This study used a retrospective design using existing data collected through a predesigned program implemented in a public school setting for quality improvement purposes (see Multimedia Appendix 1 for the checklist used to report the results of this retrospective database study, as recommended by the International Society for Pharmacoeconomics and Outcomes Research Task Force [18]). A pre-post design with no control group was used to evaluate the efficacy of a school-based mental health program, The Reassured Self. The intervention was conducted with middle school female students in an underserved rural area in the Medina region, Saudi Arabia. Saudi Arabian schools are required to offer health programs to students; however, reports on the efficacy and acceptability of these programs are limited. This study documents a partnership between a non-profit organization and a school to develop a mental health program and evaluates its efficacy and acceptability for future development.

Most rural areas in Saudi Arabia have a single girls' school. This project was implemented for all female middle school students (N=133) in grades 1-3, with no exclusion criteria, as the program was mandatory for all students (see Multimedia Appendix 2 for details on data completeness for intervention participants).

The Reassured Self is a culturally adapted, low-intensity intervention program designed for Saudi Arabian students. Based on the principles of self-compassion, the program integrates cultural and religious values with evidence-based practices to promote mental and emotional resilience. It addresses anxiety, game addiction, and body image dissatisfaction through tailored strategies. The program was delivered to middle school female students in a classroom environment, fostering peer support and shared learning experiences. Each class received three 30- to 35-minute sessions within 2 weeks. To ensure consistency, a trained nurse with experience on delivering the program to other schools delivered the same program to all classes. The intervention content focused on 5 core components, as outlined in Table 1.

Data were collected at 2 time points: baseline (2 weeks before the intervention) and postintervention (2-3 weeks after the intervention). Assessments were conducted during school hours in a quiet classroom setting. The teacher distributed the printed surveys (paper-and-pencil format) to students, who were given 45 minutes to complete the questionnaires. The teacher remained available in the classroom to answer any questions. After the follow-up data collection, students exhibiting high levels of psychological distress, identified through their questionnaire responses, were referred to the school health counselor at that time for additional support.

Given the retrospective nature of the study, all students participated in the program as it was mandated by the school health unit as part of the standard curriculum. Written consent was obtained from students specifically for their participation in completing the surveys associated with the program. Information about the surveys, including their purpose and voluntary nature, was communicated to the students in an age-appropriate manner. This included verbal explanations by teachers and written summaries that were easy to understand. Students were assured that completing the surveys was voluntary and would not affect their grades or school standing. To encourage participation, all students received a small gift (a relaxation squeeze toy) after completing the program satisfaction survey. Parental consent was not required, as the program itself was a required school activity, and the decision to waive parental consent for the surveys followed ethical guidelines for school-based health programs. This approach was approved by the University of Taibah Nursing College Ethical Review Committee (IRB No. TUCN-REC 11 2024). To ensure the privacy and confidentiality of participants, all data from school project records were securely stored and deidentified prior to analysis.

Table 2 presents the descriptive statistics for the study variables, including age, anxiety symptoms, video game addiction, and body image discrepancy. A total of 133 students participated in the program. However, only 93% (124/133) completed the preanxiety symptoms survey, 92% (123/133) completed the video game addiction, and 88% (117/133) completed the body image discrepancy assessment (see Multimedia Appendix 2 for details on data completeness for intervention participants). The mean age of participants was 13.72 (SD 1.01) years. Total anxiety symptoms had a mean score of 47.60 (SD 22.02), indicating a moderate level of anxiety across the sample. Among the anxiety subscales, panic or agoraphobia symptoms were the highest, with a mean of 9.38 (SD 6.76), followed by obsessive-compulsive symptoms (mean 8.79, SD 4.54) and generalized anxiety symptoms (mean 8.66, SD 4.55). Physical injury fears (mean 7.64, SD 3.75) and separation anxiety (mean 6.31, SD 3.88) were also prominent. Social phobia symptoms had a mean of 6.82 (SD 4.12), indicating a relatively lower prevalence compared to other anxiety types.

The mean score for video game addiction was 15.57 (SD 6.67), indicating a moderate level of engagement or potential addiction to gaming. The body image discrepancy score had a mean of –0.20 (SD 0.87), suggesting a slight drive for thinness among the sample, with negative values indicating a preference for a thinner body size compared to current perception. Correlations between baseline variables showed a significant, moderate positive relationship between anxiety and gaming addiction (r=0.457, P<.001). Age and body image discrepancy demonstrated weak, nonsignificant correlations with other variables.

