3.1. Step 1. Logic Model of the Problem
Through our literature review, we found that the mental health and related quality of life concerns of runaway adolescents comprise an important global public health problem. Compared to the general adolescent population, runaway and homeless adolescents were found to have higher rates of mental health problems such as conduct disorder, depression, anxiety, bipolar disorder, PTSD, suicidal ideation, and schizophrenia [1
]. Regarding the quality of life, runaway adolescents also face a high risk of reduced emotional well-being [10
], and dissatisfaction with family life [25
Problematic alcohol use, risk behaviors [24
], delinquency, criminal behavior, and school drop-out have been identified as behavioral factors associated with mental health problems and related quality of life issues [10
Environmental factors can be classified as either interpersonal or community-level factors. At the interpersonal level, family factors such as poor communication, financial problems, poor psychological well-being of the parent or caregiver, poor emotional support at home [27
], parental conflict, parental separation or divorce, parental alcohol abuse, and domestic violence [6
] are associated with mental health problems and quality of life issues. Among runaway adolescents, relationships with peers and the presence of a caring adult are also related to mental health and quality of life issues [28
]. At the community level, poor social connectedness, school and community environments, and economic opportunities can affect the mental health and quality of life of adolescents [28
Poor self-esteem; a lack of adolescent resilience [28
]; a lack of self-regulation, interpersonal, and/or problem-solving skills; a lack of self-efficacy [28
]; poor parent–adolescent attachment [10
]; a lack of family resilience; a lack of knowledge of parenting and adolescent development; parenting competency have all been identified as determinants of behavioral and environmental factors [28
For two focus group interviews, five social workers and three youth counselors working at two youth shelters participated. They indicated that most of the runaway adolescents residing in youth shelters had experienced family-related difficulties such as parental divorce and family poverty, and were vulnerable to stress and mental health problems. They suggested the importance of providing an intervention targeted at improving the vulnerable mental health statuses and family functioning of adolescents. They also stated that an intervention should include promoting mutual understanding and emotional support between parents and adolescents, and having positive experiences with family through regular meetings. The focus groups explained that the return of adolescents to their homes may not be a possible outcome in some family cases because of financial difficulties and changes in the family structures due to parental divorce and remarriage. However, the focus groups suggested that improving the mental health status of adolescents and providing them with opportunities for positive experiences with family members are important in themselves, rather than as pathways to visible short-term outcomes such as the return of the adolescents to their homes.
Regarding the feasibility of an intervention, based on the focus group interviews, youth shelters strongly support the need for an intervention that aims to improve the mental health and family relationships among runaway adolescents. Shelters were willing to provide time and space required for the relevant intervention. In addition, the focus groups indicated that younger adolescents expressed a stronger will to reconcile with their family. However, the focus groups also had some concerns regarding encouraging adolescents’ parents to participate in an intervention owing to the parents’ lack of time and motivation attributed to their respective occupations.
The runaway adolescents who participated in individual interviews were likely to engage in risky and maladaptive behaviors in response to stress associated with family problems. They reported experiencing chronic family conflict and dissatisfaction with family life. They wanted individual mental health counseling and stated that their family members must have time to understand each other through an intervention.
Based on the results of this needs assessment, the program goal was set that mental health status and perceived family functioning are improved among runaway adolescents.
3.2. Step 2. Program Outcomes and Objectives—Logic Model of Change
The needs assessment in the first process resulted in the establishment of two expected outcomes for behavior and environment: Adaptation to stressful situations and family resilience as the capacity to be resourceful in dealing with family adversities.
While reviewing the relevant theories, we selected two theories providing rationales for performance objectives for the outcomes. The transactional model of stress and coping [30
] was used as a basis for the behavioral outcome-related performance objectives, which were the use of effective coping strategies for stress and the seeking of help from social support networks in stressful situations. In addition, using the Walsh family resilience framework [31
] as a rationale for the interpersonal environmental outcome-related performance objectives, we specified the performance objectives as the ability of family members to rebuild family relationships, communicate clearly and honestly, and collaborate to solve family problems.
Based on the results of our literature review conducted in step 1 of the IM process, attitudes, knowledge, skills, and self-efficacy were selected as determinants for the outcomes. Table 1
presents a matrix of the change objectives, which was constructed by crossing the performance objectives with the determinants and thus recording the change objectives.
3.3. Step 3. Program Design
We reviewed existing empirical evidence in the literature and theories of change to identify and choose theory- and evidence-based methods intended to influence changes in the determinants. As a result, we identified that motivational interviewing and cognitive reappraisal methods applied to the change objectives related to activating a positive attitude. Motivational interviewing to provide strength and motivation for positive changes [32
] is used to facilitate changes in attitudes. According to the transactional model of stress and coping [30
], a cognitive appraisal, which refers to the personal subjective interpretation of a situation and coping resources, influences an individual’s coping efforts and adaptation to a stressor. The ability to use cognitive reappraisal, which refers to the reframing of one’s thoughts to influence one’s responses to situations, could be a protective factor that enables an individual to adjust to stressful situations and reduce depressive symptoms [33
]. To enhance knowledge, we derived the method of consciousness-raising from the transtheoretical model, which refers to increasing awareness about a specific problem behavior [34
]. Skills training and guided practice methods were selected to enhance skills. Social modeling, emotional state improvement, and verbal persuasion were derived from Bandura’s theory [35
] and selected to enhance self-efficacy. Table 2
lists the theory- and evidence-based methods and practical applications.
