Exploring Mental Health Services for Youth Experiencing Homelessness in East Asia Pacific Regions: A Systematic Scoping Review

2.Methods

This review followed the Centre for Evidence-Based Management (CEBMa) for Critically Appraised Topics guidelines[54] and PRISMA Extension for Scoping Reviews checklist[55] (Appendix A) to ensure that the review process was conducted in a comprehensive manner and to minimise potential researcher bias.[56] The research question was formulated using the PICO (population, intervention, comparison, and outcome) framework.[57] Table 1 presents the full inclusion and exclusion criteria with definitions.

Insert Table 1 Here.

• Databases and search strategy

The following major electronic databases were searched for this review: Medline, PsychInfo, PubMed, Scopus, and Web of Science. Additional records were hand-searched through other sources, such as web-based publications and grey literature specific to homelessness, reference lists of included texts and related publications. These included Centre for Homelessness Impact (CHI)[60]: A non-profit organisation dedicated to providing evidence-based solutions and innovations with the goal of improving the outcomes of people experiencing homelessness. The search was conducted on 13^th May 2023 and was limited and filtered to English records published between 1990 and 2023 in all databases. Table 2 presents an example of search terms used for Medline, with slight variations employed in each database. See Appendix B for full search terms used in all academic databases. A prior search was conducted across official government websites to compare different definitions of homelessness within EAP and to inform the search terms used (Table 2; Appendix B).

Insert Table 2 Here.

• Screening process

Results were imported into EndNote 2.0 for screening and deduplication. An initial title and abstract screening was conducted. Full-text articles were then read and thoroughly evaluated to determine eligibility for inclusion in the systematic scoping review. Studies meeting the inclusion criteria were selected, and subsequent data extraction was carried out. Any conflicts were discussed between co-authors KCE and DMR until a consensus was reached. This is demonstrated in the PRISMA Flow diagram[61] in Figure 1.

• Analysis

A study quality assessment was performed using The Critical Appraisal Skills Programme (CASP) checklists[62,63,64,65] (see Appendix C for the CASP checklist that was matched and employed for each selected text and its study design). Each selected study was evaluated to assess its methodological robustness, validity, and relevance to the research question. Applicability to clinical practice and ability to generalise results were also assessed, which was crucial for this review. This ensured that the evaluated interventions and programs were relevant for addressing specific mental health needs of YEH. CASP[62,63,64,65] aims to inform evidence-based practice as generalisability helps identify interventions that have demonstrated its effectiveness across diverse settings for the target population.[66] Lastly, interventions/programs in the results were thematically grouped based on the type of interventions they encompassed.

3. Results

• Study selection

A total of 3,543 publications were identified from the literature search across all databases and through hand searching additional resources, which represented 3,467 publications after duplicates were removed and screened for eligibility. After the selection process, a total of eight studies published between 2000-2023 met the inclusion criteria and were included in this review. Fig. 1 is the PRISMA Flow diagram[61] showing individual database numbers and articles retrieved.

Insert Figure 1 Here.

• Study characteristics

All included articles were conducted within the EAP region: Indonesia (n = 2),[67,68] Malaysia (n = 1),[69] South Korea (n = 3)[27,70,71], and The Philippines (n = 1).[72] The location of one study (n = 1) was withheld for confidentiality reasons, but, it was conducted in Southeast Asia[73] e.g., Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand, and Vietnam,[74,75] indicating it still fit the inclusion criteria. Outreach settings for YEH primarily consisted of participants residing in orphanages (n = 8), shelters (n = 8), centres (n = 4), and children residing on the street (n = 2).

Participant characteristics

The age range of the participants varied across the studies, with the majority falling between the inclusion criteria age 12 to 18 yrs. (n = 4).[27,69,71],[72] However, a case study included participants as young as seven yrs. old,[67] with the oldest participants in another study being 21.[70] Both male and female participants were included in the studies; some studies focused exclusively on one gender to examine gender-specific effects of interventions for YEH[27,70] while others had a balanced representation of both genders.[69] A summary of the study and participant characteristics is reflected in Table 3. As the selected studies were conducted within the EAP regions, the studies encompassed a diverse range of participant ethnic and religious backgrounds, such as Christianity and Islam. In the Malaysian study,[69] there were different ethnicities included as participants, although they only reflected a small percentage. For example, a large percentage of participants in this study were of Malay ethnicity (67.5%), followed by Indian (21.8%), Chinese (4.8%), and Indonesian and Orang Asli [indigenous] (5.9%). Lastly, a large majority of participants across all eight studies belonged to families of low socioeconomic position (SEP). (Table 3).

