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Impact of School-Based Mental Health Programs in
Reducing Adolescent Depressive Disorder in Sub-Saharan
Africa: A Qualitative Systematic Literature Review
Bridget Nana Aa Addae
Birmingham City University
Natalie Quinn – Walker
Birmingham City University
Systematic Review
Keywords: mental health, school-based intervention, depression, adolescent, sub-Saharan Africa
Posted Date: May 16th, 2025
DOI: https://doi.org/10.21203/rs.3.rs-6378654/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License
Additional Declarations: No competing interests reported.
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Abstract
Aim: This study aimed to examine the impact of school-based interventions on depressive disorder in adolescents living
in sub-Saharan Africa (SSA).
Adolescents living in SSA are even more vulnerable due to cultural misunderstanding and superstition associated with
the condition, deprivation and poverty, increased burden of disease, and exposure to traumatic events such as
bereavement, violence, and child abuse. The inadequacies of the local health infrastructure also undermine the
population’s mental health. The weaknesses of the regional health infrastructure also undermine the population’s mental
health.
Methodology: This study adopted a qualitative systematic review approach based on secondary data and thematic
analysis to analyse the qualitative data collected.
Results: Eleven studies were included in the sample, which represented six countries: Kenya (4), Nigeria (3), Burundi (1),
Uganda (1), South Africa (1), and Rwanda (1).
These ndings reiterate the need for more studies exploring mental health treatments and interventions in SSA. All the
studies reported improvements in the mental health outcomes of participants, and only one study recommended
avoiding school-based interventions for depressive disorders linked to bereavement. Interventions were effective in
increasing reach and providing resources for task shifting. Many researchers have used teachers and other adolescents
as lay providers, adapted interventions to the local context, and praised the eciency of brief interventions.
Introduction
Depressive disorder (commonly referred to as depression) is a global public health issue, but it represents an even more
signicant threat to adolescents in sub-Saharan Africa. Depressive disorders are complex mental disorders that threaten
psychological and physical well-being. Common symptoms experienced by patients include depressive moods
(sadness, emotional emptiness, among others), a lack of interest in pleasurable or daily activities, fatigue, and
insomnia1, 2. These emotional symptoms impair the individual's daily functioning, increasing the individual's daily
functioning and increasing the risk of other issues. The WHO3 estimates that, globally, approximately 280million
individuals suffer from this disorder, with specic subsets of the population having a higher risk than others.
Adolescents are, however, exposed to this mental health issue, with a prevalence rate of more than 30% four compared
with the 5% reported among adults.
Adolescence (ages 10–19, according to UNICEF6 is a critical stage of development. The link between suicide and
depressive disorders and the observed increasing prevalence of adolescent suicide7, 8. Others have reported that the
prevalence of depressive disorder in adolescents has risen sharply over the past decade, with the global prevalence
reaching 34% in 20221, 9. The intensity of reported symptoms was further noted, increasing the disease in adolescents4.
The biological changes during puberty can create opportunities for emotional stress as the individual adapts to the
psychological and cultural consequences. Hormonal changes may also impair an individual’s emotional and
psychological stability, increasing the risk of depression11.
Adolescents are often viewed as rebellious and immature while required to act ‘properly’ and mature12. The development
of frustration as an attempt to meet societal expectations is met with ridicule or dismissal can undermine self-esteem,
self-image, and self-condence, increasing the risk of depressive disorder7, 2, 13. Traumatic experiences, such as
maltreatment and abuse14, the loss of a loved one, bullying15, and relationship problems7, also increase the risk of
depressive disorders in adolescents16. The lack of personal resources and skills makes adolescents particularly
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vulnerable to deprivation, either due to parental neglect or familial poverty15, 17. A lack of life experience and coping
strategies can often cause these traumatic experiences and environments to have a more signicant than usual impact
on adolescents’ psyche18.
