The African youth in mind (Y-MIND) brief psychological intervention for depression among school-going adolescents in Ghana: a development case series

Abstract

Background

Depression is common among adolescents, particularly in low- and middle-income countries, such as Ghana. Yet, access to mental health care in these settings remains limited. There is a need for research to focus on innovative strategies to improve access to care. The African Youth in Mind consortium, together with a group of young people with depression and relevant stakeholders have developed a novel six-session lay professional intervention (Y-MIND) to treat depression.

Method

As part of the early phase of intervention development, we conducted a case series aimed at testing the feasibility, acceptability, and preliminary safety of Y-MIND when delivered by a trained clinical psychologist within Navrongo, Ghana. Four adolescents, aged 16–18 years, with a primary DSM-5 diagnosis of major depressive disorder were purposively recruited and received the intervention. The Patient Health Questionnaire-9 (PHQ-9) was administered at baseline and weekly, and each session audiotaped. In addition, semi-structured interviews were conducted after each session and at two weeks’ follow-up. PHQ-9 data were analysed using Stata 17 to generate descriptive statistics. A deductive framework guided the analysis of semi-structured interview transcripts and participant evaluations using NVivo 12.

Results

Three of four adolescents completed all six sessions. The mean session duration was 58 minutes (SD = 12.0). All four participants demonstrated a ≥50% reduction in PHQ-9 scores by end of treatment. Mean PHQ-9 scores decreased from 14.5 (SD = 0.6) at baseline to 2.3 (SD = 4.0) at endline. By the beginning of session five, two participants had PHQ-9 scores ≤5. No participant showed symptom deterioration during the intervention. Qualitative interviews indicated that participants found the intervention understandable and relevant to their context. The interventionist identified areas for refinement, including clarifying sections of the manual and worksheets, addressing variability in remission rates, and strengthening the emphasis on mutual respect within the therapeutic relationship.

Conclusion

The Y-MIND intervention appeared to be feasible, acceptable, and safe for treating depression among senior high students in Ghana. Planned piloting with non-specialists will include adaptations for training, supervision, and fidelity monitoring.

Trial registration

Clinical Trials.gov Trial registration number ID NCT06740084, Trial registration data, December 9, 2024.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12888-026-07938-w.

Introduction

Major depressive disorder is a public health concern, with its onset typically occurring in adolescence [1]. Globally, an estimated 25% of young people experience a depressive episode by age 19 [2, 3]. The early onset of depression is predictive of poor quality of life, recurrent physical and mental illness, a high risk of self-harm and elevated suicide risk in adulthood [4, 5]. The burden of depression is disproportionately higher in low-and middle-income-countries (LMICs), where timely and developmentally appropriate care remain limited [5]. In Sub-Saharan Africa, approximately 27% of adolescents are at risk for developing a depressive disorder [6], countries however report varying prevalence rates and suicidal behaviour [7, 8]. In Ghana, studies among senior high students report high prevalence rates of depressive symptoms and suicidality, depending on the age group, sampling frame and clinical thresholds [9, 10]. Adolescence marks a critical developmental period in Ghana particularly in settings such as senior high schools where stressors - academic pressure, financial difficulties, bullying, family conflict and relationship problems – linked to depression may be more pronounced [10, 11]. Despite this burden, early detection and treatment of depression in schools remains a major challenge, even though young people spend most of their time in these environments [12, 13].

In Ghana, recent and historical studies have reported a mental health treatment gap ranging from 9595% to 98% [14, 15]. There remain few mental health professionals such as clinical psychologists available, majority of whom are located in urban areas, depriving peri-urban and rural areas of evidenced based care [16]. Although, the Ghana adolescent health service policy exists, specialized adolescent mental health services remain limited with no structured, evidenced based care pathways for adolescents [17–19]. At the senior high school level, majority of the schools typically have an assigned school counsellor popularly known as guidance and counselling coordinator (GCC) [20]., However, majority of these counsellors have limited mental health training in delivering psychosocial interventions, and the mental health component of the Ghana School Health Education programme is underdeveloped [21]. As a consequence, senior high school students with depression risk receiving suboptimal care and general advice rather than structured evidence based psychological care [22]. Similar challenges are noted in other West African and LMICs where targeted adolescent mental health services are rare and empirical evidence from these regions remain scarce [23 ,24]. Taken together, this high burden of adolescent depression and treatment gap, highlights the need for relatively simple, brief, scalable, developmentally efficacious and cost-effective interventions that can be implemented in adolescent-accessible settings such as schools [25–28]. Rather than attempting to re-invent the wheel, adapting an existing evidence-based youth intervention seems a pragmatic and appropriate approach [29, 30].

One promising innovation in Africa is the Friendship Bench (FB), a proven task- shifting approach, where non-specialists use an evidenced based Cognitive Behavioural Therapy technique, problem solving (PS) to treat depression in Zimbabwe, in six sessions [28, 31, 32]. The youth version of the Friendship Bench, the Youth Friendship Bench (YouFB) has shown promising results in Zimbabwe, reflecting strong acceptability, feasibility and symptom reduction among young people particularly for those who value consulting with their own peers [33, 34]. Similar to Zimbabwe, another LMIC, India has implemented lay-counselor-led PS interventions in a range of school settings to help address depression and other mental health concerns demonstrating PS effectiveness in reducing depressive symptoms, psychosocial distress and problem severity, as well as showing strong feasibility and acceptability among adolescents [35].

PS is a valuable approach designed to enhance a sense of resilience while teaching young people essential skills on how to analyse problems, brainstorm solutions and act in a systematic manner [36]. By empowering young people to handle their problems better, PS boosts coping skills and helps to reduce depressive symptoms [37]. In spite of evidence supporting the effectiveness of problem solving, our literature review clarified that an intervention purely based on PS is not sufficient for treating depression in adolescence, particularly moderate to severe depression [38, 39]. PS requires the use of certain critical skills including sustained attention, abstract reasoning, planning and brainstorming solutions, however, this can be challenging for young people as the brain is still maturing during adolescence [40]. To complicate issues further, core symptoms of depression such as fatigue, loss of concentration and hopelessness can interfere with cognitive domains crucial for the implementation of PS [41, 42]. Further, adolescents with depression typically respond to life challenges with avoidant coping or impulsivity rather than approaching problems in a systematic manner thus limiting the effectiveness of standalone PS [43–46].