Insert Table 3 Here.

Study designs

Of the eight studies, three involved some type of randomised-control trial (RCT) study design. One of these included a parallel single-blind (subject-masked) RCT[69]; one study had randomly assigned participants to either a control group or intervention group[27]; the other study was a development of an intervention program for YEH, with the aims of using an RCT to evaluate its effectiveness of the developed program.[71] Four studies used quasi-experimental and qualitative designs,[68,70,72,73] and the remaining one was a case study[67] (Table 3). Each selected study was subjected to quality checks using the CASP checklists[62,63,64,65] matched by study design (see Appendix C).

Outcome measures

A structured overview of measures and outcomes for each selected study is displayed in Table 4. Evidently, a range of outcome measures were utilised to evaluate various aspects of mental wellbeing and health status of YEH. For example, depression was measured with different scales across the studies: Brillantes-Evangelista[72] used the Self-Rating Depression Scale (SDS),[76,77] while Hyun et al.[27] and Mohammadzadeh et al.[69] used alternative scales to measure depression (Beck Depression Inventory [BDI] and Depression, Anxiety and Stress Scales [DASS-21]; respectively).[78,79] For specific outcome measures, the choice of instruments varied across studies which were usually translated into the country’s main language (Filipino, Malay, or Korean).

Insert Table 4 Here.

• Mental health interventions/programs

1. This review identified eight unique mental health programs and interventions for YEH in EAP. These were clustered thematically into six categories:

• art: interventions that provide a creative and non-verbal outlet for self-expression, healing, and personal growth for YEH[72,73];
• cognitive behavioural therapy: an intervention that targets negative emotional states and cognitive distortions by developing coping strategies[27];
• life skills education: interventions that equip YEH with essential practical abilities in the real world[69];
• resilience enhancement: an intervention to improve protective factors associated with resilience[70];
• family strengthening: interventions that explicitly target families in the program as a key focus that fosters positive relationships and support networks[71];
• government interventions/services: the role of the government in supporting YEH. [67,68]

Each selected study was organised by thematic category below and subjected to quality checks using the CASP checklists[62,63,64,65] matched by study design (see Appendix C).

Art Two studies used a quasi-experimental design to evaluate the effectiveness of different forms of art as a therapeutic intervention for abused youth in orphanages and militarised children in centres, which took place in the Philippines[72] and in Southeast Asia. [73] Art as an intervention for these studies included art psychotherapy, poetry psychotherapy and art without boundaries as a general communication and therapeutic tool.

The objectives of these studies were to evaluate the effectiveness of visual arts and poetry as interventions to alleviate depression and PTSD symptomatology,[72] as well as to understand the children’s perceptions of hope. [73] Although each study reported on different measures of art as an intervention, both studies reported themes of art creating a sense of agency, catharsis, and personal empowerment for YEH. In one study, Brillantes-Evangelista (2013)[72] measured PTSD and depression symptoms using various instruments (see Table 4), including self-reported scales and participant observation throughout the intervention period. Results showed a decrease of depressive symptoms in mean scores pre-test to post-test among the group receiving poetry psychotherapy, indicating a positive impact on their wellbeing (Table 4). Whereas a reduction of PTSD symptoms in mean scores was evident among the visual arts group, suggesting that this form of art therapy was beneficial for addressing trauma-related symptoms for YEH.[72] Brillantes-Evangelista[72] noted that although these results suggest that visual arts and poetry psychotherapy were effective in reducing psychological symptoms for abused adolescents living in orphanages, art seemed to have been helpful in other ways by empowering YEH to actively engage in their own healing and recovery. For instance, poetry allowed youth to find meaning and purpose in their experiences, by transforming hardships into something meaningful and artistic which can inspire hope. The notion of ‘hope’ was also noted in the second study[73] where militarised children had visualised their aspirations, dreams, and personal goals through art. Miles (2000)[73] concluded that despite their circumstances, art had allowed them to envision a positive future and work towards achieving it, instilling hope for a better tomorrow.