The risk factors identied above highlight the increased vulnerability of adolescents in sub-Saharan Africa (SSA). Studies
reported that Africa (along with the Middle East and Asia) had the highest prevalence of adolescent depressive
disorder4, 18. This observation is predicted by SSA's relatively more signicant presence of risk factors. A target of SDG 1
is to “end all poverty” Poverty and deprivation are severe in SSA19, 20, resulting in inadequate health infrastructure and
public health investments. Both outcomes increase the rate of mortality, and the burden of disease increases the
susceptibility of the populace to depressive disorders21–24. Additionally, social stigma towards mood disorders is
common across SSA. This contributes to bullying, superstition, and seeking alternative non-health treatments, which
obstructs access to proper healthcare for Nigerian adolescents25–27. The stigma, along with other factors previously
mentioned, results in severe underdiagnoses and underreporting of depressive disorders in SSA28.
Depressive disorders are connected to the development of other disorders (including anxiety and eating disorders) and
an increased risk of suicide7, 30, 8. Additionally, symptoms may disrupt adolescents’ ability to focus on school31, resulting
in low grades, absenteeism, and a high risk of dropout32. This condition is also linked with withdrawal from social
activities, low self-esteem, and an increased risk of bullying and being bullied33. This condition has also been linked to
an increase in risky behaviour in adolescents34 and poor socioeconomic and mental health outcomes in adulthood35.
The condition produces signicant distress in the individual and can recur in episodes with increasing intensity29, 4.
Critical Analysis of the Current Debate
Despite the dearth of studies, there is a debate on the most appropriate strategies for delivering depressive disorder
treatment to adolescents. The discussion does not concern treatments for depressive disorders since they are effective
in other regions36. However, methods for providing these treatments could affect their effectiveness and accessibility37.
The limitations in available health resources mean that most adolescents are not in contact with the local healthcare
system and that treatment deliveries must leverage other systems 38, 39. The existing healthcare systems in Africa are
generally underfunded and overcrowded, with insucient personnel and resources40, 41. Attempts at extending the
system’s responsibilities might be counterproductive and bogged with ineciencies.
Consequently, delivery methods for SSA adolescents cannot depend on the already overburdened existing healthcare
system while remaining affordable and increasing coverage. One such method employs electronic and digital
technologies to provide mental health treatment and support for patients42. These programs have been deemed
successful at providing treatment and increasing accessibility to mental healthcare at a cost that is associated with
fewer face-to-face deliveries. However, it is inequitable, with programs lacking coordination, integration, and scalability43.
Inequitable internet access, poor digital literacy, scepticism, and recidivism limit the eciency of depressive disorder
intervention programs 44, 45.
In contrast, school-based intervention programs are more effective at increasing accessibility, treatment, and cost-
effectiveness. Equipped with the necessary information, teachers can represent an effective screening and monitoring
system to detect and recommend mental healthcare for potentially depressive students29, 46. School-based programs
are also cost-effective, as they can employ teachers and existing school counsellors to provide the necessary diagnosis
and treatment for depressive disorders. Inequalities are also less common, as more adolescents are registered in
schools than can access the internet47. Relationship bonds formed among students can also encourage participation in
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and completion of treatment and prevention programs48. Adolescents not enrolled in schools cannot be accessed via
the school-based approach.
Gaps in Knowledge
Several authors28, 35, 43 have observed the need for more studies into adolescent depressive disorder in the SSA context.
While a few primary studies29, 47 examining the impact of school-based depressive disorder interventions on
adolescents’ mental health exist, a compilation of such ndings could guide future research. Compared with other
regions, the SSA region is extensive but contains few studies that address the nuance and diversity of its populations.
More studies on depressive disorders within this context will further guide policy development and the modication of
treatment strategies to t local needs. Due to potential bias, current research has primarily underserved mainly girls in
the study population. Gold observed that adolescent girls were more vulnerable and exposed to a higher number of risk
factors, including nancial insecurity, unwanted pregnancies, trauma, and sexual abuse8. However, the excessive focus
on these factors contributes to a publication bias that makes it dicult to identify other depression risk factors – like
sexuality and gender dysphoria – within the adolescent female population in SSA49. A summary of best practices for
executing and managing school-based intervention programs is also needed to inform future primary studies. Collated
ndings on challenges, the impact of cultural factors, local policies, and others that future studies would nd helpful to
guide their efforts50.