In response to addressing some of these problem solving related challenges, the African Youth in MIND National Institute for Health Research (Y-MIND NIHR) research group developed Y-MIND, a task shifting scalable intervention for treating depression among young people in Ghana and Zimbabwe. This novel intervention was designed to optimise and adapt the YouFB model for senior high school adolescents in Ghana [47]. Y-MIND is guided by a developmentally informed cognitive behavioural framework which integrates youth- friendly psychoeducation, Behavioural Activation (BA) and PS to address cognitive, emotional and motivational constraints typical of adolescent depression [34, 40, 48]. The Y-MIND model draws on developmental cognitive and sociocultural frameworks that emphasise the use of concrete, narrative-based, and socially mediated learning approaches that scaffold abstract reasoning and skill acquisition during adolescence [49, 50]. Through this model, it is assumed that young people with depression will experience improved insight and reduced stigma in a culturally meaningful way, increased motivation and energy by reengaging in valuable daily activity, leading to enhanced cognitive processing and focus [51]. This in turn will equip them to generate solutions for their problems, anticipate positive outcomes and develop adaptive coping strategies to manage life problems better, ultimately yielding tangible improvements in mood, self-efficacy, and functioning [52–54].

While the standard forms of psychoeducation, BA and PS (YouFB) demonstrate clear strengths, culturally sensitive adaptation was essential for the successful deployment of Y-MIND. This is because Ghanaian senior high schools house younger youth (15–18 year) compared to the broader 15–24 range typically known of YouFB users in other settings. Leveraging similarities with Zimbabwe’s collectivist culture and prioritizing ecological validity, adaptations in Ghana focused on tailoring language, metaphors, goals, methods, concept, content, and contextual nuances [55] for a younger population in senior high school setting. Within the communal senior high school environment, institutional structures, hierarchies, and shared norms, may diverge from the larger community setting, thereby shaping the intervention content distinctively [47]. These context-specific considerations informed the development of the Ghana-specific Y-MIND version, necessitating rigorous testing prior to wider implementation.

As an initial step in this intervention development process, this case series aimed to assess the feasibility, acceptability and the preliminary safety of the Y-MIND intervention when delivered by an expert as well as indications of change in symptoms of depression among adolescents. This process is in line with best practice, recommended by the Medical Research Council’s framework for developing and evaluating complex interventions [56–59]. This early evaluation was intended to inform subsequent refinement of the intervention and guide future research, including task shifting to non-specialists. Accordingly, in this case series, we assessed the feasibility, acceptability, safety and symptom change signals as a critical step to inform future adaptation and scaled delivery.

Methods

Design

We employed a mixed methods pre-during-post-test design case series which consisted of administering measures to four participants at baseline, during and after the intervention, conducting interviews and documenting observations. Case series are important in providing descriptive information, building knowledge and hypotheses for early stage development of new interventions [60, 61]. This research design offers preliminary insights into feasibility, acceptability, and safety, and is well suited for informing future iterations of a new intervention [62, 63].

Settings

This case series was conducted in Navrongo, a town located within the Kassena-Nankana Municipality of the Upper East Region of Ghana. Similar to other parts of Ghana, in Navrongo there is an existing treatment gap for mental health conditions, including depression. Using convenience sampling, we selected one of the twelve senior high schools located in the Health and Demographic Surveillance site of the Navrongo Health Research Centre to conduct our study.

Recruitment

To identify potential participants, the African Y-MIND research team conducted a mental health sensitization session on depression for first- and second- year senior high school students. Considering that low mental health awareness, religious beliefs and stigma can impact how young people seek appropriate mental health care in Ghana [64, 65], we deemed this approach appropriate. The session was facilitated by a local mental health nurse. A total of sixty-three (63) students volunteered to be screened by the research team. Guided by PHQ-9 local norms, six (6) students who scored 14 or more on the PHQ-9 were shortlisted for a case confirmation of clinical depression [66, 67]. A licensed, experienced and locally based clinical psychologist (DA) conducted a clinical assessment, including the Structured Clinical Interview for DSM-5 (SCID-5) [68], to confirm that participants met threshold for a diagnosis of major depression.

Participants

The final sample size comprised of four students. The literature shows heterogeneity in what sample size is considered suitable for a case series, the inclusion of four participants reflects the lower end of the range typically reported [61, 69]. The main criteria for selection is that participants share common clinical characteristics [62, 70]. Participants were enrolled if they were: a) 15 to 18 years old; b) scored 14 or more on the locally validated PHQ-9 [67]; c) had a confirmed diagnosis of depression assessed by the clinician using the SCID and a clinical interview; d) willing and able to be followed up over a period of 8 weeks. Participants were excluded if they met the inclusion criteria but; a) were currently receiving any psychological treatment for any common mental disorder through formal health care services; b) had an active mental disorder, or advanced physical illness that would interfere with their ability to participate in the study, or actively suicidal (assessed using the P4 screener) [71]; c) had a visual and/or hearing impairment, defined as being unable to see and read the intervention manual or hear the interventionist sitting approximately 1 meter away. Four out of the six students who received a confirmed diagnosis of major depression met the study eligibility criteria. The remaining two eligible cases recorded high suicidality risk and thus were excluded and referred to formal health services for treatment in accordance with the African Y-MIND project’s protocol and standard operating procedure (SOP). See the patient flow chart below in Fig. 1.

Fig. 1.

Patient chart flow

Ethical considerations

Prior to being enrolled, all four adolescents were invited to take part in the intervention. They were provided an information sheet, and details of the study were explained. For students under 18 years, a parent/a legal guardian provided informed consent while the student provided assent by signing/thumb printing an informed consent form if they agreed to participate in the study. All four participants agreed to take part in the study. The semi-structured interviews were audio-recorded and transcribed with the participant’s consent. In addition, the clinicians notes and observations were documented and filed for analysis.

Measures

Our primary outcomes were the feasibility of delivering the prototype Y-MIND psychological treatment and its acceptability to in-school adolescents. The safety profile (no risk of harm) of the psychological treatment and improvement in symptoms of depression were assessed as secondary outcomes, by tracking changes in symptoms of depression across sessions. Quantitative and qualitative measures were used to assess these study outcomes, see descriptions of these below:

Quantitative measures

The Patient Health Questionnaire-9

The PHQ-9 is a widely validated, brief nine item screening tool used to assess symptoms of depression [72]. It aligns with the DSM-5 criteria for depression and uses a Likert scale with scores ranging from 0 to 27. Higher scores reflect high levels of severity. It has been locally validated in Ghanaian adolescent populations, making it a culturally appropriate and psychometrically sound choice for this research [66, 67]. For the purposes of this study, the PHQ-9 was administered at baseline and at each session to (1) assess the change in clinical symptoms and (2) safety or risk of no harm. Details of these constructs are described below:

Depressive symptom reduction: a 50% or more reduction in the PHQ-9 score indicated evidence of change or improvement

(2) Safety: Safety (no risk of harm) was assessed by closely monitoring changes in depression severity across sessions or “adverse events.” This was assessed by specifically using the item 9 of the PHQ, which assesses the presence and frequency of suicidal ideations. As per the study protocol, if a participant endorses item 9 of the PHQ as positive, discloses suicidal ideations, a plan or intent of suicidality, a further evaluation is conducted using the P4 suicidality screener. The P4 suicidality screener is a brief screening tool used to determine the level of suicidality risk, which could range from minimal, lower or high. As per the Y-MIND SOP on suicide, if suicidal risk is minimal or lower risk a safety plan is required to proceed or continue with the intervention. However, high risk cases are immediately referred to formal services as the next line of action.