3.4. Step 4. Program Production
By integrating information from steps one to three, we developed a family-based mental health intervention for runaway adolescents aged 12–18 years who reside in youth shelters. Based on the results of needs assessment in step 1, we integrated the individual approach and family approach in the intervention. Considering the vulnerability of mental health among runaway adolescents, we consisted that adolescent individual sessions would precede family sessions. The focus group interviews conducted in step 1 revealed that most runaway adolescents residing in shelters experienced poverty, and adolescents’ parents lack time and motivation to participate in an intervention as they work to address financial difficulties. Therefore, considering the feasibility of the expected degree of family participation, an intervention format comprising four individual sessions with the adolescent and four subsequent family sessions in which the adolescents and their family members can engage together was considered appropriate. Hence, an eight-session program will be delivered in a shelter-based setting during a two-month period, and each session is expected to require approximately 60–90 min. Although the program was structured, the number of actual program sessions can be increased or decreased to accommodate the needs of adolescents and their families.
Based on the program plan from steps 2 and 3, the program components, tools, and materials were designed to ensure the achievement of the change objectives and effective operationalization of the methods and practical applications. In the first session, program engagement and motivational establishment through motivational interviewing techniques are the major emphases. In the second session, the cognitive reappraisal method is used to change the negative attitudes or beliefs influencing the adolescent’s negative emotions or behaviors on stressful events into positive attitudes or beliefs. In the third session, the participants are trained to cope effectively with stressful situations. The fourth session includes practical applications such as the provision of information about helpful resources, role-playing, mentor–mentee activities, and strong encouragement and support to encourage adolescents to seek help from social support networks in stressful situations.
The fifth to eighth sessions of the intervention will involve the family. The fifth session aims to improve family engagement and motivation for change. The sixth session includes the positive reframing of family adversities, education regarding differences between adolescents’ developmental needs and parental needs, and expressions of empathy and support to reconcile and rebuild the wounded family relationships. In the seventh session, family members are trained to communicate clearly and honestly. In the eighth session, family members identify family strengths, acquire problem-solving and decision-making skills, and practice these skills through family meetings to acquire family competence in collaborative problem-solving. Detailed information about the program components is presented in Table 3
3.5. Step 5. Program Implementation Plan
We considered the community context to develop an implementation plan. Youth shelters refer runaway adolescents who need help with their mental health to community mental health centers, and adolescents residing in youth shelters are the subjects of the services provided by these centers. Therefore, to enable adoption, implementation, and maintenance of the developed program, the program implementers will comprise psychiatric and mental health nurses working at community mental health centers which were associated with youth shelters.
The psychiatric and mental health nurses at the community mental health centers will visit the youth shelters and deliver the program in counseling rooms. They will approach adolescents with cooperation from social workers at shelters and provide a program tailored to the characteristics of each adolescent.
The program implementers will receive education, training, and supervision by a nursing professor and principal investigator, and will provide the program to adolescents according to the program protocol. To maintain the quality of the services, the nursing professor and principal investigator will hold regular once-weekly meetings with the program implementers and youth shelter workers. Partnerships will be established between youth shelter workers and nurses from community mental health centers to enable cooperation.
3.6. Step 6. Evaluation Plan
According to the program goal, which was set based on the need’s assessment in step 1, the hypotheses will test whether the mental health status and perceived family functioning improved in the intervention group relative to the comparison group. The primary outcome will be the effect of the program on mental health issues including depression, internalizing and externalizing behaviors, psychological distress, and suicidality among adolescents. These indicators were determined based on a review regarding outcome variables used in previous experimental studies of runaway and homeless adolescents. The secondary outcome will be the effect of the program on perceived family functioning among adolescents. The process evaluation should address the reach (percentage of the intended participants who used the program) and the dose of the intervention (average dose received by program participants). We will evaluate whether the needs of participants, as assessed in step 1, will be satisfied, and the new information and perspective generated in the evaluation process of the program will help us revise the previous steps in the IM process.
The effectiveness of the developed program will be evaluated in a randomized controlled trial (RCT). The participants will be divided into experimental and comparison groups via computer-generated random allocation. The participants that meet the following criteria will be included: runaway adolescents residing in youth shelters and 12–18 years of age. The exclusion criteria will be as follows: (1) adolescents diagnosed with an intellectual disability or specific learning disorder that can impair their ability to understand the intervention procedure and (2) those who are currently receiving other psychiatric treatments. In addition, family members currently receiving treatment for acute psychiatric symptoms will not be allowed to participate in the family sessions.
The participants’ data will be collected using self-administered questionnaire surveys, which will be completed individually in quiet counseling rooms to protect the participants’ confidentiality. The assessment time points will include the baseline (before the program) and immediately and 1 month after program completion.
The data will be analyzed statistically using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA), and the intervention effects will be examined using a one-way repeated measure multivariate analysis of variance (MANOVA). A power analysis conducted using the G * Power program [36
] indicated that a total sample of 211 subjects would be needed to detect a medium effect (f
= 0.25) with 80% power using MANOVA at an alpha level of 0.05. Therefore, we will collect data from 118 participants each in the experimental and comparison groups (N
= 236) to accommodate the expected attrition of 10% over the three-month period from the baseline assessment to the final evaluation.