Depressive disorder prevalence rates among adolescents are higher than those among children and adults and are
steadily increasing4. The impacts of depressive disorders on the burden of disease, self-care, social relationships, and
suicide8, 17, 51 also emphasise the importance of the situation. The socioeconomic and cultural prole of SSA also
increases the risk of depressive disorders in adolescents living in the region 15 52 53. Collated ndings could guide future
researchers on potential study paths to pursue and information on best practices and challenges to guide intervention
production54. This study could also help unify denitions and perspectives regarding the lack of comparisons between
research ndings and national prevalence data. This study aimed to examine the impact of school-based intervention
programs on reducing adolescents’ depressive disorder in sub-Saharan Africa via a qualitative systematic review.
Methods
Systematic reviews (SRs) are a common and critical part of medical and clinical research. They represent an effective
tool for optimising previous research output by collating, comparing, and analysing previously discovered results to
identify consensus (or lack of consensus), present a summary of knowledge on a topic, compare the outcomes of
different strategies, and identify research gaps 55, 56. In medical research, systematic reviews constitute the gold
standard for establishing evidence-based practices and treatments, as their conclusions are based on various studies.
Still, the quality of these studies impacts the SR quality [57]. More specically, qualitative SRs (also called qualitative
evidence synthesis) focus on qualitative medical studies and results 58. The qualitative SR can provide much
information, including descriptions of interventions and their design, experiences of participants, valued outcomes,
reasons for adoption, rejection, and outcomes, and factors impacting the effectiveness of the
intervention/tool/treatment55, 59, 60. These functions are most appropriate for meeting the research objectives of this
study.
Aims and Objectives
This study aims to answer the question: “What is the impact of school-based mental health programs in reducing
adolescent depressive disorder in sub-Saharan Africa?” Using a systematic review, it collates the results of school-based
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interventions, evaluating their impact and the mechanism of effect on adolescents with depressive disorders. This
approach will also collate information on obstacles limiting the eciency of depressive disorder interventions in SSA
and facilitate the examination of attempted resolutions.
Aim
This study aimed to examine the impact of school-based intervention programs on reducing adolescents’ depressive
disorder in sub-Saharan Africa via a qualitative systematic review.
Objectives
1. To analyse the impact of school-based mental health programs in reducing depressive disorder in adolescents in
SSA
2. To identify best practices and effective strategies for implementing school-based mental health programs for
depressive disorder among adolescents in SSA.
3. To identify obstacles to the effectiveness of school-based mental health programs in reducing depressive disorder
in adolescents in SSA
4. To make recommendations to guide future research and policy design regarding adolescent depressive disorder
and school-based interventions in SSA.
Sub-Saharan Africa continues to labour towards development but is limited by inadequate data and resources. This
study attempts to mitigate the second limitation. Systematic reviews are popular because of their ability to produce new
insights from existing datasets54. The researcher aims to provide insights that will guide future research while providing
a practical summary of ndings to policymakers and other readers. The conclusions of this study are expected to guide
the design of future research, inform policymakers on the depressive disorder crisis among adolescents in SSA and the
effectiveness and limitations of school-based interventions, and present a practical summary for other readers.
Research Strategy
This study collected data by searching for studies on school-based depressive disorder interventions in the SSA region.
Studies will be found via search engines in three databases: PubMed, PsycInfo, and Zendy. PubMed is an extensive
database containing over 37million citations of biomedical and life sciences studies. The database is connected to the
American Psychology Association, increasing the credibility of the studies referenced on the website. PsychInfo is a
smaller database with 5million peer-reviewed records covering social sciences, business, law, medicine, and
neuroscience. Zendy is a database partnering with Emerald and other global publishers with access to 311 journals from
Africa. All three databases were chosen for their focus on medical studies, their connection to credible associations, and
the inclusion of only peer-reviewed works. The size of these databases will also increase the search eciency of the
studies and the quality of the studies available to make up the study sample.
