Effect of multi-level interventions on mental health outcomes among adolescents in sub-Saharan Africa: a systematic review

Abstract

Objective

In sub-Saharan Africa (SSA), multiple factors contribute to the considerable burden of mental health disorders among adolescents, highlighting the need for interventions that address underlying risks at multiple levels. We reviewed evidence of the effectiveness of community or family-level interventions, with and without individual level interventions, on mental health disorders among adolescents in SSA.

Design

Systematic review using the Grades of Recommendation, Assessment, Development and Evaluation approach.

Data sources

A systematic search was conducted on Cochrane Library, MEDLINE, EMBASE, PSYCINFO and Web of Science up to 31 March 2021.

Eligibility criteria

Studies were eligible for inclusion in the review if they were randomised controlled trials (RCTs) or controlled quasi-experimental studies conducted in sub-Saharan African countries and measured the effect of an intervention on common mental disorders in adolescents aged 10–24 years.

Data extraction and synthesis

We included studies that assessed the effect of interventions on depression, anxiety, post-traumatic stress disorder and substance abuse. Substance abuse was only considered if it was measured alongside mental health disorders. The findings were summarised using synthesis without meta-analysis, where studies were grouped according to the type of intervention (multi-level, community-level) and participants.

Results

Of 1197 studies that were identified, 30 studies (17 RCTs and 3 quasi-experimental studies) were included in the review of which 10 delivered multi-level interventions and 20 delivered community-level interventions. Synthesised findings suggest that multi-level interventions comprise economic empowerment, peer-support, cognitive behavioural therapy were effective in improving mental health among vulnerable adolescents. Majority of studies that delivered interventions to community groups reported significant positive changes in mental health outcomes.

Conclusions

The evidence from this review suggests that multi-level interventions can reduce mental health disorders in adolescents. Further research is needed to understand the reliability and sustainability of these promising interventions in different African contexts.

PROSPERO registration number

CRD42021258826.

Strengths and limitations of this study.

• Study selection was done by two independent reviewers to ensure all relevant studies were included.

• As we only searched published studies, we may have missed important evidence from unpublished literature.

• The diversity in the characteristics of included studies limited our ability to meta-analyse the findings.

Introduction

Mental health disorders account for 16% of the global burden of disease and injury in young people.¹ Common mental disorders such as depression and anxiety are among the leading causes of illness and disability in adolescents aged 10–24 years.^{1 2} Globally, an estimated 10% of adolescents have a mental disorder and majority of these cases are not diagnosed or treated, leading to high risk of long-term physical and mental health problems in later life.³ It is vital to intervene early, as half of mental disorders that are experienced during adulthood have their onset during adolescence.⁴ Additionally, mental disorders are associated with poor academic and work performance and risky behaviours during adolescence.^5–7

In sub-Saharan Africa (SSA), adolescents are disproportionately exposed to traumatic life experiences such as violence, armed conflicts and natural disasters, leading to high post-traumatic stress disorder (PTSD) prevalence rates.^{8 9} They also face other multiple challenges, including HIV-AIDS, early pregnancy, substance abuse and poverty.^10–13 All these factors can directly or indirectly contribute to the risk of mental health disorders. For example, mental disorders are common in both people living with HIV and those at high risk of HIV acquisition,^14–16 and they can also increase the risk for HIV acquisition.^{17 18} Given the complexity of problems that adolescents face and dearth of resources for mental health in SSA, there is a critical need for combination interventions that will address the underlying risk factors at multiple socio-ecological levels to improve mental health.^{19 20}

To date, there is limited evidence from SSA regarding interventions that promote mental health and prevent or treat mental disorders in adolescents.²¹ Previous reviews from low/middle-income countries (LMICs) tended to focus on interventions that intervene only at interpersonal (family) or community-level to improve mental health outcomes in adolescents, or among specific groups (eg, HIV positive adolescents).^{22 23} For example, Bhana and colleagues²³ previous study reviewing interventions targeted to adolescents living with or affected by HIV in LMICs found family-based and economic strengthening interventions to be effective in improving mental health. Similarly, Barry and colleagues demonstrated that mental health interventions can be implemented effectively in school and community-based settings.²² Despite growing evidence on the effectiveness of combination interventions on health outcomes (eg, HIV and sexual health outcomes) among adolescents in SSA,²⁴ little is known about how these interventions could improve mental health in adolescents. The aim of this review was therefore to assess the effect of combining community or family-level interventions with individual level interventions on mental disorders in adolescents living in SSA. We used a socio-ecological model for combining interventions which suggests that people’s behaviour is influenced by multiple factors operating at different levels of influence (eg, individual, interpersonal-level (family/community)).^{25 26} This approach has been used by few studies to deliver mental health interventions to people living with HIV.²⁷ The objective of the review was:

1. To assess the effect of interventions that are delivered to either individuals, groups or both on mental disorders (depression, anxiety, PTSD and substance abuse) among adolescents in SSA.

Methods

The conduct of this study was informed by the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.²⁸

Search strategy and selection criteria

A systematic literature search was conducted on the following electronic databases: Cochrane Library, MEDLINE, EMBASE, PSYCINFO and Web of Science. The search was restricted to English language. A search strategy was developed and evaluated in MEDLINE and adapted for other databases. Cochrane and SIGN filters for RCT search were applied in Ovid databases.²⁹ The results were not filtered by publication date. A detailed search strategy is shown in online supplemental S1 appendix. Other articles were searched by manually reviewing the references of the selected studies. The last search was completed on 31 March 2021. All retrieved articles were sent to EndNote which was also used to remove duplicates. The screening of articles and full-text review were conducted by two independent reviewers (NM and AMR), and disagreements were resolved through discussion. Studies were included in the review if they met the following criteria:

1. Randomised controlled trials (RCTs) (individually or cluster randomised) and quasi-experimental studies (with control group) that were conducted in SSA.

2. Participants were adolescents aged between 10 and 24 years (age when the intervention was implemented). We used an expanded definition of adolescence based on the culturally and contextually influenced delays in the transition roles to adulthood in resource-limited settings.^{30 31} Studies with adults above 24 years were only considered if data was disaggregated by age group so that outcomes in those aged 10–24 could be extracted. Studies were excluded if they did not specify age range of participants or did not mention that participants were adolescents.

3. Measured depression, anxiety, PTSD and substance abuse using a validated screening tool. Substance abuse (alcohol or drug abuse) was only included if it was measured alongside common mental disorders or PTSD.

Studies that met the criteria were classified according to the type of intervention which they delivered as: (a) individual-level only; (b) community-level only (including family-based); or (c) multi-level. Interventions were defined according to whether they were delivered directly to individuals or groups, irrespective of level of randomisation (cluster or individual). We defined individual-level interventions as those delivered directly to individuals (eg, one-on-one counselling, drug therapy) to develop copying strategies, change attitudes and behaviour. Community-level interventions were defined as interventions delivered to groups of people, including families and communities. Multi-level interventions were defined as a combination of individual and community-level interventions; interventions that were delivered to groups but also included one-on-one counselling sessions were categorised as multi-level interventions.

Data extraction and management

For each study, we extracted data on methods, participants, interventions and outcomes (see online supplemental S1 and S2 tables). For studies with multiple reports, we selected the most complete report, preferably including both baseline and last follow-up/postintervention data. For studies with pilot and main study reports, we preferred main study reports. Mean differences and SEs were used to generate forest plots. For studies that did not report SEs, the CIs, F statistic and p value were used to calculate SEs.²⁸ For studies that reported ORs or rate ratios, a natural logarithm of each estimate was calculated.

Assessment of risk of bias in the included studies

Studies were critically assessed for risk of bias using Cochrane Tools.^{32 33} Random sequence generation or allocation concealment (or bias due to confounding for non-RCTs), blinding of outcome assessment and incomplete outcome data were considered critical for assessing the quality of studies in this review. No studies could blind participants due to the nature of interventions and we therefore did not include this criterion. Other biases which may rise due to use of inappropriate statistical analyses were also considered for cluster randomised trials, cross-over and non-randomised trials. None of the studies were excluded based on their risk of bias.

