa. Gains were particularly evident in mental health disorder knowledge, help- seeking/first aid skills, self-help strategies, and overall MHL, with moderate-to-large effect sizes. These findings are well aligned with recent reviews suggesting that structured and interactive psychoeducational approaches may enhance literacy when implemented in diverse cultural contexts [19, 20].
For the Malaysia setting, the analysis indicated that participants showed significant improvement in mental health disorder knowledge, erroneous belief, help-seeking/first aid skills, self-help strategies, and overall MHL, with large effect sizes. These findings indicated that the intervention was successful in enhancing both conceptual understanding and practical skills related to mental health. However, no significant reduction was observed in erroneous beliefs, suggesting that misconceptions about mental health may be more resistant to change (Table 4).
Table 4.
Reliability analysis of mental health literacy dimensions among participants
| Dimension | No of items | Cronbach’s α (Baseline: Pre+Control) – Malaysia (n = 200) |
Cronbach’s α (Post) – Malaysia (n = 109) |
Cronbach’s α (Baseline: Pre+Control) – Saudi (n = 255) |
Cronbach’s α (Post) – Saudi (n = 82) |
|---|---|---|---|---|---|
|
MHD Knowledge |
6 | 0.83 | 0.91 | 0.83 | 0.91 |
| Erroneous Beliefs | 3 | 0.85 | 0.97 | 0.80 | 0.94 |
| Help-Seeking/First Aid | 3 | 0.81 | 0.84 | 0.84 | 0.95 |
| Self-Help Strategies | 4 | 0.83 | 0.53 | 0.92 | 0.96 |
Cross-cultural interpretations
The significant improvements across knowledge-based and skills-related dimensions in Malaysia setting s of structured psychoeducation in raising mental health awareness, which is consistent with prior research demonstrating that educational and skills-based interventions can substantially enhance MHL [21]. In particular, the large effects observed in the help-seeking/first aid and overall MHL in the Malaysia setting accentuated the practical benefits of providing participants with actionable strategies that can be applied in everyday contexts [22]. The lack of change in erroneous beliefs aligns with evidence that stigma and misconceptions are more deeply rooted and less responsive to short-term interventions. Meta-analytic reviews have shown that while knowledge can be improved through education, attitudes and stigma require more sustained, multifaceted approaches [23, 24]. Cultural norms and stereotypes often reinforce such beliefs, making them more resistant to modification through brief psychoeducation alone.
One significant outcome was the observed change in erroneous beliefs after the intervention among the participants Saudi setting. This increment of scores within the Saudi Arabia participants compared to Malaysian participants, where erroneous beliefs remained the same, suggesting a higher receptivity among Saudi Arabia participants to corrective educational content. Such results are consistent with contemporary evidence showing that well-designed interventions, particularly those that are interactive, contact-based, or digitally supported can reduce erroneous beliefs, provided they move beyond a purely symptom-focused model [25, 26].
Practical implications and public health relevance
These findings identified the potential of personalized, and tailor made MHL e-promotion programs to deliver broad impact, not only by improving knowledge but also by challenging erroneous beliefs in a society. Recent large-scale and digital initiatives emphasized combining psychoeducation with erroneous beliefs reduction strategies maybe effective in contexts where cultural beliefs shape mental health perceptions [26].
The interventions demonstrated overall effectiveness across both the Saudi Arabia and Malaysian groups, with participants showing gains in mental health disorder knowledge, help-seeking/first aid skills, and self-help strategies. These findings reinforced recent systematic reviews which conclude that structured psychoeducational and digital interventions can substantially improve MHL in diverse cultural settings [25, 27].