The PEO framework is widely used in medical SR studies to identify a qualitative research topic's key concepts and guide
the literature review60, 61, 62 also Table1 below shows the application of the PEO framework to this study’s research
question.
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Table 1
Research title (PEO)
The impact of school-based mental health programs on reducing adolescent depressive disorder in sub-Saharan
Africa
Population Adolescents in SSA
Exposure School-based intervention for depressive disorder
Outcomes Changes in mental health condition
Search 1 (P): adolescents OR youth OR teenagers AND in Sub-Saharan Africa OR SSA.
Search 2 (E): School-based intervention for depressive disorder or depression
Search 3 (O): Changes in mental health status
Search 4: Search 1 AND Search 2 AND Search 3
Inclusion and Exclusion Criteria
The inclusion and exclusion criteria represent the standards that articles and journals must satisfy to be part of the
study’s sample and comply essential with the SR standards and preventing personal or group bias from inuencing the
sample composition63. Establishing the eligibility criteria before the sample is composed and documenting it is also
important and essential for ensuring transparency64. The eligibility criteria used for this study are presented in Table2.
Table 2
Eligibility criteria
Criteria Inclusion Exclusion
Population Adolescents (ages 10–19) in sub-Saharan
Africa Adults or children outside the 10–19 age
range
Setting School-based programs Community-based or home-based programs
Geographic
Location Countries within sub-Saharan Africa Countries outside sub-Saharan Africa
Type of
Intervention Mental health programs aimed at reducing
depression Programs targeting other mental health
issues (e.g., anxiety, PTSD) without focusing
on depression
Study Design Qualitative studies, case studies, reviews, or
meta-analyses Quantitative studies, including RCTs, cohort
studies, cross-sectional studies
Outcome
Measures Measures of depression reduction (e.g.,
standardised depression scales) and other
descriptive reports
Measures not related to depression (e.g.,
general well-being, anxiety)
Publication
Date 2014–2024 Pre 2014
Language Studies published in English Studies not published in English
Full-text
Availability Full-text articles available Abstract-only or inaccessible full texts
Peer-reviewed Peer-reviewed journal articles Non-peer-reviewed articles, grey literature
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The eligibility criterion was chosen carefully to ensure that the studies in the sample all contributed positively to the
study’s completion. The focus on adolescents aligns with the study subject and eliminates the effects of confusing
factors relevant to other populations. The same reasoning applies to SSA, the type of intervention, and the school
setting. Additionally, the limitation of the study designs follows the qualitative SR, and the preference for qualitative data
has been explained in the previous subsections. The limitation of results linked to depression outcomes allows the study
to focus on its aims and full its research objectives. Limiting the SR sample studies from 2014–2024 ensures that the
results are not outdated or too old to reect current conditions. Engaging only peer-reviewed studies published in
English with full texts ensures that the SR uses credible and high-quality data and can be reviewed.
Each data entry is properly labelled to ensure that its source is clearly dened. The research questions will guide the
data collection, providing an organised system for the author. The author rst organises the extracted data.
Quality Assessment Tool
The quality assessment phase is critical for ensuring the accuracy and reliability of the data included in the SR. Since the
quality of SRs depends on the data used to compose their sample, quality assessment is essential in producing valuable
material (57, 82 Moore et al., 2022). This study adopts the JBI65 Checklist for Qualitative Research (2020) created by the
Joanna Briggs Institute for evaluating qualitative systematic reviews. The JBI was chosen because of its specialization
for qualitative studies and because the tool has been designed and peer-reviewed by a reputable organization65, 66.
Munn added that the tool was specically designed for medical research and includes 10 questions to determine
internal validity, risk of bias, selection and information bias, and clear/complete reporting55. This critical/quality
evaluation tool ensures that the included studies are of acceptable quality and that their aws are not considered during
the analysis process.
Method of Synthesis: Thematic Analysis
The thematic analysis is a qualitative research tool used to analyse and synthesise data collected from the SR sample.