Assessment of heterogeneity

Clinical heterogeneity was assessed by considering the type of participants, duration of intervention and intervention components as these factors are likely to influence the effect of intervention.³⁴ Statistical heterogeneity was assessed using visual inspection of forest plots and subgroup analysis in RevMan V.5 software.³⁵ χ² tests for heterogeneity with 10% level of significance was used and the degree of heterogeneity was measured using I² statistic with values above 50% indicating substantial heterogeneity.³⁴ For outcomes with enough studies (minimum five studies per subgroup), subgroup analyses were conducted based on the type of participants and type of intervention.³⁴

Data synthesis

As the interventions and participants in the included studies were too diverse to allow a quantitative synthesis of the study findings, synthesis without meta-analysis was used to summarise the results.³⁶ For all studies, we used outcomes measured at the last follow-up or postintervention regardless of whether the study had multiple follow-up times. The findings were synthesised separately for studies that delivered multi-level intervention and community-level interventions. Within each group, studies were subdivided according to type of participants who participated in the studies.

Assessment of the certainty of the evidence

The certainty of the body of evidence for each outcome was assessed using Grades of Recommendation, Assessment, Development and Evaluation approach within each of the four domains (risk of bias, inconsistency, imprecision and indirectness). The inconsistency in the findings was measured by looking at the direction of the effect among studies which measured the same outcome. The imprecision was measured by looking at the number of participants within each study and studies with less than 100 participants were judged as having serious imprecision. Indirectness was measured by looking at whether the included studies addressed the research question for this review. The quality of evidence was downgraded to a lower level (starting from high to very low) if one of the domains raised serious concerns.

Patient and public involvement

Since this is a systematic review, it was not possible to involve patients or public in the design or conduct or reporting of our research.

Results

The search results are described in figure 1. A total of 1197 articles were identified through database search and hand searching. Of these, 122 articles were assessed for eligibility and 30 studies were included in the synthesis.^37–66 The remaining 92 articles were excluded due to various reasons described in online supplemental S3 table. Most studies were RCTs, except for three which used controlled quasi-experimental designs.^{54 58 61} Fourteen studies were cluster-randomised trials including one cross-over trial.⁶⁶ Most studies had two groups except for four studies37 44 51 58 which randomised participants into three groups (two intervention groups and one control). Study durations ranged from 1 week to 4 years and the length of the interventions ranged from 1 hour to 4 years.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. PTSD, post-traumatic stress disorder; RCT, randomised controlled trial.

Intervention

Interventions were heterogeneous across the included studies. The included studies were categorised according to the type of intervention (multi-level, community-based or individual). Of 30 included studies, 10 studies delivered multi-level interventions and the remaining studies delivered only community-based interventions. None of the included studies reported only individual-level interventions. For multi-level interventions, studies were divided into following categories: HIV affected; orphaned or bereaved; and war-affected adolescents. The studies that delivered community-level interventions were grouped in a similar way using the following categories: vulnerable adolescents comprised orphans, adolescents with trauma experiences and from poor households, students and general population.

Multi-level interventions

The multi-level interventions included a combination of community-level and individual- level interventions (table 1, online supplemental S4 table). Two studies delivered trauma-focused cognitive and behavioural therapy (CBT) for groups which also included trauma narratives modules that were delivered to individuals.^{45 46} Three studies delivered economic empowerment interventions which were combined with antiretroviral therapy (ART) or counselling.^37–39 One study delivered HIV status disclosure to groups, and ART and counselling to individuals.⁴⁰ One study delivered CBT and interpersonal therapy (IPT) intervention for groups (families) which included trauma narratives sessions for individuals.⁴¹ Participants in this study were all required to take ART. Two studies delivered a writing therapy or IPT in combination with counselling.^{43 44} One study delivered a peer-support intervention to participants who also had access to monthly healthcare.⁴² Most interventions targeted multiple mental health outcomes including those that are not common mental disorders (eg, self-concept, hopelessness, self-efficacy, grief, etc) and three studies targeted physical and sexual health in addition to mental health^{37 40 41} (online supplemental S5 table).

Table 1.