Qualitative measures

Qualitative data was collected using semi-structured interview guides (see supplementary material 1–5), clinician notes and an evaluation of each participant to assess comprehensibility, feasibility and acceptability. The semi-structured interview guides consisted of questions designed by the team to assess the following domains:

Feasibility

The practicality of delivering and engaging with the Y-MIND intervention was assessed by the ease of administration, session duration, delivery context, homework and activity adherence, client motivation and participation, and clinician flexibility.

Acceptability

This domain assessed two constructs:

1. Comprehensibility: How well participants understood the intervention content and the Y-MIND process. Specifically, questions addressed the understanding of the Y-MIND core concepts (depression, BA, and PS), clarity of intervention purpose, language comprehension, session sequencing and structure.

2. Saliency: How well the intervention was received by adolescents based on its perceived relevance and appeal.

The clinicians notes and observations were also documented and filed for analysis

The interventionist

To establish safety and appropriate protocols for Y-MIND before its delivery by lay persons, this intervention was delivered by an expert (DA). DA co-developed the Y-MIND manual with other expert clinicians (TB, PS, & MA) and also led the cultural adaptation of the Ghanaian version. DA’s involvement in this process guaranteed a profound understanding of the intervention’s theoretical underpinnings and practical elements. Prior to delivering the intervention, DA received formal training from DC and MA who developed the original YouFB adapted for Y-MIND. DA also received training on adhering to the study protocol and the suicide risk SOP. In addition, she received weekly clinical support and supervision from other members of the Y-MIND clinical team throughout the delivery phase.

The Y-MIND intervention development and formative research

The Y-MIND intervention was informed by a rigorous formative research process. This process included a review of data from situational analyses and qualitative interviews with key stakeholders in Ghana and Zimbabwe, as well as iterative input received from the study’s Young People’s Advisory Group [73, 74]. International clinical guidelines, existing manuals, lessons and best practices for treating depression among young people were also reviewed by the team clinician experts [75–85]. From this formative work, a prototype of the Y-MIND intervention was first developed by the expert clinicians on the research team and subsequently an external group of experts to further shape the intervention design. In line with best practices for designing a brief psychological intervention to treat adolescent depression, this prototype included three core components: psychoeducation, BA, and PS, and an additional constituent, relapse prevention to help reinforce learned skills, ensuring a strong foundation for dealing with future problems.

This Y-MIND prototype was further reviewed by young people with lived experience of depression, mental health professionals, and other key stakeholders in separate participatory workshops in Ghana and Zimbabwe, resulting in two culturally adapted versions. The adapted versions of the Y-MIND prototype exemplify the culture in which they were developed (Supplementary 6 presents a table with a summary of qualitative data from the participatory workshops, which informed session content, cultural adaptations, and delivery decisions). Findings on the Zimbabwe version of Y-MIND are reported elsewhere [86]. This case series focuses on the Ghana version of the Y-MIND intervention, which incorporates Ghanaian values and norms related to experiences of distress, depression and recovery, details of each constituent are described briefly below:

Psychoeducation: Educating young people about their condition of depression – psychoeducation - with age appropriate material is a core component of effective multimodal treatments for depression [77]. In a systematic review [87], researchers demonstrate that psychoeducation helps young people recognise their symptoms and provides insight about these symptoms and resulting functional impairment, as well as viable treatment options that often appear misunderstood, complex, mysterious or unclear for lay persons. The Y-MIND psychoeducation component was designed to address how mental health challenges influence the development, maintenance and treatment of depression, in a way that resonates with young people. Further this component introduces practical skills (BA and PS) that can help the young person cope better with mental health challenges. In Ghana, psychoeducation is key because adolescents typically interpret mental illness through moral, relational, or spiritual framing, rather than an individual psychological state [88]. These interpretations of depression can delay help-seeking, increase stigma and affect treatment adherence, if psychological explanations are absent or poorly contextualised [89, 90]. Psychoeducation addresses issues of stigma, self-blame and spiritual condemnation thereby improving adherence to treatment and spiritual wellbeing [91]. Through psychoeducation young people can view depression as a legitimate and treatable condition, rather than a personal weakness or moral failing [92].

Behavioural activation: Emotional distress associated with depression is usually recognised through behavioural changes such as withdrawal from social roles, loss of productivity or a disengagement with communal activities. BA emphasises action over rumination, low mood and inaction or withdrawal, which typically characterise and reinforce the cycle of depression [93, 94]. By breaking this cycle of depression, BA helps the young person regain control over their lives and experience of depression [51, 95]. Through BA, adolescents learn how to re-engage in meaningful activities; address avoidance, low motivation and mood. which are typical of a depressed adolescent. The core tenets of BA seem consistent with Ghanaian local norms of recovery that emphasize the restoration of responsibility, reciprocity and social functioning. In many Ghanaian societies wellbeing is linked to being active, productive and socially engaged through various tasks including academic work, house chores, religious activity and social interaction. Therefore, BA’s focus on the re-engagement of meaningful activity mirrors markers of improvement and offers a culturally resonant way of tackling withdrawal and inactivity. BA helps young people with depression reengage with routine activities that offer a sense of pleasure and meaning [96].

Problem solving: Based on the YouFB model [85], the PS component was designed to help adolescents break down seemingly overwhelming problems into manageable ones, identify and focus on the most critical problems, and brainstorm effective solutions. PS complements psychoeducation and BA by reflecting everyday Ghanaian practices of solving problems via practical reasoning, consultation with trusted persons, and incremental action [21, 22]. In Ghana, adolescents are typically socialised to seek counsel from trusted peers of adults of good character and focus on what is feasible and practical, in the face of hardship, making PS a culturally congruent technique [74, 97].