CBT One RCT study conducted by Hyun, Chung and Lee (2005) in South Korea evaluated the effects of group CBT on self-esteem, depression and self-efficacy of runaway adolescents residing in shelters.[27] The authors measured these using Western-derived scales (Table 4) that were translated into Korean and employed at pre- and post-test. In this study, the most common reason for running away was parental abuse, especially by their father (40.7%), and family conflict (29.6%). There were also high rates of reported problem drinking (66.7%) and smoking (77.8%) among YEH. Results demonstrated a reduction in depression and improved self-efficacy in the experimental group from pre-test to post-test, while there were no significant changes in self-esteem documented pre- and post-test for both experimental and control groups (see Table 4). However, the authors revealed that an eight-week intervention period may be too short to yield noticeable results to self-esteem.[27] The study’s RCT design and use of validated measures (e.g., BDI[78]; Table 4) enhanced the reliability of the study’s findings (CASP[64]; Appendix C).[62] However, the geographical limitations should be considered when applying the results to YEH populations in different regions in EAP (see Table 5 for the full strengths and limitations of each study).

Insert Table 5 Here.

Life skills education Mohammadzadeh et al. (2017)[69] conducted a parallel single-blind (subject-masked) RCT conducted in Malaysia which evaluated the effects of life skills-based intervention programs on the emotional health and self-esteem of adolescents residing in orphanages.[69] This program was designed based on the Life Skills Education (LSE) formulated by the World Health Organisation (WHO)[96]— a structured evidence-based guideline for children and adolescents, stemming from the stress-coping theory by Lazarus and Folkman.[97] The LSE framework was a valuable resource for YEH, as it equipped them with essential skills and abilities to effectively navigate challenges they experienced in everyday life, promoting personal growth and resilience.[96] The study’s intervention sessions focused on a range of life skills: self-awareness, critical and creative thinking, communication, intra- and interpersonal relationships, problem solving, decision making, empathy, and coping with emotion and stress. Outcomes were assessed using DASS-21[79] and a Malay version of Rosenberg’s[86] Self-esteem Scale (RSES)[87] at pre-test, post-test and at a four-month follow-up (F/U). Results revealed that the LSE program significantly decreased mean scores for anxiety, depression and stress, and increased self-esteem from pre-test to post-test for participants receiving intervention. Notably, there was an increase of depression scores from post-test to the four-month F/U implying that LSE demonstrated efficacy in addressing depression, yet its impact was insufficient for sustainable change beyond the four-month period (Table 4). These findings[69] could have high potential for research in different regions in EAP because of its good replicability and RCT design, especially because this study had a diverse range of ethnicities. However, an important consideration was that the intervention period was not specified (Table 5).

Resilience enhancement A study on Korean female runaway adolescents by Noh (2018) assessed the efficacy of a Resilience Enhancement Program using a quasi-experimental design.[70] This design was appropriate based on ethical considerations and real-world settings, as it allowed the researcher to observe the program in an orphanage without compromising ethical guidelines or manipulating variables (CASP[64]; Appendix C). The Resilience Enhancement Program was developed based on interviews with female runaway adolescents residing in shelters and a comprehensive review of literature focused on individual protective factors relevant to YEH and runaway adolescents. Resilience, depression, anxiety, and problem drinking were assessed using self-reported questionnaires (Table 4) at pre-test, post-test, and at a one-month F/U. While the intervention group exhibited notable reductions in depression at pre-test and at a one-month F/U, this decrease was not exclusive to the overall study period: Depressive symptoms decreased over the study duration for both the intervention and control groups. Reductions of anxiety levels were also observed in the intervention group compared with control; and interestingly, the control group experienced a rise in anxiety levels at the one-month F/U.[70] In terms of problem drinking, the average levels decreased consistently for the intervention group throughout the three time points (Table 4). Although these were preliminary results, the small p-value suggested that the program had an effect on the dependant variables that was unlikely to occur by random chance alone.[70]

