What's Up With Everyone? A qualitative study on young people's perceptions of cocreated online animations to promote mental health literacy

Abstract Introduction Adolescence and young adulthood are especially critical times to learn about mental health, given that 75% of mental health issues are developed by the age of 24. Animations have great potential to effectively deliver mental health information to young people. A series of five short animated films to promote mental health literacy were created with and for young people in partnership with the multi‐award‐winning independent animation studio, Aardman Animations. The aim of this study was to explore young people's perceptions of the cocreated animated films. Methods Seven Youth Juries were conducted to capture young people's opinions and recommendations about the content related to mental health literacy and presentation style of the cocreated animated films. Thematic analysis was used to analyse the audio transcripts. Results Many participants reported a view that the animated films had the potential to promote mental health literacy, especially for understanding mental health and reducing stigma. Some recommendations were provided to improve the films, such as including subtitles and having a better transition to the companion website. Conclusion Cocreated animations have great potential to promote the mental health literacy of young people. We hope that the findings from the present study will inform future media development to make them as effective as possible. Patient or Public Contribution Young people were actively involved in the development, production, implementation and evaluation (up to the time before data analysis) of the animated films.


| INTRODUCTION
The growing burden of mental ill-health facing society is clear.

Increases in mental disorders observed by the Lancet Commission on
global mental health, for instance, are estimated to cost the global economy $16 trillion by 2030. 1 Young people are particularly at risk.
Transitioning into adulthood is challenging as young people face pressures and issues related to mental health, such as perfectionism, independence, loneliness, social media and competitiveness. [2][3][4][5][6] Adolescence and young adulthood are especially critical times to learn about mental health, given that 75% of mental health issues are developed by the age of 24. 7 An objective of learning about mental health is to enhance mental health literacy. 8 Mental health literacy is defined as 'understanding how to obtain and maintain positive mental health; understanding mental disorders and their treatments; decreasing stigma related to mental disorders; and, enhancing help-seeking efficacy (knowing when and where to seek help and developing competencies designed to improve one's mental health care and self-management capabilities)'. 9 Interventions oriented towards the improvement of mental health literacy have tremendous potential in addressing deteriorating youth mental health.

| Digital media
Creative practices, in particular, have documented potential for transforming people's mental health literacy. 10,11 One of the methods used to creatively promote mental health literacy is digital media. The use of online and social networks is especially suited to reach young people because the modality of delivery reflects how they are consuming information. The vast majority of young people aged 16-24 years in high-income countries use social media. 12 In the United Kingdom, 99% of young people have a smartphone and 92.7% of young people use social networking. 12,13 Not surprisingly, social media-friendly digital films are one of the most effective and costeffective media to improve mental health literacy among young people. 14,15

| Cocreation of digital films
To maximize the impact on the target audience, it is suggested that media content should be cocreated with end-users at the centre of the creative process. 16 In academic parlance, cocreation is defined as 'the collaborative generation of knowledge by academics working alongside stakeholders from other sectors'. 17 Stakeholder engagement generates inclusive and representative conversations among multiple sectors that can drive the development of meaningful and more relatable media interventions. 18 Therefore, engaging end-users is crucial when creating a digital film intervention. However, according to a recent scoping review, only a few of the mental health film interventions were cocreated with end-users. 14 Of these, the authors argue that animations are perhaps one of the most useful media for cocreation since they contain an active voice, while enabling anonymity for those end-users involved in the creative process. 14,19

| Animation
Animation has great potential to communicate knowledge and promote learning. 20 Animation has been used to communicate health-related information and has been found to be effective in improving health literacy and intentions to change health-related behaviours positively. [21][22][23] The recent study by Dunn et al. 19 is the first of its kind to report on a cocreation process, in which young people were involved in creating animations to communicate mental health information. 19 In this study, a group of young people who had been diagnosed with depression created a short animation about depression and therapy with filmmakers. The film was promoted on social media, and was viewed 12,000 times on YouTube. In another recent study, young people cocreated a series of short animations to raise awareness of mental health issues commonly experienced by young people. 24 The cocreated animations gained 16,000 views on social media in the 12 months following its launch.
These previous studies show that animations have great potential to deliver mental health information to a large number of young people. However, no studies have involved young people in creating animations to promote mental health literacy throughout the creative process (i.e., development, production, implementation and evaluation) as suggested by Jirotka et al. 16 In the present project, young people were actively involved in the cocreation process from the development to the evaluation (up to the time before data analysis). Furthermore, the present study is the first to invite an independent group of young people (i.e., different from the young people who were involved in creating the animations) to evaluate the cocreated mental health animations. The use of an independent sample is an important practice as it helps to reduce bias.

| The What's Up With Everyone project
The What's Up With Everyone (WUWE) project is a campaign developed to promote mental health literacy among young people. In this project, a series of five short animated films were created with and for young people in partnership with the multi-award-winning independent animation studio, Aardman Animations. Each film is 40-50 s long and focused on an issue related to loneliness and isolation, perfectionism, competitiveness, social media and independence. The films are embedded in a companion website 25 and are also available on Aardman's YouTube Channel, 26 Instagram, 27 Twitter, 28 Facebook 29 and TikTok. 30 Full details of the project and context can be accessed on the website and the UKRI announcement. 31 In a 4-month media campaign following the launch of WUWE on 8 February 2021, the films reached over 17 m people, with Instagram the highest performer, followed by Twitter and Facebook. By 4 June 2021, there were 4.93k followers, with more than 638k views of the films across the channels. In this initial period, the companion website alone attracted 33.1k users with 44k sessions, 101k unique page views, 994k total page views and 4.5k

| Objective
This study aims to explore young people's perceptions of cocreated animated films. We adopted a qualitative approach and facilitated a  Table 1.