Relapse prevention: This component was designed to acknowledge the progress of the adolescent, consolidate learned skills and identify early warning signs by planning for future difficulties to avoid relapse. This element provided the adolescent with local resources from within the school and community, strengthening support networks, reflecting Ghana’s ethos of ‘shared care’ [98].

The Y-MIND intervention

Y-MIND was built on the premise that in Ghana adolescent depression can be triggered by an interplay of life difficulties. Life difficulties may include socioeconomic stress, academic pressure, school related stress, peer and social pressure, family conflict, neglect, loss or abuse and which can be overwhelming to cope with, affecting perceptions of life and yielding negative thoughts about oneself, others (including God) and the future. These negative thoughts can lead to the experience of depression, which is characterized by maladaptive feelings (i.e. sadness, hopelessness) and behaviours (i.e. withdrawal from meaningful activity). The theory of change guiding Y-MIND assumes that if adolescents are supported to understand the causes and consequences of depression (psychoeducation), re-engage with meaningful activity (BA), and develop a structured approach to solving problems (PS) they will experience: a reduction in depression and an improvement in mood, self-efficacy, daily functioning and social engagement, sustained wellbeing at school and in social relationships. Details of the intervention content are presented in Table 1 below:

Table 1.

Goal of each session and accompanying activities and worksheets

Session	Focus & Goals	Core activities	Worksheets and resources
Session 1: Psychoeducation	Build rapport; normalise depressive experiences; introduce Y-MIND framework; set goals collaboratively	Narrative-based psychoeducation using the vicious cycle of depression; a culturally resonant and hypothetical story (Awe & Anuwe); establishing commitment and collaborative goal setting	Y-MIND binder; hypothetical Awe and Anuwe story of depression stimulus; depression handout; vicious cycle visual; goal-setting, activity scheduling, and mood monitoring worksheets
Session 2: Behavioural Activation I	Increase motivation and improve mood by identifying values and meaningful activities	Values clarification; selection of initial activities; action planning	Mood check-in; values cards; action plan; activity scheduling and mood monitoring
Session 3: Behavioural Activation II	Address barriers; strengthen activity engagement and mastery	Problem identification related to barriers; graded task planning; reinforcement of success and social connection	Mood check-in; revised action plan; activity scheduling and mood monitoring
Session 4: Problem Solving I	Introduce structured problem-solving	Problem definition and categorisation; solution generation; pros/cons analysis; solution selection	Mood check-in; PS worksheets; action plan; activity scheduling and mood monitoring
Session 5: Problem solving II	Consolidate and generalise PS skills	Review outcomes; refine strategies; apply PS to new problems	Mood check-in; PS worksheets; action plan; activity scheduling and mood monitoring
Session 6: Relapse prevention	Maintain gains; prepare for future challenges	Skills review; identify early warning signs; develop personalised relapse-prevention plan; programme closure with recognition of achievement via the presentation of a certificate.	Mood check-in; relapse-prevention plan; community resources; certificate

Procedure

This study received ethical approval from three institutional review boards: the Navrongo Health Research Centre (Ref.App/Youth-in-Mind/09/2022), Ghana Health Service (GHS-ERC: 027/10/23) and the Kings College London, Health Faculty (RESM-23/24– 40,071). Permission was also obtained from the Ghana Education Service (GES/DD-G/Q&A/24/016) and the school headmaster to gain access to the Senior High School. The mental health sensitization, screening and recruitment exercise was conducted, prior to seeking informed consent and the enrolment of the four adolescents.

A trained research assistant collected data for each participant by administering the PHQ-9 before each session, conducting semi-structured interviews afterwards, and at two weeks-follow up. The Y-MIND intervention was delivered in 1-hour sessions over a period of six weeks, in a staged school counselling room setting. In line with the Y-MIND manual and cultural norms of privacy and secrecy, each session opened with an emphasis on confidentiality and the limits of confidentiality. Each session continued with a discussion of the agenda. From sessions two to six, a mood check-in and a review of homework was routinely conducted. This was followed by the implementation of the main session activity. The adolescent received a sticker as part of reinforcement, after completing the main session task, and developing an action plan for homework. As part of the homework assignment, the adolescent received accompanying worksheets. Finally, at the end of each session feedback was solicited from the participant and the next appointment scheduled. The therapy sessions and semi-structured interviews with the adolescents were audio-recorded and transcribed with participant’s consent. The clinician took clinical notes to document observations for each participant during sessions and also completed an evaluation, at the end of each session and at the end of the intervention. Each Y-MIND session was timed and recorded in hour and minutes, timing was used as a proxy for the session duration.

Data analysis

The PHQ-9 data and session durations were collected and stored on Research Electronic Data Capture (REDCap) tool, hosted at the Navrongo Health and Research Center and exported into Stata 17 and excel for analysis. Clinician documentation and transcripts of audio files from the semi-structured interviews were imported into NVivo 12 software for coding and thematic analysis. The method of analysis varied, with some outcomes involving a quantitative analysis, qualitative analysis, or a mix of both. Details of the specific analysis are described below:

Reductions in symptoms of depression

PHQ-9 scores were analysed across sessions for each adolescent, with a score ≥ 50% indicating a signal of change in symptoms of depression.

Safety

Safety was quantitatively analysed by monitoring PHQ-9 scores, particularly an endorsement of item 9 and using the PS4 screener to assess suicidality risk. Qualitative themes related to emotional safety and protective factors were deductively derived from the clinicians notes and participants’ responses.

Feasibility

Descriptive statistics of session duration and intervention adherence were quantitative measures of feasibility. Qualitative themes related to ease of delivery and participant engagement were derived deductively from the interviews, the clinician notes and evaluation data.

Acceptability

Themes of acceptability focusing on comprehensibility and saliency were deductively derived from the interviews, the clinician notes and evaluation data.

Results

Demographic information of participants

Four adolescents with ages ranging from 16 to 18 years took part in this case series. Three out of the four participants were in Senior High School (SHS) Two and one in SHS One. Three out of the four participants were females. Demographic information is presented in Table 2.

Table 2.