The distribution of anxiety symptoms among students reveals that a substantial portion experience elevated or clinically concerning levels across various anxiety types (Table 3). Specifically, 25.8% (32/124) of students had a high anxiety level, and 19.3% (24/124) fall within the clinical concern or very high clinical concern category, indicating that a significant subset may require attention. Generalized anxiety is particularly prevalent, with 33.1% (41/124) of students classified in the clinical concern or very high clinical concern categories. In addition, fears related to physical injury show one of the most severe patterns, with 33.9% (42/124) of students in the very high clinical concern category, highlighting this as a critical area for mental health support. Separation anxiety also shows a high prevalence, with 33.9% (42/124) of students in the clinical or very high clinical concern categories. Symptoms of panic and agoraphobia are notable as well, with 28.2% (35/124) of students in the very high clinical concern category, indicating a significant impact. Obsessive-compulsive symptoms present another area of concern, with 21% (26/124) of students in the very high clinical concern category. In contrast, social phobia has a lower prevalence of severe concern, with only 2.4% (3/124) of students in the very high clinical concern category.

Overall, the findings suggest that while some anxiety symptoms present moderate concern, specific areas—particularly physical injury fears, separation anxiety, and obsessive-compulsive symptoms—are more prevalent at clinically concerning levels, underscoring the need for focused mental health support in these domains.

Regarding body image dissatisfaction, the results indicate a slight drive for thinness among most of the students. Approximately 29.1% (34/117) of students exhibit a moderate inclination toward weight reduction, while a smaller proportion, 5.1% (6/117), express a strong desire for thinness.

The data on video game status among students reveals varying levels of gaming involvement, with a significant portion showing signs of problematic or addictive behavior (Table 3). Overall, 59% (73/123) of the students are categorized as engaged gamers, indicating regular gaming without notable adverse effects. However, 26% (32/123) are identified as problem gamers, suggesting a level of gaming that may interfere with daily responsibilities or personal well-being. Additionally, 14% (18/123) of students fall into the addicted gamers category, indicating a more severe level of dependency that likely impacts various aspects of their lives.

The Reassured Self intervention demonstrated a positive effect in reducing anxiety levels among students, as shown by a significant decrease in anxiety scores from preintervention to follow-up (see Table 4). The effect size, with a mean difference of –4.11, was small but statistically significant (P=.005). Additionally, the intervention had a beneficial impact on reducing video game addiction, with an estimated mean reduction of –1.62 in game addiction scores, which was also statistically significant (P=.009). In contrast, although the intervention led to a slight decrease in the drive for thinness, this change was not statistically significant (P=.057), suggesting a minimal effect on body image dissatisfaction. Overall, these findings indicate that the intervention was effective in reducing both anxiety and game addiction among students, while its impact on body image discrepancy remains inconclusive.

The program received positive feedback across multiple dimensions, as reflected in the high mean scores for various aspects of participant satisfaction (Table 5). The overall satisfaction sum score ranged from 7 to 35, with a mean of 28.49 (SD 6.31), indicating a generally favorable response. The overall results suggest that participants responded positively to the program, finding it engaging, clear, and psychologically beneficial, with a strong likelihood to recommend it to others.

This study conducted a retrospective analysis of data collected from female adolescents who participated in a CFT-based school program, The Reassured Self, in a rural setting. The program, collaboratively implemented by a nonprofit organization and an academic institution, aimed to reduce anxiety, video game addiction, and body image dissatisfaction among rural Saudi female adolescents, addressing critical mental health challenges within this population. The findings revealed a high prevalence of anxiety and video game addiction, consistent with national averages. The intervention effectively reduced anxiety and video game addiction symptoms but showed no improvement in body image dissatisfaction, highlighting its potential as a health education tool.

The overall high anxiety symptom prevalence of 25.8% (32/124) and the high severe anxiety symptoms of 19.3% (24/124) in our sample are comparable to global postpandemic figures (20.5%) [1] and align closely with the recent national prevalence of lifetime anxiety disorders among adolescents (26.84%) [10]. Our results underscore the urgent need for interventions targeting adolescent anxiety in underserved areas. Recent literature argues that school well-being programs should consider children’s and adolescents’ anxiety levels as a key metric for measuring program impact [29]. The Reassured Self program demonstrated a significant reduction in anxiety symptoms, suggesting that a culturally adapted CFT approach can effectively address anxiety. This aligns with recent meta-analyses and systematic reviews, which consistently show that compassion-based interventions reduce anxiety and psychological distress among adolescents [30-32].

This study’s findings also align with recent evidence on compassion-based school interventions. For instance, Maratos et al [29] evaluated a Compassionate Mind Training (CMT-Pupils) intervention among Year 7 students aged 11-12 and found significant improvements in anxiety levels compared to the control group. Similar to our intervention, CMT-Pupils emphasized emotional regulation and prosocial behaviors through compassion-based practices, including mindfulness and self-compassion. Their study highlighted the importance of promoting kindness, emotional awareness, and classroom inclusivity, which aligns with the core mechanisms of The Reassured Self program.