Despite these shared improvements, we can observe a difference emerged in relation to erroneous beliefs. In the Saudi Arabia group, erroneous beliefs scores reduced after the intervention, suggesting that participants were receptive to corrective educational content. In contrast, the Malaysian group showed no change in this domain, reflecting the persistence of embedded erroneous beliefs despite after being reading from the RLO regarding this topic. This divergence echoes recent literature indicating that while educational approaches reliably improve knowledge, their impact on stigma varies depending on cultural context and the inclusion of targeted stigma-reduction strategies [23, 24]. Reusable Learning Objects modular, interactive digital resources, provide a scalable, culturally adaptable tool to boost mental health literacy (MHL) among youth, addressing low recognition of symptoms, stigma, and delayed help-seeking in diverse contexts like Saudi Arabia and Malaysia.
The results highlight the need for culturally responsive program design. For Saudi Arabia participants, structured educational content alone was sufficient to reduce misconceptions, while Malaysian participants may require more integrated approaches that combine psychoeducation with stigma-focused elements such as contact-based learning, narratives, or digital storytelling. This aligns with emerging evidence that interventions using holistic and culturally grounded messaging are more likely to reduce stigma sustainably [26].
For Objective 2, which is to examine interactions between countries and intervention effects, we found interesting findings. Findings indicated that while both groups demonstrated improvements, Malaysian participants showed an increased scores in knowledge of mental health disorders and overall mental health literacy. These results suggest that contextual and language factors may shape the extent to which interventions translate into measurable knowledge gains. Culturally responsive approaches that integrate local beliefs, practices, and educational norms consistently produce stronger outcomes, as they align more closely with participant experiences. The stronger effects observed in the Malaysian cohort may be due to previous mental health literacy initiatives and public health campaigns, which likely fostered a more receptive environment. Interestingly, no improvement was observed in help seeking/first aid skills, self-help strategies, or erroneous beliefs dimensions. This aligns with recent findings suggesting that while brief interventions can improve recognition and knowledge, deeper changes in beliefs and self-help behaviours often require sustained, multi-component engagement [28]. Future research should therefore consider longer-term follow-up and integration of peer-led or digital components, which have been shown to enhance retention and application of skills [29].
The findings found in Research objective 2 demonstrates that mental health literacy interventions can be improved in diverse cultural contexts. Our results also the need to explore further how to custom made interactive e-learning to specific cultural settings to achieve improvement in learning.
The overall findings of this study contributed to the growing body of research on e-learning in mental health promotion. Given that mental health issues among youth are increasingly prevalent, particularly in post-pandemic contexts, equipping youth with adequate MHL is critical. Poor MHL is associated with increased stigma, reduced help-seeking/first aid skills, and a greater risk of untreated mental health conditions. By addressing these gaps through RLO-based learning, this study has the potential to inform future educational policies and mental health interventions (Table 5).
Table 5.
Wilcoxon signed-rank test results comparing baseline and post-intervention mental health literacy dimensions among Saudi Arabia participants (Bonferroni-adjusted α = 0.01)
| Dimension | N | Z | p-value | r | Interpretation |
|---|---|---|---|---|---|
| MHD Knowledge | 82 | -5.584 | < 0.001 | 0.62 | Large improvement |
| Erroneous Beliefs | 82 | -2.301 | 0.021 | 0.25 | Small–medium (ns after correction) |
| Help-Seeking & First aid | 82 | -3.308 | < 0.001 | 0.37 | Medium improvement |
| Self-Help Strategies | 82 | -2.997 | 0.003 | 0.33 | Medium improvement |
| Total MHL | 82 | -3.749 | < 0.001 | 0.41 | Medium improvement |
Effect size r = Z / √N. Bonferroni-adjusted α = 0.01
Theoretical and conceptual framework
The ASPIRE framework used [9, 10], in the development of RLOs ensures that these e-learning materials are pedagogically robust, evidence-based, linguistically adaptable, and interactive. The emphasis on active learning, multimedia engagement, and self-paced study aligns with contemporary educational best practices. Furthermore, the integration of Campos’s Mental Health Literacy Model [12], within the RLO ensures comprehensive coverage of essential MHL dimensions, such as recognizing mental health disorders, erroneous beliefs, and identifying appropriate help-seeking strategies. RLOs offer a scalable, low-cost digital intervention suitable for integration into national youth mental health programs, school and university curricula, and public health campaigns in both countries. In resource-limited settings, the self-paced, bilingual nature supports broad dissemination with minimal infrastructure, potentially enhancing cost-effectiveness while addressing cultural nuances through localized adaptations (Table 6).