Background demographic information of individual participants

Demographic	M(SD)	n/%
Age	17.00 (±0.82)
16		1
17		2
18		1
Gender
Female		3
Male		1
School level
Year 1		1
Year 2		3
Diagnostic criteria
Major depression		3
Major depression, panic disorder		1

Case 1: Major depression, Panic disorder

Participant A, a 17-year-old female student in second year of senior high school, presented with moderately severe depression and panic symptoms. She reported a long-standing history of academic difficulties, despite remediation and hypersensitivity to noise. She reported a previous suicidal attempt and current suicidal thoughts but had no plan because of concerns for her mother. Participant A was visibly shy, anxious and fidgety during the first session, but appeared at ease after playing the drums, as part of an anxiety reduction exercise to ease tension and establish rapport. She set goals to improve social engagement. In session two, she identified her top three values as education, family and creativity and selected to implement an activity related to the later. In session three, she reported the experience of financial barriers and her inability to execute her original plan of action. Not deterred, she worked out a plan to address the previous barriers, as well as planned for a second activity. In session four, she shared excitedly how she had been able to watch a football match and cheer on her team, in spite of a physical injury. Her homework log revealed her active engagement in other relevant mood booster activities such as chatting with friends, playing ampe (a local Ghanaian energetic game that involves a pair of individuals usually female jumping and clapping). Notably, by session four, her PHQ-9 score had improved steadily, dropping from “10” in the previous session to a “0”. Consistent with this, she reported no existing problem but was open to learn the problem solving skill and help the hypothetical character (Awe & Anuwe) solve their problems in session four and five. In session six and at follow-up, despite continued academic struggles, she expressed confidence in mastering BA and PS skills.

Case 2: Major Depression

Participant B, a 16-year-old female student in second year of senior high school, presented with moderate depression. Following her father passing on in 2015, she reported financial hardship and family tension. She often felt emotionally burdened but frequently masked her true feelings or pretended to be happy in public. She expressed grief over her father’s absence and the ongoing maltreatment of her mother. In session one, participant B showed enthusiasm, resonated with Awe’s story and expressed a sense of hope. Her goals included improving concentration in class, eating better, and enhancing social interaction. In session two, she demonstrated keen interest in learning more about depression. Independence, family and kindness were among her top values. In line with her value of kindness, for her BA task, she chose to fetch water for a senior, despite existing tension between the two. In session 3, after a successful execution of her previous action plan, she confidently planned other activities such as studying alone and writing a letter to a special friend. Her activity monitoring sheet showed record of other mood boosting activities such as church activity, reading and socializing. In session four and five, she addressed concerns of loneliness and boredom, in anticipation of the school holidays. By session six, her PHQ-9 score had declined from 15 at baseline to 0 post intervention. For her relapse plan, she identified personal triggers such as “family tensions” and “conflict with senior” mapping it to the warning signs of “low appetite” and “overthinking”. At the end of the sessions, she had accomplished her goals and also appeared emotionally stronger and hopeful.

Case 3: Major Depression

Participant C, a 17-year-old female student in first year of senior high school, presented with moderately severe depression. At the age of 15, she was forced to drop out of school due to an early pregnancy. Returning to school, she was faced with issues of stigma and financial hardship. Both parents are deceased, and she reports losing a major sponsor of her education in a vehicle accident. Although, she was a beneficiary of Ghana’s free senior high school education programme she struggled to access money for snacks and school resources. Initially disengaged and hesitant in session one, Participant C expressed doubt about the value of the Y-MIND program, due to her experience of stigma by association. However, by the end of the session 1, she appeared hopeful. In session two, she was disappointed to find out that Y-MIND intervention did not offer financial support. Nonetheless, she actively participated in subsequent sessions, uncovering personal values (e.g. kindness, work, and success) and identifying valuable activities (e.g. learning fashion designing skills, running household chores for teachers) in session two and three. By session four, Participant C had a good understanding of the connection between activity and mood but did not have an existing problem to solve. Nonetheless, she was happy to apply her problem solving skills to help Anuwe, the hypothetical female character with depression, solve problems. In session five, she worked on the challenge of wanting to visit a sick sibling while in boarding school and also began exploring potential income generating activities for the future. By the end of the Y-MIND intervention, Participant C’s PHQ-9 score had reduced from 16 to 7. She acknowledged a significant reduction in her habit of overthinking and acquisition of proactive coping skills, including BA and PS. At the conclusion of the session, she proudly received her certificate, stating that it could be shown to others as evidence of achievement.

Case 4: Major depression

Participant D, an 18-year-old male student in second year of senior high school, presented with moderate depression. He reported emotional distress stemming from his parent’s separation and the constant conflict and tension between them. Maintaining communication and contact with his father seemed to have intensified the tension, leaving him sad, angry, and overwhelmed. He also struggled with finances and often had to work to fend for himself. He feared that this could interfere with his schoolwork. He reported a previous suicide attempt at the age of 12, and his struggles with suicidal thoughts. He shared that his Christian faith discouraged him from self-harm. In session one, Participant D participated in the session activities but showed flat affect and visible struggles with expressing himself. The drumming exercise helped to establish rapport. Despite limited connection with the hypothetical peer – Awe, he committed to continue with attending the Y-MIND. In session two, he appeared more cheerful and scored “very happy” during the mood check-in. For his BA task, he actively participated in a task to determine his values which revealed his orientation to family, contribution to community and friendship. His list of valued activities included talking to a friend, playing football, and doing something nice for a senior. By session three, his mood diary revealed fluctuating emotions—he had felt accomplished after scoring a goal in football, but had also experienced low moods for days due to an injury he sustained. For subsequent activities, he chose to play football and study alone, to avoid distraction from his peers. Participant D exited the intervention at session three, his last recorded PHQ-9 score was 4 showing a decline from 14 at baseline. While he did not complete the full intervention, his partial engagement may support short-term emotional relief and BA.

Symptoms of depression

By the end of treatment, on average, participants PHQ-9 scores had reduced steadily PHQ-9 from 14.5 to 2.3. One hundred percent (100%) of the adolescents who completed the intervention reported a 50% reduction in baseline score at the end of the last session. Two participants (Participant A & Participant B) presented with no symptoms of depression by the end of treatment (PHQ-9 score ≤ 5). The descriptive statistics are presented in Table 3.

Table 3.

Session-wise PHQ-9 performance for each adolescent. X: missed sessions

PID/Summary	Baseline Score	Session 1 Score	Session 2 Score	Session3 Score	Session4 Score	Session5 Score	Session6 Score
Participant A	14	15	12	10	0	0	0
Participant B	15	12	8	12	5	4	0
Participant C	15	16	14	12	9	8	7
Participant D	14	15	14	4	X	X	X
Mean(SD)	14.5(0.6)	14.5(1.7)	12.0(2.8)	9.5(3.8)	4.7(4.5	4.0(4.0)	2.3(4.0)

Safety

Participants PHQ-9 scores were monitored closely from session to session. Figure 2 below shows the details. At the start of session one, Participant A, Participant B and Participant C endorsed the item nine of the PHQ-9 tool, a further assessment using the P4 suicidality Screener showed minimal suicidality risk for the former participants and lower for the latter. While they seemed to struggle with suicidal ideations, they did not have a concrete plan and also seemed to be restrained by protective factors, particularly family (“I am the only daughter so I don’t want to do anything that will harm her too” and religion “God’s time is the best, I have the fear of God”). As per the SOP, separate safety plans were developed for them, along with a trusted (adult) caregiver within the school. By session two, Participant A and Participant B made no further reports of suicidal ideations. Participant C’s struggle with suicidal ideations declined completely after session three.

