Adolescence is a formative period in which foundational social and emotional habits are shaped, which inform health and well-being throughout the life course. It is a time of pronounced transition—physiologically, socially, and emotionally. Several lifelong risk factors put children and adolescents at risk for mental disorders, including but not limited to nutritional status; caregivers’ physical and mental health; exposure to violence, armed conflict, and war; natural disasters; and gender disparities.1 When one or more of these factors coalesce, adolescents become vulnerable to poor mental health outcomes.2 Globally, one in seven adolescents experiences mental health conditions, which often go undiagnosed and untreated.3 This is of urgent concern in low- and middle-income countries (LMICs), where resources to detect and treat mental health concerns among children and adolescents are limited.1
RISK-TAKING BEHAVIOR AND MENTAL HEALTH
Poor mental health has broad-reaching effects, in both the immediate and the long term. Directly relevant to the findings of Ssewamala et al., published in this issue of AJPH (p. 306), is the link between mental health and HIV risk-taking behavior. Specifically, poor mental health conditions can lead to increased risk-taking behavior, including early sexual activity, resulting in higher risk for HIV and other sexually transmitted infections and unwanted pregnancy.1 Youths often seek out risk-taking behaviors to cope with emotional difficulties. For example, research by Brown et al. highlights that adolescents with a major depressive disorder struggle with self-esteem and assertiveness, which are critical for supporting safer sex practices.4 Therefore, providing youths with appropriate and safe coping mechanisms and skills to regulate emotions and build resilience for overcoming adversity is needed to improve youths’ mental health, reproductive health, and other health concerns.2
ECONOMIC EMPOWERMENT AND MENTAL HEALTH
In LMICs, poverty can have detrimental effects on social and emotional development in children.5 Financial insecurity directly affects life decisions at the household level, which in turn affect health. Often, limited household income puts parents under pressure to choose between meeting the needs of sons versus the needs of daughters. Preference for sons over daughters is widespread globally, particularly in Asia and North Africa. A review of data from 66 developing countries found that preference given to sons disproportionally affects children of disadvantaged backgrounds, such as rural and poor families.6 As a result of prioritizing sons’ needs, daughters tend to experience poorer health and development outcomes, such as malnutrition and dropping out of school, where they could have gained critical information about sexual health, HIV, and other health issues as well as the interpersonal and communication skills needed to negotiate in health decision-making. Out-of-school girls are also more likely to engage in risk-taking activities, such as transactional and unprotected sex, to either meet immediate financial needs or increase their social and economic status.7
To address these risks, conditional cash transfers are an example of a programmatic approach that seeks to improve financial security and, in doing so, can improve health and education outcomes. Such programs provide cash to families if they follow certain requirements, which allows families to meet immediate household needs and encourages them to invest in their children’s health and development.8 Oportunidades, implemented in Mexico, is one of the first conditional cash transfer programs and serves as a global model.9 Cash is provided to the female head of household, conditional on children attending school and the family taking part in preventive health education talks. A randomized control trial of Oportunidades demonstrated reduced socioemotional problems in children aged 8 to 10 years and reduced behavioral problems. Thus, receiving cash reduces economic stress on the household and improves parental mental health and family relationships, directly affecting the mental health outcomes of children and adolescents.9 Furthermore, a systematic review by Klasen and Crombag indicates that parental training and engagement is promising for addressing behavioral disorders in LMICs.10
INTERVENTION
Acknowledging the importance of economic security is the foundation for the intervention of Ssewamala et al., which aims to reduce HIV risk-taking and improve mental health in Uganda. The authors investigated the effect of an economic empowerment intervention on HIV risk behaviors and mental health among school-going adolescent girls. Although the intervention did not have significant effects on HIV risk behaviors, likely because of the young age of the participants, it significantly improved mental health outcomes for participants. This work, importantly, provides a model that combines an economic intervention with family strengthening, which can be applied in LMIC contexts to improve youth mental health.
Ssewamala et al. tested two arms of the intervention. The first was Youth Development Accounts (YDAs), in which each participant was provided a savings account with matched one-to-one funding. The second arm of the intervention included YDAs plus Multiple Family Group, a 16-session intervention facilitated by parents and community health workers that aimed to strengthen family relationships. The Multiple Family Group sessions included children, caregivers, siblings, and extended family members such as aunts, uncles, and grandparents. Training addressed an array of topics, including health knowledge and behaviors, stigma and discrimination, building family strengths, problem-solving at home, and respectful communication.
To test the intervention, participants were randomized at the school level to one of three options: (1) standard health and sex education (control), (2) YDA, and (3) YDA plus Multiple Family Group. Although both interventions that went beyond the standard health and sex education witnessed significantly lower depressive symptoms and better self-concept among participants, the YDA plus Multiple Family Group participants had significantly lower hopelessness than did those in the control group. This suggests that an economic intervention combined with family strengthening is a promising approach for improving mental health among adolescent girls.
LEVELS OF THE SOCIOECOLOGICAL MODEL
The work of Ssewamala et al. establishes the importance of intervening at multiple levels of the socioecological model for maximum impact. For example, in the Uganda study, intervening at the individual level through YDAs significantly improved mental health; however, the intervention that included an additional component of family strengthening (i.e., interpersonal level) had a positive impact on hopelessness, which was not found in the YDA arm of the intervention. These findings suggest that adolescent mental health is influenced by a variety of factors and that improving family life in combination with economic security can significantly affect mental health outcomes and outlook on life.
Future interventions aiming to build on this work may consider multilevel interventions that intervene not only at the individual and family level but also at the organizational, community, and policy levels. One example of this is intervention through peer education at school as part of the national curriculum. Another approach is intervention through women’s groups and microfinance groups at the community level, which have demonstrated promise for addressing other complex health issues among youths such as malnutrition and child marriage.11,12 Finally, establishing a supportive policy environment that protects the rights of youths—such as child marriage laws—will help to ensure a fruitful living environment for healthy decision-making and improved health.
CONCLUSIONS
The findings of Ssewamala et al. highlight the importance of intervening at multiple levels. The intervention illuminates the critical link between economic status, family functioning, and mental health outcomes, which demonstrates potential for future scaling to improve adolescent health in LMICs.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.
Footnotes
See also Ssewamala et al., p. 306.
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