Table 6.
Wilcoxon signed-rank test results comparing baseline and post-intervention mental health literacy dimensions among Malaysian participants (Bonferroni-adjusted α = 0.01)
| Dimension | N | Z | p-value | r | Interpretation |
|---|---|---|---|---|---|
| MHD Knowledge | 107 | -5.82 | < 0.001 | 0.56 | Large improvement |
| Erroneous Beliefs | 109 | -0.96 | 0.335 | 0.09 | No significant change |
|
Help-Seeking / First aid Skills |
109 | -6.45 | < 0.001 | 0.62 | Large improvement |
| Self-Help Strategies | 109 | -5.16 | < 0.001 | 0.49 | Large improvement |
| Total MHL | 107 | -5.95 | < 0.001 | 0.58 | Large improvement |
Effect size r = Z / √N. Bonferroni-adjusted α = 0.01
Strengths and limitations
A key strength of this study is its cross-country comparison approach, allowing for a comparison of MHL improvements between youth in Saudi Arabia and Malaysia. By assessing the transferability of RLOs across diverse educational and cultural settings [1], this research shed light on the relationship of elearning tool and mental health literacy awareness.
Additionally, the quasi-experimental design allows for a structured evaluation of baseline and post-intervention MHL levels, ensuring methodological rigor.
Despite its strengths, the study has several limitations. First, the non-randomized allocation of participants into intervention and control groups may introduce selection bias. While efforts were made to ensure baseline equivalence between groups, uncontrolled confounding variables may still influence outcomes. Second, the reliance on self-reported measures for MHL assessment may introduce response bias, as youth may overestimate or underestimate their knowledge and attitudes toward mental health. To mitigate this, a validated MHL instrument was used, and triangulation with qualitative feedback from participants will be considered for future research.
Third, the short-term post-intervention assessment limits conclusions about long-term knowledge retention and behavioural changes, which is crucial from a public health perspective for evaluating sustained impact.
Fourth, research directions could include expanding the study to a broader age range of youth or implementing a longitudinal design to assess the long-term retention of MHL. Additionally, exploring the integration of RLOs with blended learning models, combining digital and face-to-face instruction could provide further insights into optimizing mental health education for youth.
There are several threats to internal validity. For the testing, the researchers used the same questionnaire (presented in the Google form) as the baseline (pre) and post intervention evaluations within a single session for each participant. This may lead to testing effects. Participants’ familiarity with the baseline questions could resulted to improved scores in the post assessment. To address this in future work, we will consider using parallel versions of the assessment or introducing a time delay between measurements to reduce practice effects.
Second, for maturation and history threats, this research might not be affected as much since the data collection was done without any time lapse (pre and post assessment was done immediately for each cohort). However, since the data collection period was about 5 months, the baseline assessments score might vary across cohorts as some participants may have been exposed to mental health topics through their coursework, campus activities, or media coverage, which could have influenced their initial responses.
Third, while the RLO was not made publicly available during data collection and was only accessible through internal links provided to participants, there remains a possibility of contamination between groups. Because some intervention and control participants were recruited from the same educational institutions, informal conversations about the RLO content may have occurred. Participants who were in the intervention group might share unintentionally what they learned with friends who were in the control group, potentially reducing the observed differences between the intervention and the control group. For future research, employing a RCT design that will separate the two groups either temporally or geographically, along with a protocol of randomization and blinding to limit interaction between participants in each group (Table 7).
Table 7.