Fig. 2.

Trends of PHQ-9 score across sessions for each adolescent

Overall the results showed a decrease in symptoms of depression, reduction in suicidal ideations with no evidence of depression aggravation, suggesting that the intervention is safe and may contribute to symptom reduction.

Acceptability and feasibility

Table 4 provides a summary of the findings with illustrative quotes explaining the acceptability and feasibility of the Y-MIND psychological treatment. The results show that by the end of the intervention, the adolescents clearly understood depression as a mental health condition. They also grasped the essence of the Y-MIND program and applied mood regulation and problem solving skills to overcome depression. The Y-MIND manual instructions were easy for the clinician to follow, and helped to keep the adolescents engaged and interested in completing session activities, worksheets, and homework. The sequencing of the Y-MIND sessions, particularly the strategic positioning of psychoeducation before BA, followed by PS was helpful. After the psychoeducation session, clients seemed to have developed a sense of hope and appeared motivated to commit to attending Y-MIND sessions. The data revealed that positioning BA after psychoeducation may have been helpful, as by the end of the first problem-solving session, the mood of two adolescents had improved and their problems were almost negligible. The majority of the participants (75%) completed all six sessions, with each session lasting an average of 58 minutes. The adolescents seemed content with the Y-MIND intervention citing the acquisition of newly acquired coping skills, greater confidence and reduced stigma.

Table 4.

Summary of findings on acceptability and feasibility of the Y-MIND intervention

Domain	Key Themes	Description of key themes	Illustrative Participant Quote	Clinician Observation
Acceptability (a) Comprehensibility (b) Saliency
	Depression	Understood the symptoms and impact of depression	“Sometimes, you feel like being alone can’t sleep or lack energy.” (Participant C)	Adolescents were able to define depression in their own words and articulate its effect on daily life.
	Behavioural Activation (BA)	Understood BA as a way to regulate mood	“The activities that help overcome your mood.” (Participant B)	Adolescents linked BA to emotional improvement
	Problem Solving	PSPS associated with proactive recovery	“It helps you solve problems and do the things you enjoy.” (Participant B)	Adolescents understood the principle of problem solving and how it impacted on activity and mood.
	Clarity of intervention purpose	Y-MIND not designed to offer financial/material support	“I didn’t understand at first but now I do.” (Participant C)	Adolescent gained increased clarity of the interventions purpose as the intervention progressed.
	Language and manual comprehension	Language and communication barrier	I spent extra time simplifying depression for clarity.” (Clinician, Participant D)	Initial difficulty comprehending improved with repetition and clinician clarity
	Therapeutic relationship	Adolescents valued privacy, trust, and warmth	“It was just us.” (Participant A); “She helped me stay focus.” (Participant C)	Confidentiality and rapport-built engagement was important for these adolescents
	Treatment completion	Most completed the intervention	“I didn’t encounter any challenge.” (Participant C)	3 of 4 adolescents completed all sessions.
	Skill acquisition	Learned to solve problems and manage mood	“I learned to solve problems and manage sadness.” (Participant A)	Participants developed self-management strategies.
	Empowerment and stigma reduction	Certificate boosted confidence	“I can show it to people as proof.” (Participant C)	Adolescent overcame concerns about stigma as a result of taking part in the Y-MIND program
Feasibility	Ease of administration	Manual and flow were straightforward	“I completed the session with great ease.” (Clinician, Participant B)	Clinician found the sequencing of psychoeducation → BA → PSPS logical and easy to deliver.
	Counselling techniques	Empathy, silence, reflecting, paraphrasing enhanced delivery	“She was confident and encouraging.” (Participant C)	The clinician employed essential counselling strategies regularly.
	Homework and adherence	Worksheets and activities supported engagement	“The homework is helping you become so engaged it makes you happy.” (Participant A)	All clients except one completed homework regularly.
	Session length and timing	Flexible session length enabled attention and reflection	N/A	Sessions averaged 58 mins; longest was 84 mins.
	Manual navigation challenges	Difficult navigation between stimulus cards and worksheets	“navigating the use of stimulus cards, making notes and assisting the participant was cumbersome (Clinician, Participant D)	Organizing the stimulus card and worksheets in a systematic manner to facilitate ease of access and use was helpful.
	Literacy and expressive barriers	Some adolescents had difficulty with writing tasks	“He memorized his goal instead of writing.” (Clinician, Participant D)	Providing an verbal alternative was helpful
	Adolescent motivation	Engagement increased over time	“Started hesitant, and later actively engaged.” (Clinician, Participant C)	Low mood impacted task initiation in early sessions. However, as the intervention progressed and mood improved, participants were more engaged with the process.

Challenges with Y-MIND Intervention/Suggestions for improvement

Generally, the Y-MIND psychological treatment was well received by the participants as illustrated in the following quotes, “I don’t want you to change anything” (Participant A) and, “the changes that are already there are very nice. If you leave those ones to bring in new ones, it will be confusing (Participant D)”. Despite their recommendation for no changes, some potential barriers were noted by the clinician, including the client’s low motivation, manual and worksheets limitations, managing sudden gains and the need for further cultural adaptation. These are summarised in Table 5 below:

Table 5.

Summary of implementation challenges and recommendations

Challenge Area	Observed Issue	Recommendation
Manual and worksheet limitations	Complex language and content transitions created barriers for some participants.	Simplify language further and reduce reliance on written tasks; allow verbal alternatives when needed. Also leverage on culturally adapted language and metaphors
Adolescent motivation	Some adolescents displayed initial reluctance due to low mood or fatigue, but this resolved with time.	The training and supervision of future interventionists should highlight this observation, so that interventionists are adequately prepared to deal with it.
Sudden symptom gains	Two adolescents had “no problems” to work on in PSPS sessions by week 4.	Revise manual to include instructions on how to address clients with sudden gains.
Counselling techniques	Based on clinical judgment more counselling skills were used than frequently prescribed in the manual	Revise manual to incorporate the frequent use of relevant counselling skills
Literacy and expressive barriers	Some adolescents demonstrated poor writing skills or had poor expressive skills.	The interventionist can offer oral narration as an alternative
Need for further cultural adaptation	One adolescent consistently requested a fridge for the clinician’s space – reflecting cultural norms of reciprocity. Similarly, three adolescents sense of respect and responsibility towards family, religious faith served as a protective mechanism against suicidal ideation, further highlighting the role of reciprocity.	When setting up the Y-MIND counselling environment consider clinician comfort and other relational norms. Also explore other ways to enhance reciprocity aligning with Y-MIND’s goals and strategies.