Characteristics of included studies that delivered multi-level and community-level interventions

Study (author) and setting	Target population	Study design, sample size	Study and intervention duration	Intervention components
Multi-level
HIV/AIDS-affected adolescents
Ssewamala et al, Uganda37	Adolescents, AIDS orphans in fifth or sixth grade (average age=12)	RCT (cluster) N=1383	48 months. The intervention was provided for the first 24 months. Twelve 1–2 hour workshops	Group: economic empowerment Individual: counselling
Cavazos-Rehg et al, Uganda38	Adolescents living with HIV, 10–16 years	RCT (cluster) N=702	48 months: The intervention was received for the first 24 months. 4 sessions and additional 12 sessions with a mentor for 24 months	Group (family): economic empowerment Individual: ART, weekly-monthly healthcare
Han et al, Uganda39	AIDS orphaned adolescents, 10–14 years	RCT (cluster) N=297	12 months, 1–2 hours training sessions and one mentorship meeting per month over 12-month period	Group: economic empowerment Individual: counselling
Vreeman et al, Kenya40	Adolescents HIV-infected and in active care, 10–14 years	RCT (cluster) N=285	24 months	Group: HIV status disclosure (counselling) Individual: ART, counselling
Dow et al, Tanzania41	Young people living with HIV, 12–24 years	Pilot RCT (individual) N=105	6 months. Ten group sessions, two one-on-one sessions. 90 min every Saturday for 3 months	Group: cognitive and behavioural therapy (CBT), interpersonal therapy (IPT), motivational interviewing (MI) Individual: trauma narratives, ART
Kumakech et al, Uganda42	Adolescents AIDS orphans, 10–15 years	RCT (cluster) N=326	16 exercises over 10 weeks. 1-hour play	Group: peer-group support Individual: monthly healthcare
Orphaned adolescents
Thurman et al, South Africa43	Bereaved female adolescents, 13–17 years	RCT (individual) N=382	8 sessions. Weekly 90 min sessions (average three activities)	Group: theory-based support group (IPT), cultural adaptation Individual: counselling
Unterhitzenberger and Rosner, Rwanda44	Orphaned adolescents, 14–18 years	RCT (individual) N=69	3 weeks. 30 min writing periods each week on three consecutive Thursdays	Group: writing therapy Individual: counselling
War-affected adolescents
O'Callaghan et al, Democratic Republic of Congo45	Sexually exploited, war-affected adolescent girls aged 12–17 years	RCT (individual) N=52	3 months. The intervention was offered for 2 hours per day, 3 days per week for 5 weeks	Group: CBT Individual: trauma narratives
McMullen et al, Democratic Republic of Congo46	Adolescent boys-former child soldiers aged 13–17 years	RCT (individual) N=50	3 months. 15 sessions. The intervention was delivered for approximately 5 weeks	Group: trauma Focused-CBT Individual: trauma narratives
Community_level
Vulnerable adolescents
Green et al, Kenya47	Orphaned adolescents (average age 14 years)	RCT (cluster) N=835	4 years. The intervention was provided annually from 2011 until 2015, or until the student dropped out of school	Cash transfers (school support)
Ismayilova et al, Burkina Faso48	Children aged 10–15 years from extremely poor households	RCT (cluster) N=360	24 months. Monthly one-on-one mentoring over 24 months. Family sessions conducted once monthly (35–45 min each)	Economic strengthening, family coaching
Cluver et al, South Africa49	Adolescents aged 10–18 years and their caregivers from families reporting conflict with their adolescents	Pragmatic RCT (cluster) N=552	9 months. 10 weekly child-caregiver sessions four separately	Parenting programme
Rossouw et al (2018), South Africa50	Adolescents who had experienced or witnessed an interpersonal trauma and had chronic PTSD (>3 months), 13–18 years	RCT (individual) N=63	6 months. 7–14 weekly, 60 min sessions	Prolonged exposure therapy, control group received supportive counselling
Betancourt et al, Uganda51	Adolescent war-survivors, 14–17 years	RCT (individual) N=314	1 year. 16 weekly group meetings, lasting 1.5–2 hours each	Group interpersonal psychotherapy (IPT) and creative play
Getanda and Vostanis, Kenya52	Adolescents aged 14–17 years and experienced traumatic events in the past year	RCT (individual) N=54	1 week. Six sessions of writing over three consecutive days	Writing for recovery-psycho-social-educational group intervention
Thurman et al, South Africa53	Orphaned and vulnerable adolescents, 14–17 years	RCT (cluster) N=489	2 years. 16 weekly 90 min group sessions	Interpersonal psychotherapy for groups (IPTG)
School/college-based adolescents
McMullen and McMullen, Uganda54	Adolescent students, 13–18 years	Quasi-controlled (cluster) N=620	1 year. 24 sessions, 45–60 min each	The Living Well manualised intervention (based on CBT)
Rivet-Duval et al, Mauritius55	Adolescents from single-sex secondary schools, 12–16 years	RCT (individual). N=160	6 months. 11 1 hour weekly sessions	The Resourceful Adolescent Programme based on CBT and IPT
Ede et al, Nigeria56	College adolescents, 16–21 years	RCT (individual) N=162	12 sessions (one session per week) lasted for 1 hour each.	Group cognitive behavioural therapy
Richards et al, Uganda57	Adolescent primary school pupils aged 11–14 years	RCT (individual) N=1462	11 weeks. At least one 1.5-hour training session per week over 9 weeks. 40 min game each weekend	The sport-for-development intervention
Eifediyi et al, Nigeria58	Secondary school students, 14–19 years	Quasi-experimental controlled N=160	7 weeks. 45 min each of six sessions lasted for 7 weeks	Rational emotive behaviour therapy
Osborn et al, Kenya59	Adolescent students, 14–17 years	RCT (individual) N=51	4 weeks. Four 1-hour sessions that were 1 week apart included homework exercises	Wise intervention
Berger et al, Tanzania60	Primary school students, aged 11–14 years in grades 6–8	RCT (cluster) N=183	16 sessions=two weekly 45 min sessions	Stress-Prosocial programme (ESPS)
Jordans et al, Burundi61	School-going children aged 10–14 years with elevated psychological distress	Quasi-experimental with controls N=161	Two sessions of an average 2.5 and 3.0 hours, respectively	Brief parenting psychoeducation
Osborn et al, Kenya62	Adolescent high school students aged 14–17 years	RCT (individual) N=103	The intervention took 1 hour	Digital wise intervention
Bella‐Awusah et al, Nigeria63	Adolescents with depressive symptoms and aged 14–17 years	RCT (cluster) N=40	Five structured sessions offered weekly, each lasting 45–60 min	Brief school-based, group cognitive behavioural therapy
General population
Kilburn et al, Kenya64	Adolescents, 15–24 years	RCT (cluster) N=1960	4 years	Large-scale unconditional cash transfer
Angeles et al, Malawi65	Adolescents, 13–19 years	RCT (cluster) N=2099	2 years. Monthly cash transfers for 2 years	Social Cash Transfer Programme
Puffer et al, Kenya66	Adolescents (and caregivers) aged 10–16 years	RCT (cluster) stepped wedge (four churches, n=237)	3 months. Nine sessions (2-hour each)	Parenting programme, HIV prevention, CBT, economic empowerment