Mann–Whitney U test results comparing post-intervention changes in mental health literacy outcomes between Saudi Arabia and Malaysia
| Outcome Variable | Malaysia N |
Saudi N |
Mean Rank (MY) | Mean Rank (SA) | U | Z |
p
(2-tailed) |
r | Interpretation |
|---|---|---|---|---|---|---|---|---|---|
|
Δ MHD Knowledge |
107 | 82 | 87.25 | 105.12 | 3557.50 | –2.25 | 0.024 | 0.24 | Malaysia < Saudi (small effect) |
| Δ Help-seeking/ First Aid | 109 | 82 | 106.6 | 81.91 | 3314.00 | –3.24 | 0.001 | 0.23 | Malaysia > Saudi (small to medium effect) |
| Δ Self-Help Strategies | 109 | 82 | 100.57 | 89.93 | 3971.00 | –1.45 | 0.148 | 0.10 | No significant difference |
| Δ Erroneous Beliefs | 109 | 82 | 103.28 | 86.32 | 3675.00 | –2.36 | 0.018 | 0.17 | Malaysia > Saudi (small effect) |
| Δ Total MHL | 107 | 82 | 99.13 | 89.62 | 3945.50 | –1.19 | 0.235 | 0.09 | No significant difference |
Effect size (r) = Z / √N. Values of 0.10, 0.30, and 0.50 indicate small, medium, and large effects, respectively
Conclusion
This study found that participants using Reusable Learning Object (RLO) showed improvement in mental health literacy (MHL) among youth in Saudi Arabia and Malaysia. Participants showed improvements in knowledge of mental health disorders, help-seeking and first aid skills, and self-help strategies, suggesting the potential of e-learning as a scalable and culturally adaptable e-promotion tool. The cross-country comparison indicated differences in youth knowledge, skills and strategies towards mental health, underscoring the need for localized content to address stigma and misconceptions effectively.
The findings from this study showed a bright future in integrating RLO-based mental health education into existing curricula to promote awareness and early help-seeking among young people. Future research should explore long-term retention, integration with blended learning approaches, and user experience and usability studies that can further enhance engagement and impact.
Acknowledgements
Nasriah Zakaria would like to thank AlMaarefa University for supporting this research under project number MHIRSP2025056. The researchers also acknowledge Alfred Tan from Institute of Biological Sciences University Malaya, for his contribution in building the first version of the RLO. And thanks to University Malaya for the partial funding.
Authors’ contributions
NZ, NDNF, ST, NF and HM contributed to conception and design of the study. Material preparation, data collection, and analysis were performed by NZ, NDNF, NF and HM. RLO modifications and translation were handled by NZ, NDNF, DM. Data collection was conducted by NZ, AM, AB in Saudi Arabia while NF, NDNF, HM and EA collected data in Malaysia. The first draft of the manuscript was written by NZ, NDNF, EAR, HM, NFMN and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
This research was funded by AlMaarefa University, Saudi Arabia. Partial funding is also obtained from University Malaya, Malaysia.
Data availability
The Reusable Learning Objects (RLOs) used in this study are available online: Saudi Arabia: [https://acord.my/xerte/play.php? template_id=138#page1](https:/acord.my/xerte/play.php? template_id=138)Malaysia: [https://acord.my/xerte/play.php? template_id=151#page1](https:/acord.my/xerte/play.php? template_id=151)Data supporting the findings of this study are available from the Corresponding Author upon reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval for this study has been obtained from the relevant Ethics Committees in Saudi Arabia and Malaysia, including the Institutional Review Board in Saudi Arabia [IRB24-066] and Universiti Malaya (UM) [UM. TNC2.UMREC_4075]. Additionally, approvals have been obtained from the respective educational authorities overseeing the selected institutions in both countries to ensure compliance with local research regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The Reusable Learning Objects (RLOs) used in this study are available online: Saudi Arabia: [https://acord.my/xerte/play.php? template_id=138#page1](https:/acord.my/xerte/play.php? template_id=138)Malaysia: [https://acord.my/xerte/play.php? template_id=151#page1](https:/acord.my/xerte/play.php? template_id=151)Data supporting the findings of this study are available from the Corresponding Author upon reasonable request.