Discussion

We set out to examine the feasibility and acceptability of a culturally adapted six-session psychosocial intervention (Y-MIND) designed to treat depression among in-school adolescents in Ghana. As a development study, the findings demonstrates how the intervention operates with real adolescents, what challenges emerged during delivery, and how these experiences informed refinement and readiness for subsequent non-specialist implementation. The results from this case study indicate that the structure and content of the Y-MIND intervention are both feasible and acceptable to in-school adolescents. By the end of treatment, symptoms of depression showed a reduction with no harm or adverse events reported.

Across the four cases, depression was embedded within chronic, relational, academic and economic stressors occurring at home or within the school setting. All the adolescents reported persistent low mood, overthinking, and social withdrawal from usual activities, with one participant reporting deliberate attempts to mask her symptoms. Concerns about academic performance were central across cases, often emanating from their difficulty to cope with ongoing grief, emotional loneliness, financial hardship, family instability and ongoing conflict. Three out of the four adolescents, all females reported feelings of hopelessness, helplessness and endorsed suicidal ideations at baseline. However, protective factors, particularly responsibility towards family and religious beliefs, constrained risk and informed safety planning. These patterns are consistent with prior evidence that adolescent depression in sub-Saharan African is often relationally, religiously and structurally situated rather than purely personal [99, 100]. Despite the aforementioned difficulties, all participants demonstrated a sense of hope and a desire to work with the interventionist to overcome their challenges, by the end of the first session.

According to the clinician, at the start of Y-MIND, the adolescents displayed anxiety, shyness, detachment and flat affect, - responses typical and characteristic of new encounters and depression symptomatology - which were promptly addressed through the use of essential counselling skills, more often than originally dictated in the manual [101]. Adolescents in our study noted the clinician’s skills and highlighted the value of confidentiality and the clinician’s personality in establishing rapport and easing initial tension. Notably, a warm, humorous, empathic, encouraging, confident and collaborative therapist seemed central for establishing a strong therapeutic alliance. In response, participants demonstrated cooperation, actively engaged in the sessions and also showed concern for the clinician’s well-being (as exemplified by Participant B). Authors have argued that confidentiality and therapeutic alliance are critical to obtaining successful adolescent outcomes, irrespective of the treatment being delivered [102, 103].

All Y-MIND’s core components – psychoeducation, BA and PS were well received by the adolescents who reported gaining valuable insight and strategies to cope with their symptoms and address everyday challenges. For instance, the psychoeducation component seemed to help address the adolescents’ initial confusion, self-blame, and stigma surrounding their experiences of distress. This improved understanding of depression was reflected in how the adolescents described depression and the Y-MIND approach in their own words. The impact of this awareness may account for Participants A and B’s enhanced commitment by session two, and a shift from early disengagement to active participation for Participant C when the intervention goals became clearer. This finding highlights the strength of psychoeducation. Consistent with previous studies [104–106], psychoeducation helped normalize adolescents’ experiences clarify the link between stressors and mood, and support treatment adherence.

In this case series, BA targeted withdrawal, low energy, and reduced functioning through culturally and contextually meaningful activities aligned with participants’ values—such as academic engagement, church participation, social connection, creative expression, physical activity, and helping others. As presented in the results section, each participants selected personalized BA activities that resonated with their identified values. This finding is consistent with data from a systematic review [96] that showed locally suited behavioural strategies help young people cope with their experience of depression. Within the school context, BA activities were shaped by institutional hierarchies, peer dynamics, academic and financial constraints, with adolescents flexibly adapting plans in response to competing demands or constraints. Such adaptations preserved engagement and reinforced self-efficacy. Overall, BA appeared beneficial for adolescents by reducing avoidance and re-establishing routine and promoting meaningful activity, leading to clinically significant change [51].

Adolescents described PS as empowering, echoing qualitative reports from YouFB users who expressed hope and optimism after PS training [34]. Problem solving was well matched to the concrete, ongoing stressors driving depressive symptoms, including financial insecurity, family conflict, peer tension, and school-related challenges. Importantly, the sequencing of Y-MIND sessions—with BA preceding PS—appeared clinically advantageous. BA likely enhanced routine, motivation, and mood, creating a foundation for effective problem-solving [107, 108]. At the onset, the adolescents struggled to define problems narrowly, reflecting developmental limitations and the cognitive burden of depression. However, once mood and motivation improved through the introduction of BA in the second session, PS became increasingly manageable and empowering. Notably, Participants A and C reported having “no problems” by session four, suggesting that symptom improvement itself reduced problem salience. The use of hypothetical characters (Awe and Anuwe) to practise PS in these moments helped consolidate skills despite the absence of immediate personal stressors. These findings align with evidence that BA is a key active ingredient for youth depression and that PS is most effective when delivered as part of a multicomponent intervention [36, 81, 96, 107, 108].

Adolescents’ responses to homework assignments, the relapse prevention and programme completion components further highlight Y-MIND’s developmental and cultural fit. Homework assignments, supported by structured worksheets and between-session activities, were well received and facilitated engagement across cases. Participant A remarked, “The homework is helping you become so engaged it makes you happy,” and all adolescents except one completed homework regularly. This pattern indicates that homework may be both feasible and acceptable, serving as a key mechanism for reinforcing skills beyond the therapy sessions. Homework is a standard component of CBT-based interventions in Ghanaian mental health practice and has been implemented in similar research work [109].

By the final session, participants were able to identify personalised triggers, early warning signs, and corresponding coping strategies (e.g., linking family tension and peer conflict to overthinking and appetite changes), reflecting improved emotional insight and self-monitoring. This is consistent with evidence that relapse-prevention strategies strengthen metacognitive awareness and long-term symptom management among adolescents [110]. The certificate of achievement presented at the end of the intervention seemed to function as a powerful motivational and psychosocial reinforcement. Participant C’s description of the certificate as “proof” of success underscores the importance of recognition, mastery, and identity formation in adolescence [111]. In contexts such as Ghana where mental health difficulties carry substantial stigma, such tangible markers of progress may also strengthen self-efficacy and support positive recovery narratives [112]. Culturally, the certificate aligned with Ghanaian norms that value accomplishment, social credibility, and communal acknowledgment of growth [113, 114].