The thematic analysis is used to identify and categorise the themes and patterns that exist in the data sample67. This
tool allows the researcher to identify and organise the meanings, compare ndings, and develop further insights from
the patterns identied in the dataset68. The standard structure for the thematic process involves familiarisation, coding,
theme development, and data interpretation68–71. The familiarisation process involves reading, understanding, and
conversing requires with collected data. This process will require multiple and thorough readings to ensure no
information is later misconstrued or forgotten.or misunderstanding information
RESULTS
The search strategy identied 530 papers from three databases—PubMed, PsycInfo, and Zendy. While PubMed and
PsychInfo had more modest registers, Zendy's search engine was more liberal and included registers that even had one
of the search terms. In addition to the database search, eight papers were also found from other sources, such as
systematic reviews. Ten studies were deemed t for inclusion in the review sample after removing duplicates and
screening abstracts and entire documents. The screening process follows the PRISMA model and is described in the
ow chart in Fig.1. The characteristics of the studies are also presented in Table2.While all the included studies were
based on interventions presented in the school setting, the studies involved a variety of national backgrounds and
covered a variety of treatment approaches. Categorising the studies by nationality reveals that Kenya was the most
represented country, with four studies72–74, followed by Nigeria, with three studies75–77. Other countries represented in
the sample included Burundi78, Rwanda79, South Africa80, and Uganda50.
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The studies cover many traditional intervention treatments, but some have used interventions adapted or uniquely
developed for the local culture. Two studies75, 76 employed conventional cognitive behavioural therapy (CBT), one
study78 used classroom-based intervention (CBI), one study72 adopted the nancial support approach, and two others50,
77 used training in resilience-based life skills and peer support activities to treat adolescent depression. Another
common intervention was the writing sessions used by two studies79, and one study74 adopted a similar but unique
intervention called the pretexts (or arts literacy) intervention. The unique localised interventions include ‘
Shamiri’
intervention—a localised treatment developed with a Swahili theme to build resilience—which was selected by two
studies 73 83 and Abangane—a blend of resilience-based training using indigenous stories and CBT components using
the isiZulu cultural theme—which was used by one study80.
Other essential characteristics of the studies include the issue examined, the age range of the sample, and the use of lay
providers. A majority of studies50, 73, 77–81 have examined other issues along with depression, usually anxiety. Only three
studies focused exclusively on depression. Additionally, the use of lay providers was a common factor among the
sample, which used teachers75 or high school graduates73, 74 or social workers80. The other studies were not clear about
the use of mental health professionals alone, but Bella-Awusah et al.76 suggested that the authors themselves provide
interventions. The sample ages were usually within the denitions of the WHO (10–19), except in the cases of study 72,
who reported ages 13–22 years, and another78, who reported ages 8–17 years. Finally, the studies were all of high
quality based on the JBI qualitative assessment tool. All the studies scored positive on nine of the ten questions. The
only varied metric was the researchers’ inuence on the research and vice versa. This metric is critical because specic
internal and external sources of bias could skew the researcher’s conclusions, especially qualitative assessments.
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Table 4.1
Data extraction
Author/Year
/Country
Study design Study aim/
Intervention
Participants Data Collection
method Key Findings
1. Are et al., 2022
Nigeria
Controlled
clinical trial Evaluating a
teacher-
delivered
Cognitive
Behavioural
Therapy (CBT)
programme for
depressed
adolescents in
Nigeria.
Five weekly
sessions of
manulised
group-based
CBT delivered
by two
teachers and
supervised by a
psychiatrist
40
adolescents
(13–18
years) with
clinically
diagnosed
depressive
disorder
Benck
Depression
inventory scores
before the
intervention and
in the 6th week
Controlling for
baseline BDI score,
the intervention
group had
signicantly lower
post intervention
depressive
symptoms (Means:
4.60 vs. 17.05; t =
4.13; p = 0.0001, F(1,
39) = 16.76, p =
0.0001, Effect Size
(Cohen’s d) = 1.3 g.
Eighty-percent of
the intervention
group achieved
remission
compared with only
15.8% of the
controls (p <
0.0001).