ART, antiretroviral therapy; N, sample size; RCT, randomised controlled trial.

Community-level interventions

Twenty studies delivered community-level interventions including CBT, IPT, writing for recovery, wise interventions (group and single digital session), psychoeducation (including parenting), prolonged exposure therapy, economic empowerment, cash transfers, parenting programme and sport for development (table 1). Five studies delivered economic empowerment interventions,47 48 64–66 of which two delivered economic empowerment alongside family coaching or parenting programme.^{48 66} Five studies delivered CBT including CBT-based interventions50 54 56 58 63 such as prolonged exposure therapy,⁵⁰ rational emotive behaviour therapy⁵⁸ and The Living Well intervention.⁵⁵ Prolonged exposure therapy helps individuals to gradually confront their fears. Rational emotive behaviour therapy involves identifying and altering negative thoughts and beliefs that lead to unhealthy behaviour. The Living Well programme teaches about different behaviour change techniques such as problem solving, monitoring of emotional consequences and self-talk. Two studies delivered IPT^{51 53} and one study delivered The Resourceful Adolescent Programme which used both CBT and IPT techniques.⁵⁴ Two studies delivered group and digital wise interventions that focus on how people make sense of themselves, the people or situations they are in.^{59 62} Ten studies delivered community-level interventions that targeted multiple outcomes and two of these studies did not target mental health as primary outcomes.^{49 66}

Implementation of interventions

The follow-up periods of the studies varied by type of intervention (online supplemental S4 table). Studies that delivered economic empowerment or HIV disclosure interventions had longer follow-up time ranging between 12 and 48 months. The retention rates at follow-up were high (above 80%) for both multi-level and community-level interventions, except two studies that reported attrition rates of 23% and 37%^{53 65} and one study that did not report retention rate.³⁸ Interventions in most studies were delivered by non-specialists (lay community health workers, teachers) who were trained and supervised by mental health specialists (see online supplemental S5 table).