Altogether, the Y-MIND treatment based on psychoeducation, BA, PS and relapse prevention theoretical framework seemed safe to implement, with the potential to support depressive symptom reduction. Our findings align with the global evidence on active ingredients that can treat depression among youths [81]. Consistent with this observation, the qualitative data showed that acceptability of the Y-MIND content was generally high and the adolescents requested for minimal to no changes. However, the clinician identified a number of potential barriers that warranted attention. These challenges included, the adolescents negative affect, limitations in the manual and worksheets, sudden gains and the need to strengthen the use of cultural values and norms.

Findings from these individual cases offered some concrete guidance on addressing these challenges, refining the Y-MIND manual and preparing it for delivery by non-specialists within the school system. Key considerations for working with depressed adolescents in this context, included preserving culturally resonant Y-MIND elements—such as narrative-based psychoeducation, values linked to social contribution, and certificates of completion—which were consistently experienced as motivating and stigma-reducing. Other considerations included emphasising confidentiality and a strong working alliance (Participants A-D), flexibility in delivery while keeping with Y-MIND goals and strategies (e.g., as seen when Participants A and B practiced PS via hypothetical scenarios), addressing language barriers through simplification (as evident in the case of Participant D).

Leveraging cultural norms and values relevant to healing via further adaptation was key [103, 115, 116]. Participants A, B, and C demonstrated that a sense of respect and responsibility towards family and religious faith served as a protective mechanism against suicidal ideation. Participants. Notably, respect and responsibility is reciprocal in this context (as demonstrated by Participant B, who consistently showed concern for the clinician’s comfort), reflecting Ghanaian relationship dynamics, including adult-child relationships [114, 117]. Mirroring this reciprocity in Y-MIND was therefore key. Consistent with previous work by Jordan and colleagues [118], the goal is simplification so that teachers can deliver it, and iterative cultural adaptation so that it is relevant to the target population.

To our knowledge, this is the first case series of a six-session psychosocial intervention for treating depression among adolescents in Ghana. Despite the known high risk for depression, no psychosocial intervention has been evaluated in this population, nor have any been delivered within the Ghana school system. A strength of this work is that the majority of participants completed the sessions within a six-week period and showed a trend suggestive of reduction in symptoms of depression. Further, the results have led to an improved version of the Y-MIND intervention, which has enhanced features including enhanced counsellor skills prompts, local terminology, visuals and metaphors and improved considerations for training and intervention setting.

Despite the strengths of this case series, we note several limitations. First, a case series design is inherently limited by its small sample size and the absence of a control group, thus no causal inferences can be made at this stage. Second, males were underrepresented in this sample; the majority of the participants and all who completed the six sessions were female. Whilst establishing external validity is not a realistic expectation of a case-series design, we recognize this as a potential limitation in terms of understanding the appropriateness of our Y-MIND prototype intervention for male adolescents. Specifically, this underrepresentation of boys may reflect gender norms that discourage help-seeking among male adolescents, often due to stigma and expectations around emotional stoicism [119, 120]. This could pose challenges for scaling the intervention, particularly in recruiting and retaining boys in school-based mental health programs. Future adaptations should include gender-sensitive outreach approaches and training to ensure inclusivity and engagement across genders [121]. Third, we acknowledge that placebo and expectancy effects such as a participant’s, expectation of improvement may have influenced reports of symptom reduction [122, 123]. Particularly because the interventionist was a highly experienced clinician who evidenced high patient engagement, a strong therapeutic alliance and responsiveness to the use of advanced counselling techniques. The clinician’s own allegiance bias may have influenced how the intervention was delivered. While these factors highlight the potential benefits of expert delivery, they also underscore the need for caution when generalizing these findings to other contexts, such as the planned delivery of Y-MIND by lay providers in real-world settings, which may yield different results. To address this, we have emphasized the need for: (1) comprehensive training with a simplified, improved culturally adapted version of the manual that includes sufficient prompts for use of counselling skills (2) ongoing weekly supervision with the clinical team to ensure support and quality assurance, and (3) fidelity monitoring through session checklists, audio recording and structured feedback forms. These considerations are central to the next phase of the Y-MIND project, which involves piloting the intervention with non-specialists in school settings to assess scalability and fidelity.

Conclusion

Y-MIND aligns well with Ghana’s adolescent health policy and the WHO Special Initiative on mental health, which aim to improve access to care [103]. Our development case series illustrates the potential of a six session psychological treatment to support symptom reduction for depression among senior high students in Ghana. The Y-MIND intervention was delivered as intended, was acceptable to participants, and was not associated with worsening of symptoms. These preliminary findings support further piloting of the intervention with non-specialist providers to assess feasibility, fidelity, and clinical outcomes in a larger sample.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Authors’ contributions

DAA contributed to conceptualization of the paper, methodology, contributed to writing/editing and final reviewing of the paper. KSA prepared the first draft, contributed to the conceptualization of the paper, methodology, writing/editing multiple drafts and final reviewing of the paper. SB analyzed and interpreted the data. FA managed the administrative aspects of the research as well as data analysis. ED and CA collected data and analysed the data. LO collected data and contributed to reviewing the paper. RJ managed the administrative aspects of the research and contributed to the methodology. RA supervised data collection and contributed to reviewing the paper. FG & DC contributed to conceptualization and methodology. PS, TB and MA contributed to conceptualization, methodology, the writing/editing and reviewing drafts of the paper. BW contributed to supervision, conceptualization, methodology, the writing/editing and reviewing drafts of the paper. All authors reviewed and approved the final version of the manuscript.

Funding

This paper represents independent research funded by the National Institute for Health and Care Research (NIHR) (NIHR133384). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study implemented in compliance with the ethical principles outlined in the Declaration of Helsinki, and the ethical guidelines of the following ethics review boards: The Navrongo Health Research Centre Institutional Review Board (Ref.App/Youth-in-Mind/09/2022/Approval #: NHRCIRB480); Ghana Health Service Ethics Review Committee (GHS-ERC: 027/10/23); and the Kings College London, Health Faculties (Purple) Research Ethics Subcommittee (RESM-23/24– 40,071). Participants provided written consent/thumb printed as proof of consent. For students under 18 years, a parent/a legal guardian provided informed consent while the student provided assent by signing/thumb printing an informed consent form if they agreed to participate in the study.

Consent for publication

Participants provided written consent for publication, as part of the informed consent process.

Competing interests

The authors declare no competing interests.