2. Bella-Awusah
et al., 2016
Nigeria
Nonrandomized
controlled trial Evaluating the
impact of
school-based
CBT program
on depressed
adolescents in
south‒west
Nigeria
Impact was
measured by
changes in BDI
score to
determine the
primary
outcome. Two
questionnaires
(the Short
Mood and
Feelings
Questionnaire
(SMFQ) and
the Impact
Supplement of
the Strengths
and Diculties
Questionnaire
(SDQ)) were
used to
determine the
secondary
outcome.
40
adolescents
(14–17),
scoring 18
and above
on the BDI,
were
recruited
from two
schools.
Benck
Depression
Inventory (BDI)
measures
Short Mood
and Feelings
Questionnaire;
and the Impact
Supplement of
the Strengths
and Diculties
Questionnaire
Controlling for
baseline scores and
other confounders,
the intervention
group had
signicantly lower
depressive
symptoms scores
on the BDI and
SMFQ one week
post-intervention,
with large effect
sizes. The
intervention group
maintained the
treatment effect,
with signicantly
lower depression
scores 16 weeks
post-intervention
compared with their
baseline scores.
The effect sizes
remained large. The
intervention and
control groups did
not differ in their
SDQ impact
supplement scores
post intervention,
but the intervention
group improved
signicantly on this
measure at 16
weeks.
3. Green et al.,
2019 4-year
experimental To determine if
a school 410
adolescent Five items from
a self-reported The intervention
prevented increase
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Author/Year
/Country
Study design Study aim/
Intervention
Participants Data Collection
method Key Findings
Kenya longitudinal
study support
intervention for
adolescent
orphans in
Kenya had
effects on
mental health,
a secondary
outcome.
orphans
(ages 13–
22) (and
425 control)
beneted
from school
support
Intervention
involved
direct
payments
for school
tuition,
uniforms,
and nurse
visits
screening
instrument (20-
item Center for
Epidemiologic
Studies
Depression
Scale, Revised)
in severity scores in
the intervention
group.
There was no
evidence of
treatment
heterogeneity by
gender or baseline
depression status.
Intervention effect
was partly mediated
by higher levels of
continuous school
enrolment.
4. McMullen &
McMullen, 2018
Uganda
Cluster
controlled
experiment
To determine if
a school-based,
teacher-led, life
skills-focused,
and
manualised
intervention
was effective in
increasing self-
ecacy,
reducing
internalizing
problems,
promoting
prosocial
behaviour, and
developing a
sense of
connectedness
among
secondary
school
students in
Uganda
Intervention
plan involved
24 lesson
plans designed
to promote
mental health
and resilience,
development
communication
skills, and
teach coping
life skills
620
students
(13–18),
170 of
these
completed
the
posttest.
Pre- and posttest
measures for
General Self-
Ecacy Scale
(GES) for self-
ecacy; African
Youth
Psychosocial
Assessment
Instrument
(AYPA)
measures
depression and
anxiety-like
symptoms;
Hemingway
Measure of
Adolescent
Connectedness
(MAC-5)
ANCOVA showed
the intervention
group had a
signicant increase
in self-ecacy
F(1,167) = 20.10, p
< .001, η2 = 0.107,
signicant
reductions in
internalising
problems
(depression/anxiety-
like symptoms),
F(1,167) = 11.14, p
= .001, η2 = 0.063,
and an increase in
overall
‘Connectedness’
F(1,167) = 15.00, p
< .001, η2 = 0.082,
compared to the
control group.
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Author/Year
/Country
Study design Study aim/
Intervention
Participants Data Collection
method Key Findings
5. Olowokere &
Okanlawon, 2018
Nigeria
Comparative
prospective
#design
To compares
the
effectiveness
of resilience-
based training
and peer-
support
activities were
compared in
339 vulnerable
children
selected from
public high
schools.
339
vulnerable
children
(11 = 15)
selected
from public
high
schools
Depression scale
was adapted
from Center for
Epidemiological
Studies
Depression scale
for Children;
Anxiety was
measured by an
adapted
Spence’s scale
and Rosenberg
self-esteem and
self-developed
social
connection
scale.