Participants

The participants in the included studies varied across studies. Among studies that delivered multi-level interventions, six studies included participants who were living with HIV or affected by HIV,^37–41 two studies included war-affected adolescents^{43 44} and two included orphans and bereaved female adolescents.^{45 46}

Of 20 studies that delivered community-based interventions, 10 included school-going or college adolescents,^54–63 seven studies included vulnerable populations such as orphans, war survivors, adolescents who have experienced trauma and vulnerable orphans (from poor households)^47–53 and three studies included general population.^64–66

Risk of bias in the included studies

All included studies were assessed for risk of bias. Ten studies were rated as having an overall high risk of bias due to not blinding the outcome assessors, incomplete outcome data and use of inappropriate statistical methods (eg, not accounting for clustering),40 42 44 54 55 58 61 63 64 66 while 11 studies were judged as having an overall low risk of bias.41 43 46–51 53 56 The remaining nine studies were judged as having unclear risk of bias. The summary of risk of bias is shown in online supplemental S6 table.

Effect of multi-level interventions on mental health

Depression

Eight studies measured depression (figure 2).^37–44 Three studies found a significant decrease in depressive symptoms among participants in the intervention group compared with control group.^{39 42 43} Of these studies, two delivered peer or theory-based support to AIDS orphans⁴² or bereaved females,⁴³ and one study delivered economic empowerment intervention.³⁹ In four studies, multi-level intervention was not significantly associated with decrease in depressive symptoms. However, one study that delivered a family economic empowerment intervention found a significant decrease in depressive symptoms at 24-month follow-up (end of intervention) but no significant effect observed thereafter at 36 and 48 months.³⁷ One study by Unterhitzenberger and Rosner evaluated the effect of emotional writing on depression and found that emotional writing was associated with increased depression symptoms compared with positive writing and no writing.⁴⁴

Figure 2.

Effect of multi-level interventions on depression, anxiety and PTSD. ART, antiretroviral therapy; CBT, cognitive and behavioural therapy; IPT, interpersonal therapy; MI, motivational interviewing; PTSD, post-traumatic stress disorder; RCT, randomised controlled trial.

Anxiety

There was only one study that measured anxiety. Kumakech and colleagues found a significant decrease in anxiety among adolescents who received a peer support and monthly care compared with those who in the control group.⁴²

Post-traumatic stress disorders

Three studies measured PTSD.^{41 45 46} Of these studies, two showed a significant decrease in PTSD symptoms among participants in the intervention group compared with participants in the control group.^{45 46} Both studies delivered CBT to war-affected adolescents.

Depression and anxiety-like symptoms

There were two studies^{45 46} that looked at depression and anxiety-like symptoms (see online supplemental S1 figure). Both studies delivered CBT and found a significant decrease in depression and anxiety-like symptoms among participants in the intervention group compared with control group.

Effect of community-level interventions on mental health

Depression

Seventeen studies measured depression (figure 3). As there were enough studies that measured depression, subgroup analyses (by intervention and participants) were conducted to assess heterogeneity among studies (see online supplemental S2 and S3 figures). There was substantial unexplained heterogeneity (I²>90%) between all studies and within each of the subgroups. Therefore, the intervention effect estimate was not calculated.

Figure 3.

Effect of community-level interventions on depression and anxiety. CBT, cognitive and behavioural therapy; IPT, interpersonal therapy.