Family strengthening Noh and Choi (2020) developed a family-based mental health program for runaway adolescents residing in youth shelters using an intervention mapping (IM) protocol.[71] Despite its efficacy and effectiveness not yet being evaluated, this program focused on family strengthening that aligned with Korean cultural values that shaped their context. It was developed by conducting a comprehensive literature review and interviews with runaway adolescents and shelter workers. A logical framework outlining family relationship and mental health issues faced by runaway adolescents was then developed based on the problems that were identified during the preliminary IM process. The program used theory- and evidence-based methods for practical applications such as motivational interviewing, cognitive reappraisal, consciousness-raising, skills training, guided practice, social modelling, improving emotional states and verbal persuasion. Runaway adolescents receiving the intervention will have a total of eight individual and family sessions altogether. The family sessions consisted of four themes: family engagement and establishing motivation for change, rebuilding relationships with family, improving family communication and improving collaborative problem-solving. The effectiveness of the developed program will be evaluated using a RCT on adolescents residing in shelters aged 12 to 18.[71] Data will be collected using self-reported questionnaires.

The developed family-based mental health program has high study potential for YEH specific to the EAP context. However, to date, this program has not been tested for its efficacy and effectiveness and might not yield the positive health outcomes expected from the authors.

Government interventions/services The following two papers[67,68] focused on government interventions/programs and/or policies regarding mental health of YEH, thereby met the inclusion criteria (Table 1).

One research case study paper addressed the policies implemented by the Makassar City Regional in Indonesia in managing street children by collecting primary data (field observations and key informants) and secondary data (official government documents and literature publications on street children).[68] They identified three social services implemented by the Makassar City Regional in managing street children (Table 6).

Insert Table 6 Here

Despite these service policies, Solong et al.(2023) [68] identified factors inhibiting government policy in managing street children. These included insufficient quantity of human resources, budget limitations, insufficient facilities and infrastructure, unstable community economy and a lack of strict implementations for regional regulations regarding the management of street children. In spite of that, initial steps have been carried out by the government to prevent the development and expansion of street children. These included collaboration with Civil Service Police Units to patrol street children’s activities and/or removing them from street environment and into police stations so that they can be then placed into orphanages. [68]

The Kampung Anak Negeri (KAN) was a children’s village established by the Surabaya City Government in Indonesia that protected the rights of street children, aiming to empower street children, with the goal of granting them agency to enhance their self-resilience to deter them from returning to the street. Sarmini and Sukartiningsih (2018) evaluated the role of the KAN in facilitating the transition of street children towards a regular life.[67] Data was gathered by participatory observation and in-depth interviews with the street children placed in the KAN. The KAN established by the Surabaya City Government had six roles and responsibilities.[67] These responsibilities were described in Table 7.

Insert Table 7 Here.

Overall, KAN served as a comprehensive support system for street children that respects and integrates Indonesian culture into its program, aiming to improve mental health outcomes and ultimately break the cycle of street life and create a better future for themselves.[67]

4. Discussion

The main objective of this review was to provide systematic evidence on the different types of mental health services and interventions for YEH in EAP and their impact on overall quality of life and wellbeing for YEH. A wide variety of mental health interventions and programs for YEH in EAP was identified. These included art and poetry psychotherapy for abused Filipino adolescents living in shelters,[72] art without boundaries for militarised children,[73] CBT for runaway Korean adolescents,[27] a life skills education program for Malaysian adolescents living in orphanages,[69] a resilience enhancement program for female runaway Korean adolescents[70] and development of a family-based mental health program for runaway adolescents.[71] In essence, these mental health interventions and programs were effective in alleviating symptoms of anxiety, depression, stress, and PTSD, as well as targeting problem drinking. Additionally, there were notable increases in overall resilience and self-efficacy for YEH in EAP, and they were taught various life skills to tackle any daily stressors they may experience.