Both interventions
had similar positive
effects on
depression and
social connection;
but resilience-based
training produced
better outcomes
from anxiety.
6. Osborn et al.,
2023
Kenya
Randomized
controlled trial Developed and
tested Pre-
Texts, an arts-
literacy
intervention
that targets
depression and
anxiety for
adolescents in
Kenya.
Participants
went through
the Pre-Text
program (daily
1 hour
sessions for a
week). The
group
treatment was
facilitated by
high school
graduates
trained as lay
providers. The
control group
were assigned
a study skill.
235 high
school
students
(13–19)
The PHQ-8
(Patient Health
Questionnaire)
was used to
collect data on
depression at
pretest and 1-
month follow-up
Pre-Texts produced
a greater reduction
in depression (d =
0.52, 95% CI [0.19,
0.84]) and anxiety
(d = 0.51, 95% CI
[0.20, 0.81])
symptoms from
baseline to 1-month
follow-up compared
to the control group.
Similarly, in a
subsample of
participants with
elevated depression
and anxiety
symptoms, Pre-
Texts produced a
greater reduction in
depression (d =
1.10, 95% CI [0.46,
1.75]) and anxiety
(d = 0.54, 95% CI [−
0.07, 1.45])
symptoms.
7. Osborn et al.
2020
Kenya
Randomized
controlled trial Testing the
impact of a
nonclinical,
brief
intervention
(the Shamiri
‘
thrive’
intervention)
on clinically
elevated
depression
and/or anxiety
symptoms.
Intervention
group is
420 Kenyan
adolescents
(13–18)
The PHQ-8
(Patient Health
Questionnaire)
was used to
measure
depression at
pretest, 2-week
into the
intervention, at
end of
intervention, and
2-week follow-up
Results may
suggest that a brief,
lay-provider
delivered, school-
based intervention
may reduce
depression and
anxiety symptoms,
improving academic
outcomes and other
psychosocial
outcomes in
adolescents with
clinically elevated
symptoms in sub-
Saharan Africa
Page 12/24
Author/Year
/Country
Study design Study aim/
Intervention
Participants Data Collection
method Key Findings
provided 4-
week Shamiri
intervention
while the
control group
gets a study
skill
intervention of
equal duration.
8. Osborn et al.,
2019
Kenya
Randomized
controlled trial Developed and
tested an
intervention
targeting
Kenyan
adolescent
depression and
anxiety.
‘Shamiri
Wellness
Program’
targeted
developing
growth
mindset,
gratitude, and
value
armation
exercises in
participants.
Intervention
was provided
by high school
graduates (17–
21)
The control
group were
assigned study
skill training
such as
reading and
note-taking.
51 Kenyan
adolescents
(14–17)
PHQ-9 (Patient
Health
Questionnaire)
used to measure
depression;
GAD-7 measures
anxiety;
Multidimensional
Scale of
Perceived Social
Support for
social support;
Perceived
Control Scale for
Children to
determine
beliefs about
personal control;
academic
performance and
attendance; and
feedback survey
Shamiri group
experienced a larger
drop in depression
and anxiety
symptoms from the
baseline to 4-week
follow = up,
compared to the
control group.
9. Thurman et al.
2017
South Africa
Randomized
control trial To assess the
effects of an
eight-session
support group
intervention on
the
psychological
health of
bereaved
female
adolescents in
South Africa
The
intervention,
Abangane
(“friends” in
isiZulu), is a
locally derived,
Two
hundred
twenty-six
female
students
(13–17)
from 9th
grade were
assigned to
the
intervention
and 227 to
the wait list
control.
Three scales
measure grief.
Depression
symptoms in the
past 7 days were
measured with
the Center for
Epidemiological
Studies–
Depression
Scale for
Children.