Eleven studies showed a significant decrease in depressive symptoms among participants in the intervention group in comparison with the control group. Of the 11 studies, five delivered theory-based interventions (CBT, IPT and wise interventions) to school or college students55–57 62 63 and two delivered economic empowerment intervention to general adolescents.^{64 65} The remaining four studies delivered interventions to vulnerable adolescents: three delivered theory-based interventions to adolescents who had trauma experiences,^50–52 and one delivered economic empowerment (cash transfers) to orphans.⁴⁷

Four studies did not show any significant effect of intervention on depressive symptoms.48 49 54 61 One study that used sport to promote physical fitness and mental well-being showed a significant increase in depressive symptoms among adolescent boys who participated in the sport-for-development interventions compared with control group.⁵⁷

Anxiety

There were six studies that looked at anxiety (figure 3). Four studies found a significant decrease in anxiety symptoms among participants in the intervention group compared with control group and all these studies were conducted in schools.^{52 57–60} Richards and colleagues⁵⁷ evaluated the effect of sport-for-development intervention and found an increase in anxiety symptoms among participants in the intervention group compared with participants in the control group.

Post-traumatic stress disorder

Three studies measured PTSD (figure 4). Two studies that delivered prolonged exposure therapy and writing for recovery to adolescents with trauma experiences found a significant decrease in PTSD symptoms among participants in the intervention group.^{50 52} One study by Ismayilova and colleagues delivered economic strengthening intervention but found no significant effect of the intervention on PTSD.⁴⁸

Figure 4.

Effect of community-level interventions on post-traumatic stress disorder (PTSD) and substance abuse.

Substance abuse

One study that looked at substance abuse alongside mental disorders found a significant decrease in substance abuse among participants in the intervention group compared with control group.⁴⁹ The study delivered a parenting programme (figure 4).

Depression and anxiety-like symptoms

There was only one study that assessed depression and anxiety-like symptoms⁵⁴ (see online supplemental S4 figure). This study found a significant decrease in depression and anxiety-like symptoms among participants in the intervention group compared with participants in the control group.

Certainty of evidence

The main strength of this review is that it is the first to assess the effect of multi-level interventions on mental health in adolescents in SSA. However, it is important to note the quality of evidence when interpreting these findings. Full details on quality appraisal are provided in online supplemental S7 table.

Multi-level interventions

The quality of evidence for studies that delivered multi-level interventions ranged from low to moderate. The results for effect of multi-level interventions on depression were not consistent across eight studies. Anxiety was measured by only one study which had a high attrition rate in the control group and did not adjust for clustering of participants in the analysis.⁴² Among three studies that measured PTSD, two studies had small sample sizes below 100.^{45 46}

Community-level interventions

The quality of evidence for studies that delivered community-level interventions ranged from low to high. For depression, most studies showed a positive intervention effect, however, the studies that delivered economic empowerment or parenting intervention seemed to have no or smaller effect than studies that delivered CBT or IPT interventions. The quality of evidence was not downgraded as the direction of effect was consistent for most studies. For anxiety, the quality of evidence was rated as high. For PTSD, the evidence was downgraded to moderate because two of the three studies that measured PTSD had sample sizes smaller than 100. For depression and anxiety-like symptoms (combined outcome), only one study was included. This study had a high risk of bias due to high attrition rate (only 27% completed both pre-questionnaire and post-questionnaire).⁵⁴ Thus, the quality of evidence was downgraded to low. For substance abuse, only one study was included. The study included enough participants and had a low risk of bias. Thus, the quality of evidence was rated as high.

Discussion

The findings from this systematic review suggest that multi-level interventions that include economic empowerment, peer-support or CBT can improve mental health in adolescents. Similar patterns indicating the positive effect of these interventions were also observed for studies that delivered only community-level interventions. However, due to high variability in intervention components and study participants between studies identified in this review, further research on these interventions is needed to help us understand their effect when scaled up in different contexts and to demonstrate if they can be reliable and sustainable. The variability in intervention components found in this review is consistent with previous reviews that looked at mental health interventions for adolescents in LMICs.^{22 23 67}

Among five studies that found multi-level interventions to be effective in reducing mental health problems, the intervention components included group-based economic empowerment, peer support, CBT and IPT. These group-based interventions were offered alongside counselling or healthcare or included one-on-one trauma narrative sessions. One study that delivered an economic empowerment intervention did not show significant intervention effect after the intervention had been stopped,³⁷ and other two studies with longer duration (12 months or more) did not have an impact on depression.^{38 40} This suggests that some interventions may be effective but fail to show positive long-term impact on mental health. This also highlights the importance of investing in sustainable interventions that have a longer positive health impact.