Notably, there were only two programs and social services found in this review that were established and implemented by the government that targeted street children.[67,68] While the researchers did not directly assess the outcomes of these services, their reports underscored the importance of creating culturally sensitive programs empowering and improving the quality of life for YEH in Indonesia, as well as identifying factors inhibiting the effective implementation of government policies aimed at addressing the needs and challenges faced by street children.[67,68]

Prior to this review, most systematic reviews and previous studies had mainly focused on interventions conducted in Western countries. Furthermore, there was a lack of comprehensive overview of literature surrounding interventions and programs for YEH in EAP alone, although there was an extensive body of literature emphasising the different perceptions of mental illness cross-culturally, which may impact the acceptability of treatment options and adherence to treatment plans.[43] In this review, risks associated with youth homelessness in EAP, such as stress, maladaptive behaviour, and suicidal behaviours were reportedly similar compared to Western countries (e.g., Hyun et al. [27]; Moskowitz et al. [19]; respectively). Additionally, consistent with findings from Western literature,[11,13] baseline assessments also revealed high levels of adverse mental health outcomes in various studies conducted in EAP.[27,69,70],[72] Nonetheless, Western-developed therapeutic systems such as CBT and LSE were also found to be effective in alleviating symptoms in Korean and Malay adolescents.[27,69]

Having said that, it is essential to highlight that these instruments and measures were socio-cultural specific which could have influenced the efficacy and effectiveness in treatment response. For example, five studies translated the measures into the country’s main language.[27,69,70],[72,73] Translating the psychological instruments into the country’s language was crucial, given the nature of the targeted population for this review. YEH may have limited proficiency in the English language, especially if most of the participants belong to families of low SEP and were residing in orphanages, shelters or on the street and have not completed or received formal education.[27,67,68,69,70,71,72,73] Although this was not specified in the studies, YEH with limited education may lead to feelings of discomfort or shame when responding to instruments in a language they were unfamiliar with. Therefore, using their first language may have reduced stigma and encouraged them to share their experiences openly, promoting accessibility and inclusivity in the research process for this population.[98]

• Exploring mental health interventions and programs

Six key themes were identified among the eight included studies: art, CBT, LSE, resilience enhancement, family strengthening, and government interventions/services.

• Art

Art-based interventions utilise creative mediums that do not primarily rely on spoken language to convey emotions, thoughts and experiences.[99] This has been well documented in numerous past and recent Western literature with adolescents in bridging that gap between therapists and adolescents.[100,101] It uses a child-centred approach.[102] As demonstrated in a sample of militarised children in SE Asia,[73] it broke down communication barriers and acts as a facilitator between the researcher and the CYP.[73] This was especially beneficial for YEH, as art can be used as a tool to amplify their voices in a society where it is marginalised and unheard.[99] This, in turn, may reduce the overall stigma surrounding homelessness, shifting the focus from defining youth homelessness solely by their housing status to appreciating their artistic talents and creativity; it helps people see their multifaceted identities beyond homelessness as shown in The Philippines.[72] Yet, it is important to note these findings may not be generalised to youth who have learning disabilities (LDs) and/or cognitive difficulties in engaging in complex art or poetry activities. Even so, with tailored interventions and adaptations, art and poetry psychotherapy can minimise barriers and promote autonomy, which empowers YEH with LDs to enhance their self-expression and build confidence, wherein traditional therapeutic approaches can lack.[103]

• CBT

Findings from South Korea[27] have been reported in previous literature by Rohde et al. [104] for adolescents with comorbid substance abuse and in parallel with more recent findings for street children in Mexico City[105] and in Iran[106]. The effectiveness of cognitive techniques in CBT for reconstructing positive worldviews was notable as it identified and challenged negative thought patterns.[107] Importantly, the two themes in Hyun et al.’s study ‘developing coping strategies’ and ‘planning for future life’,[27] equipped runaway youths with practical coping skills suited to their circumstance. For example, it encouraged them with long-term thinking beyond immediate survival needs, thus promoting a sense of direction and pathways to stability such as housing, employment, and education. Additionally, improved self-efficacy, indicated by the theme ‘raising self-consciousness', aligned with Bandura’s[108] model of self-efficacy. In the context of homelessness, this model postulated that with the appropriate training, runaway adolescents can interpret emotional and physical reactions (e.g., anxiety and stress) as signs of competency which increased their overall self-efficacy evident in this study.[108]