| Procedure
Young people who confirmed their willingness to participate in the study received and submitted the consent form and a demographic questionnaire via email. The consent form included a consent for audio and video recording, but participants were reassured that they did not need to turn on their camera if they did not feel comfortable.
One week before the study, participants received an email containing the links to the five films and were asked to watch them before the session.
YJ, which are similar to focus groups, have an explicit objective of arriving at clear recommendations. 33

| Data analysis
Thematic analysis was used to analyse the transcripts. 34 Thematic analysis has been used to understand young people's opinions and recommendations about a newly developed digital intervention. 35 Following Braun and Clarke's 34 six phases of thematic analysis, one of the authors (1) became familiar with the content by reading and rereading the transcripts, (2) generated initial codes, (3) searched for themes, (4) reviewed the themes, (5) defined and named themes and later (6) produced the report. Throughout the process, research meetings were held for debriefing and discussing emergent themes among the authors.

| RESULTS
The YJ discussions focused on the content of the animation, particularly related to the three components of mental health literacy (i.e., understanding mental health, reducing stigma, help-seeking efficacy), and the presentation style of the animations. As presented in Figure 1, two themes were generated for each component of

| Stigma
Many participants believed that the animated films would help to reduce stigma related to mental health issues because they are relatable to young people, and they reassure young people that other people have experienced similar issues.

| Relatable
The majority of the participants reported finding the animations very relatable to their lives and experiences. They reported a belief that because of this relatability, the animations had the potential to reduce stigma related to mental health issues. It was mentioned that other films that they had watched in the past were not as relatable as the WUWE material. The comical style of the animations appeared to contribute to the feeling of being relatable. Positive feedback was provided on the animation style in general.
Most participants reported that these animated films are interesting, entertaining, playful and comforting.

| Novel and refreshing
Some participants expressed that although they have watched many mental health-related videos growing up (e.g., at schools), the WUWE videos are unique and refreshing to watch, and thus they pay more attention. They reported that these films have high production quality and are more detailed than others, and also animation is used less often to portray mental health issues than live action.

| Wording
Some recommendations were provided for the wording used in the animation. In particular, many participants stated that the phrase 'be confident' (independence) is not helpful and suggested using the alternative 'it's okay to ask for help' as more effective and best suited for this particular film.

| DISCUSSION
In the present study, we captured young people's opinions and recommendations about the content related to mental health literacy and presentation style of the animated films by facilitating a series of YJ. Many participants believed that watching the animated films had the potential to improve young people's mental health literacy, especially for understanding mental health and reducing stigma.
Additionally, participants provided positive feedback and some recommendations for the presentation style of the animations.
Most notably, many participants believed that the animations had the potential to reduce stigma because they are relatable and reassure young people that others have experienced similar challenges. This is particularly noteworthy, given that these animations are cocreated with young people to develop animations that are relatable to other young people. Cocreation is an essential practice that drives the development of meaningful and more relatable media intervention and maximizes impact on the target population. 16,18 Stakeholder engagement is one of the pillars for responsible research and innovation and a key element for developing new media interventions in a socially desirable and acceptable way. 16 The current results demonstrate and reconfirm the importance of cocreation with end-users.  [42][43][44] and trust is one of the key factors for deciding whether to use a particular kind of technology. 45 Thus, future media creators should ensure that the involvement of the established institutions is clearly presented in the media outlet.
In general, positive feedback was provided on the presentation style of the animations. The high production quality was achieved by a partnership with a multi-award-winning animation studio. It has been discussed that there is a need to attend to the production quality so that the digital video intervention is as effective as possible. 14 The present study highlights the importance of interdisciplinary collaborations with creative industrial partners.
In addition, participants perceived the films as inclusive in their use of diverse accents and animal characters relatable to a diverse population. Inclusiveness is vital for mental health promotion, given that minority groups, including Black, Asian and minority ethnic (BAME), are portrayed as a 'hard to reach' population in primary care mental health services. 46 Although other factors, such as political climate, are barriers for minority groups to access mental health services, it is hoped that these inclusive videos provide comfort for as diverse a population as possible and encourage help-seeking. 46 Subtitles were recommended to be included in the films. Past research shows that subtitles are beneficial for everyone as they increase understanding of, attention to and memory for the material. 47 Subtitles are important to further improve the inclusiveness of the films as they benefit people who are deaf or hard of hearing and people whose native language is not English. 47 Subtitles are also helpful for native English speakers who are not hard of hearing, especially when diverse accents are used in the films.

| CONCLUSION
This study provided insight into the content and presentation style of cocreated online animated films to promote mental health literacy.
The results indicate that cocreated animations have the potential to promote the mental health literacy of young people. However, several recommendations were also made to improve the films. We hope that the findings from the present study will inform future media development to make them as relatable and effective as possible.