Multi-level interventions were generally delivered to highly vulnerable populations such as adolescents infected with or affected by HIV, orphans and war-affected adolescents, with individual-level components offered based on individual’s need. While vulnerabilities may vary within youth populations, it is important to consider their individual needs when designing interventions. Engaging young people in the development of interventions may help identify their needs and ensure that interventions are relevant to their individual needs. Youth engagement have been found to be effective in improving mental health in youth,⁶⁸ however it is still limited in SSA.⁶⁹

Community-level interventions varied substantially. Sixteen of the twenty studies reviewed significantly reduced mental health problems including substance abuse. Of these studies, four delivered economic empowerment interventions and family coaching or parenting interventions. Economic empowerment interventions like cash transfers have been shown to have a positive impact on mental health outcomes in SSA.⁷⁰ Parenting and family-focused interventions have been shown to have a significant positive effect on child and youth mental health in LMICs.^{23 71} Another eleven effective studies delivered theory-based interventions such as CBT and IPT, of which ten were conducted in schools. This suggests that schools provide a good opportunity for implementation of interventions that are relevant to adolescents and youth; a previous review has demonstrated that school-based mental health interventions can be effective in improving mental health and could be integrated into education programmes.²² Nevertheless, care must be taken not to exclude out-of-school youth by targeting effort too much on school settings. Peer-led community-based and digital mental health interventions including internet-based CBT may be able to reach many young people irrespective of whether they are enrolled in school.^{72 73}

While there is overlap between mental health problems and substance abuse, in this review we identified only one study that measured both mental health and substance abuse. Cluver and colleagues found a significant positive effect of parenting programme on substance use among adolescents’ families reporting conflicts, but no observed effect on mental health.⁴⁹ This finding highlights the importance of comprehensive interventions that involve parents, to prevent and reduce substance abuse in adolescents. In SSA, where substance abuse among adolescents is a major public health problem,¹² there is need for further research to identify effective interventions that will simultaneously reduce substance abuse and mental health problems.

Most studies in this review were targeting adolescents who were already having symptoms of common mental disorders. This highlights the gap in the evidence of preventive interventions on mental health in SSA and suggests the need for universal mental health interventions (whole school or community) that can reduce the risks of poor mental health. In settings like SSA where it may not be affordable to treat mental health conditions, preventive interventions such as economic empowerment and family strengthening interventions that are already known to be effective may be vital to reducing social determinants of poor mental health in adolescents. Future research should identify strategies to implement preventive interventions and consider task-shifting delivery model to achieve sustainable long-term mental health gains.

This review has a number of limitations. First, we only searched published studies and included only RCTs or quasi-experimental (controlled) studies, therefore some evidence from unpublished and qualitative studies may have been excluded. Second, we were unable to report summary effect measures due to variability in intervention components, participants and study duration in the included studies. Third, majority of studies measured the outcomes using a continuous scale without a cut-off or further confirmation of diagnosis by the specialist. Fourth, none of the included studies looked at individual-level interventions, so we could not compare multi-level interventions with individual-level interventions. Finally, we restricted the search to studies that included adolescents aged 10–24 years, this might have excluded important information. Despite these limitations, this review adds new knowledge about mental health interventions for adolescents. Our findings highlight the need to combine individual-level and community or family-level interventions when addressing mental health problems in vulnerable youth population. For example, social support or social protection interventions such as cash transfers, parenting programmes and school-based interventions (including feeding scheme) may be delivered in combination with individual-level interventions tailored to young people’s needs.

Conclusion

There is evidence that multi-level interventions can improve mental health in young people in SSA. Economic empowerment, peer-support or CBT found to be effective when delivered alone or in combination with individual-level interventions tailored to individual needs. However, due to limited number of studies and substantial heterogeneity in intervention components, study participants and duration among studies that delivered multi-level interventions, it is difficult to identify intervention components that are most effective. Future research should involve replicating these promising interventions in different settings to understand their long-term effect and reliability under different circumstances.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The data supporting the findings of this study are provided in the supplemental material.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Not applicable.