Although results from this study demonstrated that CBT had no effect on self-esteem, this has been challenged by a recent meta-analysis that found CBT-based interventions to be efficacious for treating low self-esteem.[109] Yet, these findings may not be generalisable to Korean adolescents, as it was conducted on adults in the UK, where self-esteem is prioritised in Western cultures.[110] In contrast, self-esteem is conceptualised differently as shown elsewhere in the East among a more comparable sample of Chinese children.[111] Self-esteem is multifaceted and complex, influenced by a myriad of internal and external factors; it could simply be that the intervention period of eight weeks was too short to yield a noticeable impact on self-esteem.[27] Short intervention periods may not adequately address cultural nuances and beliefs that impact how self-esteem is perceived and influenced in Korean runaway adolescents.[43] Additionally, it should be highlighted that the subjects of this study were all male, and there could be potential gender disparities in self-efficacy, depression and self-esteem presentations and responsiveness to CBT.[27] Thus, future research could benefit in this area by exploring the long-term effects of cultural-specific and extended interventions to develop more comprehensive and effective interventions that address unique challenges for this vulnerable population.

• LSE

LSE for depressive symptoms was found insufficient for sustainable change.[69] This observation could be attributed to the inherent characteristics of youth homelessness. The lack of continued support that they had received during the intervention period may lead to a resurgence of depressive symptoms, given that depression is a highly recurrent disorder.[112] In other words, if the adolescent returned to the same challenging or unstable living conditions or environment after the intervention, the stressors associated with homelessness could be precipitating factors for the re-emergence of depressive symptoms. It appeared LSE had a more sustainable effect on anxiety, stress, and self-esteem.[69] Comparable outcomes have been observed in previous studies among Indian adolescents[113] and more recently in Indonesian students.[114]

In contrast, LSE illustrated positive effects on self-esteem and resilience for YEH living in orphanages.[69] This phenomenon could be explained by the intricate interplay between life skills development and positive feelings of self-worth. Learning and mastering certain life skills can contribute to a positive self-perception and higher self-esteem from feelings of accomplishment,[115] and conversely, having positive self-worth can motivate them to develop and practice their life skills.[113] As YEH develop practical skills, their self-worth and confidence are likely to improve and in turn can motivate them to further enhance their life skills and actively engage in efforts to overcome their challenges. Ultimately, this positive cycle can empower this population by equipping them with valuable tools and a stronger sense of self, fostering resilience and assisting their journey towards stability and self-sufficiency.

• Resilience enhancement

Resilient enhancement programs[70] offered significant advantages for runaway adolescents, as these can positively influence mental wellbeing, and appeared promising for enhancing resilience and mitigating problem drinking. Factors associated with resilience such as self-esteem and self-regulation, have been well documented in previous literature with Korean adults[18,116]; while relational and problem-solving skills[117] and goal-setting skills[118] have been considered as protective factors for runaway adolescents. Since the intervention program used in Noh’s study[70] integrated the abovementioned protective factors linked to resilience, these elements were believed to have contributed to the observed increase in resilience among participants in the intervention group.[70]

In terms of explaining reduced anxiety, Noh’s study[70] had provided progressive relaxation training and deep breathing techniques that counteracted physiological responses to stress.[119] These equipped YEH with immediate skills to manage moments of crisis and distress which therefore increased their overall resilience.[120] The issue of youth homelessness is often interconnected with the challenge of problem drinking in both the East and the West, as YEH may resort to alcohol as a coping mechanism to navigate the hardships and uncertainties they encounter on the streets.[121,122] The current finding of decreased problem drinking was consistent with previous findings in the UK by Rew et al. [123]; both Noh[70] and Rew et al. [123] included components assertive and effective communication, as well as goal-setting skills in their interventions, which are recognised as protective factors in building resilience. In essence, resilience enhancement programs hold the promise of catalysing positive transformation in the lives of female runaway adolescents by fostering their growth.[70]