Further supporting the importance of self-compassion in adolescent mental health, Hammad et al [16] conducted a cross-sectional study in Saudi Arabia that explored the relationship between perceived stress and self-compassion among adolescents during the COVID-19 pandemic. Their findings revealed a significant negative correlation (r=–0.460, P<.001) between perceived stress and self-compassion levels, suggesting that higher self-compassion is associated with lower levels of stress. These results underscore the role of self-compassion as a protective factor for adolescent mental health, reinforcing the theoretical foundation of The Reassured Self program, which aims to reduce anxiety by fostering self-compassion and emotional regulation. CFT is rooted in evolutionary psychology and attachment theory, incorporating mindfulness through activities designed to foster self-compassion toward oneself and others, particularly in relation to self-criticism, self-blame, and shame [17,31,33]. Recommended techniques and exercises to develop self-compassion include self-talk and understanding the evolved nature of the human mind, along with the origins of self-criticism and self-blame [17]. Therefore, the core focus of The Reassured Self program is to introduce students to the concepts of self-blaming and self-reassurance, fostering a supportive inner dialogue and emotional regulation.

However, while The Reassured Self program demonstrated reductions in anxiety, our study did not directly measure emotional regulation or self-compassion processes—key mechanisms observed in Petrocchi et al [33] and other self-compassion studies. Tools such as the Forms of Self-Criticizing/Attacking and Self-Reassuring Scale, developed by Gilbert et al [34] (the founder of CFT), provide validated measures for assessing self-criticism and self-reassurance. Incorporating these tools in future studies would enable a more comprehensive evaluation of how The Reassured Self program works. Specifically, measuring changes in emotional regulation, self-reassurance, and self-criticism could elucidate the mechanisms driving the reduction in anxiety and gaming addiction. As literature suggests, a decrease in self-criticism and self-blame is strongly associated with a reduction in anxiety [17,31,33]. Including these intermediate outcomes will help validate the program's effectiveness and provide deeper insights into its psychological processes. Overall, our findings suggest that culturally relevant, compassion-based programs can provide a viable solution for reducing anxiety in rural, underserved contexts. By addressing both the reduction of anxiety symptoms and fostering emotional regulation, such interventions hold promise as scalable and effective mental health solutions for adolescents. Also, our approach is supported by recent findings that advocate for brief, targeted interventions to effectively engage adolescents, particularly in an era where social media usage has impacted attention spans [35]. A recent meta-analysis of brief school mental health interventions found that programs lasting fewer than 4 sessions or 250 minutes resulted in significant, albeit small, improvements in students' mental health when assessed 1 month, 6 months, and 1 year post intervention [35].

The high baseline prevalence of video game addiction (14.6%, 18/123) among rural female adolescents in our study underscores the need for targeted mental health interventions in this area. This prevalence is close to global averages, which show approximately 12% of adolescents are at risk for problematic gaming, highlighting the specific challenges faced by this population [36]. However, the prevalence in our study is lower than that in the recent national report for the Madinah region (28%), and the overall national prevalence of 20.45% (897/4431) [37].

The program’s focus on self-compassion and emotional resilience appears to have positively impacted gaming behaviors, as evidenced by a significant decrease in video game addiction scores. Furthermore, the significant correlation between anxiety and gaming addiction underscores their interconnectedness, aligning with existing research that highlights gaming as a coping mechanism for anxiety [7].

This finding supports research suggesting that interventions emphasizing emotional regulation and coping skills such as exercise can reduce problematic gaming behaviors [38]. For example, a recent study investigating the relationship between internet gaming disorder, sleep quality, self-compassion, physical activity, and psychological distress among young adults aged 18-24 years found that internet gaming disorder was positively associated with interpersonal stress and depressive symptoms. Additionally, self-compassion and exercise behavior were found to mediate the relationship between depressive symptoms and sleep quality [39].

By providing alternative coping mechanisms, The Reassured Self may help reduce adolescents' reliance on gaming to manage emotional distress, addressing a critical mental health concern in this demographic. However, as discussed earlier, the lack of measurement of changes in emotional regulation, or adapting exercise behaviors, which could be assessed using validated tools, limits the conclusions that can be drawn about the program's overall efficacy.

The notable prevalence of body image dissatisfaction, with 5.1% (6/117) of students showing a strong drive for thinness, reveals another area for potential intervention. Although the program’s impact on body image dissatisfaction was minimal and nonsignificant, the slight reduction in drive for thinness suggests that longer or more targeted interventions may more effectively address body image issues. Body image is deeply influenced by social and cultural factors, and this program provides a foundation for future interventions to build upon by incorporating more specific strategies to address body image concerns in rural contexts. While CFT has shown success in improving body image in other studies [30], the short duration of our program may have limited its impact on this complex issue. Additionally, this study found an average of 1 size discrepancy among the students, aligning with other research indicating that rural students may have low body image discrepancy [40,41]. Future iterations of the program may need to incorporate more targeted components to address body image issues specific to the cultural context.

The integration of Islamic values and culturally sensitive practices, such as gratitude and self-compassion, likely enhanced the intervention's acceptability and effectiveness. Student feedback indicated high levels of satisfaction regarding the program's ease and clarity, perceived effectiveness, and content relevance. The concept of self-compassion, rooted in Islamic culture and religious practice, fosters self-reassurance and reduces self-blame [16]. Cultural and contextual considerations played a crucial role in the program’s design and implementation, which aligned with current recommendations for culturally adapting mental health interventions through self-compassion [17]. In addition, the program's success in a rural setting addresses a critical gap in mental health services for underserved populations and supports the need for global mental health interventions [42,43].

This study’s findings have important implications for designing school-based mental health programs in rural or underserved areas. To ensure the effective delivery and sustainability of such interventions, several strategies should be prioritized: (1) training mental health professionals, educators, and community facilitators is critical for delivering the intervention effectively. (2) Partnerships with local organizations and schools can enhance resource availability and facilitate recruitment in resource-limited settings. (3) Leveraging community partnerships: the collaboration demonstrated in this study—between a nonprofit organization, an academic institution, and a local school—provides a viable model for delivering mental health interventions in underserved areas. This approach aligns with broader recommendations to leverage community partnerships to enhance mental health support in schools [43,44]. (4) Advocacy efforts should focus on investments in culturally adapted, school-based mental health interventions to ensure they can reach underserved populations and address mental health disparities in context-specific and meaningful ways. (5) Future interventions should explore digital education methods, such as webinars, web-based workshops, and gaming-based mental health curricula, to enhance accessibility and engagement, particularly among rural students [45,46]. (6) Future research should investigate the intervention's long-term effects, including its impact on academic performance (eg, grades, school engagement) and social functioning (eg, relationships with peers, family members, and teachers). Understanding whether mental health improvements translate into better academic and social outcomes would provide a more holistic evaluation of the program’s effectiveness. (7) Further exploration of specific cultural factors, such as family dynamics, social stigma, and rural-urban differences, is necessary to understand their contributions to the program's effectiveness. Adapting the intervention for broader cultural and socioeconomic contexts is critical for expanding its applicability.

However, several limitations should be considered when interpreting these results. The retrospective design and lack of a control group limit causal inferences. Additionally, the short follow-up period (2-3 weeks) may not capture long-term effects or potential relapses [17]. The specific demographic focus on rural Saudi female adolescents may also limit generalizability to other populations. To address these limitations and build on this study, future research should (1) incorporate randomized controlled trial designs with active control groups to establish causality; (2) extend follow-up periods to evaluate the sustainability of intervention benefits over time; (3) compare The Reassured Self program with other evidence-based approaches, such as cognitive-behavioral therapy and mindfulness-based stress reduction, to assess relative effectiveness and adaptability; (4) examine the specific components of the program and their relative contributions to outcomes to refine and optimize the intervention; and (5) investigate the interplay between cultural factors and program outcomes to ensure effective adaptations for different cultural and socioeconomic contexts.

Adolescents in rural Saudi Arabia face significant mental health challenges, with high rates of anxiety, video game addiction, and, to a lesser extent, body image dissatisfaction. This study's findings underscore the potential of a culturally adapted CFT program, The Reassured Self, to address these issues. Collaboratively implemented by a non-profit organization and an academic institution, the program successfully reduced anxiety symptoms and problematic gaming behaviors among rural female adolescents, providing a promising model for school-based mental health interventions in underserved areas.

The integration of Islamic values and culturally sensitive practices, such as gratitude and self-compassion, likely enhanced the program’s acceptability and relevance, as reflected in the high levels of student satisfaction with the intervention's content and delivery. The Reassured Self demonstrates the feasibility and effectiveness of a culturally sensitive, compassion-focused intervention for adolescent mental health in rural Saudi Arabia. The promising findings of The Reassured Self program highlight its potential for widespread implementation in schools and communities, particularly in underserved areas. By addressing the unique challenges faced by this underserved population, the program contributes valuable insights for global mental health initiatives aimed at reducing disparities in mental health access and support. Future efforts to refine and scale the intervention can inform broader applications in diverse cultural and socioeconomic contexts.