• Family strengthening

The role of family in addressing runaway behaviour is important as it holds paramount importance in not only Korean culture, but many EAP cultures.[71] Although psychological interventions for youth homelessness have been evaluated in previous Western studies, the authors suggested that these interventions do not reflect the actual situation Korean runaway adolescents experience.[71] Thus, the family-based mental health program Noh and Choi[71] developed aimed to improve mental health outcomes for this at-risk population using socio-cultural contexts. During their literature review, the authors identified that runaway adolescents experience high rates of dissatisfaction with family life.[124] Additionally, family factors such as poor communication and emotional support at home, financial problems, and poor psychological well-being of the parent or caregiver[125] can affect mental health and their quality of life. As a result, the runaway adolescents who participated in the interviews revealed they were more likely to engage in risky and maladaptive behaviours as a response to stress from family problems.[125] These issues identified have been supported by a range of parent—child theories. For example, the parental monitoring theory[126] emphasised the importance of parental supervision and awareness of adolescent’ activities. If the runaway adolescent experienced a lack of parental warmth because of their poor communication and emotional support, they were more likely to be involved in risky behaviour associated with homelessness/running away. As the developed program recognised the cultural significance of family in Korean society, it emphasised the importance of re-establishing strong family connections to deter adolescents from engaging in runaway behaviour.[71] Ultimately, the parent—child collaboration aligned with the cultural fabric of Korean society and aimed to create a nurturing environment where adolescents feel supported and understood without resorting to running away. Understanding the parent—child dynamic can offer valuable insights for other EAP societies facing similar challenges. It underscores the significance of familial bonds, open communication, and community support structures to provide a safety net for YEH. This emphasises a proactive intervention in addressing root causes of youth homelessness, offering effective strategies that prioritise prevention and holistic support.

• Government interventions/services

Interestingly, while both EAP and Western countries aim to address youth homelessness, there are notable differences in their government interventions/services due to varying cultural, social, and economic contexts. For example, while Western programs often emphasise individual autonomy and direct service provision,[127] government interventions/services in EAP regions may place greater emphasis on familial or community support networks that implement spiritual values.[67] Moreover, there exists a more established network of government-funded health and wellbeing services in the West, encompassing mental health and substance abuse counselling.[128] In contrast, the selected studies in this review revealed that access to healthcare services in EAP regions were more limited, with fewer specialised services for YEH provided by the government. In summary, tailoring support specific to sociocultural contexts is crucial for effectively addressing the unique needs of YEH and future efforts should focus on bridging these gaps to ensure equitable access to comprehensive support services for this vulnerable population in EAP.

• Limitations

To the best of our knowledge, there have been no previous systematic or scoping reviews on the different types of mental health services and interventions for YEH in EAP and their impact on overall quality of life and wellbeing for YEH. Despite finding positive mental health outcomes for YEH resulting from these psychological interventions and programs, there were several limitations of this review that should be noted. First, one of the primary objectives of this review was to identify different mental health interventions and programs for youth homelessness in EAP. According to The World Bank,[58,59] there are 15 countries within EAP, and yet, this review only found evidence of effective interventions and government programs in four named countries (i.e., Indonesia, Malaysia, South Korea, The Philippines) with the majority being conducted in South Korea (n = 3). Importantly, seven (87.5%) of the reviewed studies were conducted in urban areas or in the capital city which might not be reflective of the broader population. Homelessness patterns might differ significantly between urban and rural settings. Factors contributing to homelessness, available resources, programs or interventions, and support networks can be different in various parts of a country, especially if many of the EAP cultures rely on traditional folk medicine and healers.[129]

Second, subpopulations of youth homelessness, such as LGBTQ+ or indigenous youth, might be more prevalent in certain regions or outside the capital city. Focusing solely on urban areas could also neglect the unique challenges faced by these groups. Additionally, the only variation of ‘homelessness’ that was not included in this review was ‘invisible homelessness’ as there was no existing literature that met this review’s inclusion criteria. Third, differential definitions of homelessness used by the studies and the data that were collected do not make them comparable. However, considering shared characteristics and successes of similar programs in both Western and Eastern countries, this might not have been a significant factor contributing to the effectiveness of Western therapies suggesting that tailoring and adaption could enhance their efficacy. The differences in age of YEH and sampling may have affected comparability and generalisability as some YEH were mixed with higher age groups and some studies only reported the mean age for the sample. Therefore, these settings and groups may not be comparable.

Despite these limitations, a notable aspect where this review excels was that it was not limited to one study design and high-quality methodologies (e.g., RCTs, quasi-experimental design), but it also included case studies for in-depth qualitative data, enabling a more comprehensive and nuanced understanding of youth homelessness in EAP regions. Additionally, six papers (75%) out of the eight selected for this review were all conducted and published relatively recently, ensuring that the findings provided were accurate and relevant to the current mental health interventions, policies, and outcomes for YEH in EAP.

• Implications for future research, policy, and practice

The findings of this review suggest that different mental health interventions and programs have positive impacts on overall mental health outcomes and quality of life for YEH. Despite that, a large gap of robust evidence-based research in the EAP region is still evident. Future research should prioritise filling these substantial knowledge gaps by conducting comprehensive studies that encompass various EAP regions and diverse populations like YEH. There should be a pressing need to engage in co-designing research and programs with YEH to authentically incorporate lived experience voices. For example, two included studies in this review effectively integrated YEH voices,[70,71] underscoring the importance of this approach in comprehending cultural nuances. This inclusive methodology fosters a deeper understanding of the diverse challenges faced by YEH and can enhance the relevance and effectiveness of interventions or programs aimed at supporting them.

Importantly, researchers should strive for inclusive sampling that covers urban, suburban, and rural areas to provide a holistic understanding of unique challenges faced by YEH in different settings. Providing robust research across different EAP regions could provide comparative studies that highlight disparities, commonalities, and explanations for the different pathways that lead to homelessness. This holds particular significance in EAP regions for youth homelessness when contrasted with Western studies, as it helps avoid making assumptions and generalisations that might not hold true across cultural boundaries. For instance, many of the comparative studies were compared with Western studies (such as Bandura et al. [124]; Kolubinski et al.)[109] that do not underpin cultural nuances and local dynamics such as family structures and social norms that are important EAP cultures.[71] Mixed-method studies may be useful for exploring this by combining qualitative and quantitative research techniques to understand the corresponding data while checking the validity of statistical findings.[130] In addition, although some type of RCT study design was used in three studies, there were various limitations, e.g., the intervention period was not specified,[69,70,72] too short[27,72] or yet to be conducted.[71] Robust longitudinal analysis should also be implemented to track current situations and identify trends and changes.

Subpopulations such as LGBTQ+ youth who experience homelessness, also presents a critical avenue for gaining insights into the intersection of cultural and identity dynamics in EAP regions, particularly if these dynamics contribute to pathways to homelessness. This subgroup is a very at-risk population in both the West[131] and the East[132] signifying an urgency for research. For example, Confucianism is deeply ingrained in some EAP societies that can shape perceptions of family, community, gender,[133] and perhaps even perceptions of homelessness. From a political perspective, LGBTQ+ youths represent the most fastest growing demographic within South Korea’s homeless populations.[134] They face exclusion from certain homeless shelters, thus being deprived of human rights protections and social benefits.[134] Future research working with this subgroup of youth homelessness could identify the potential multi-level barriers these youth encounter when seeking assistance. Not only will it contribute to a more comprehensive understanding of lived experiences of LGBTQ+ youth who experience homelessness, but it could also reduce marginalisation for an already marginalised group in a society where homelessness is heavily stigmatised.[41,42]

The scarcity of published literature (such as government services/programs) concerning the management and policies for youth homelessness in EAP underscores the significance gap in addressing this issue. The lack of documented programs reflects a limited institutional response to the challenges faced by this at-risk population, possibly resulting from varying levels of awareness, available resources, and prioritisation.[68] Nonetheless, the findings of positive mental health, health outcomes and quality of life from mental health interventions and programs for YEH in EAP provide valuable insight for policymakers, which has global relevance to ensure that the Sustainable Development Goals[135] are met for 2030. For instance, evidence-based policies can be developed that are rooted in the specific lived experiences and realities of EAP regions. These could potentially include root causes of youth homelessness, such as family conflict,[27] or economic factors such as being at risk of homelessness.[68] Thus, addressing these potential root causes can allow for a prioritisation of preventative measures.

Lastly, this review emphasises the importance of implementing culturally sensitive services adaptable to the diverse cultural contexts within EAP, such as translating psychological instruments and measures into the country’s language,[27,69,70],[72,73] or understanding religious values that are deeply rooted in EAP societies.[67,68] Some implications for practice should highlight the importance of collaborative learning for practitioners dealing with YEH. This fosters a more comprehensive approach to acknowledging the multifaceted challenges these youth experience, which can, in turn enhance, the quality and impact of interventions for this population.