At follow up, the
intervention group
had signicantly
lower scores for
primary outcomes,
including intrusive
grief (p = 0·000,
Cohen’s d= − 0·21),
complicated grief
(p = 0·015, d=–0·14),
and depression (p =
0·009, d=–0·21)
relative to the
waitlisted group,
while core
bereavement scores
were similar
between groups (p
= 0·269). Caregivers
Page 13/24
Author/Year
/Country
Study design Study aim/
Intervention
Participants Data Collection
method Key Findings
curriculum-
based support
group focused
on coping with
loss
incorporating
indigenous
stories and
cognitive
behavioural
therapy
components.
Weekly group
sessions were
facilitated by
trained social
workers or
social auxiliary
workers from a
local nonprot
organisation
in the intervention
group reported
lower levels of
behavioural
problems among
adolescents (p =
0·017, d=–0·31).
10. Tol et al.,
2014
Burundi
Cluster
Randomized
Trial
Evaluate the
effectiveness
of a school-
based
intervention
aimed at
reducing
symptoms of
posttraumatic
stress disorder,
depression,
and anxiety
(treatment
aim); and
improving a
sense of hope
and functioning
(preventive
aim).
CBI program
involved 15
sessions
implemented
over 5 weeks.
329
children (8–
17; mean
12)
Depressive
symptoms were
assessed using
the Depression
Self-Rating
Scale.
Other scales
were used for
PTSD, sense of
hope, and
functioning
Burundi. The
intervention was
aimed both at the
reduction of PTSD,
depressive, and
anxiety symptoms
(treatment aim,
primary outcomes),
as well as the
improvement of
hope and
functioning
(preventive aim,
secondary
outcomes).
The study did not
nd any main
effects on the
primary and
secondary outcome
measures, that is,
for either the
treatment or
preventive aims.
11.
Unterhitzenberger
& Rosner, 2014
Rwanda
Controlled
clinical trials Examining the
effect of a
school-based
unstructured
emotional
writing
intervention
(
sensu
Pennebaker
,
group 1) about
the loss of a
parent to
reduce
adaptation
problems to
loss, compared
to writing about
69 orphans
(aged 14–
18) divided
into three
groups of
23
Before and after
the intervention,
subjects
completed the
“Prolonged Grief
Questionnaire
for Adolescents
and the Mini
International
Neuropsychiatric
Interview for
Children and
Adolescents,
part A” for self-
report
depression.
Repeated measures
analyses of variance
showed no
differential effect
for any of the three
conditions but
revealed a
signicant effect of
time at post-test
regarding grief
severity.
Reduction of grief
symptoms was
signicantly higher
in subjects with
elevated grief.
Page 14/24
Author/Year
/Country
Study design Study aim/
Intervention
Participants Data Collection
method Key Findings
a hobby (group
2), and non-
writing (group
3).
Depressive
symptoms showed
no signicant
change from pre- to
post-test in the
emotional writing
condition, whereas
they signicantly
decreased in the
control condition.
NB: Due to this study’s aims, all the studies in the SR sample were performed in a school setting.
CONCLUSION
The aim of this study was to determine the impact of school-based mental health interventions in reducing adolescent
depressive disorder in sub-Saharan Africa via a qualitative systematic review. This study’s purpose and objectives
include compiling ndings made by the authors and managers of school-based intervention projects. All the studies
reported being the only study “to the extent of their knowledge” to examine their particular intervention in the school
setting. Their reports align with the experience of this researcher, as intervention studies within sub-Saharan Africa were
few and far in between. This absence is in stark contrast to the increased prevalence of depressive disorders among
SSA adolescents and the increased exposure to risk factors8. The limited number of studies could be explained by
several factors including limited resources and the social obstacles connected with mental health issues. Comparatively,
insucient resources are the main obstacle to any kind of research in SSA. The region is already generally impoverished
resulting in inadequate educational infrastructure, technological limitations, and insucient funding for research efforts.
Despite representing 15% of the world’s population, the African continent only reported 1.1% of global health
investments in research and development in 2016 – with Egypt, Nigeria, and South Africa accounting for 65% of the
investments83. Due to the lack of local funding, researchers in SSA have to depend on external funding such as research
grants from international institutions. External funding is, however, not dependable as the application process is very
time-consuming, highly competitive with very restrictive criteria84. Furthermore, mental health research is severely
underprioritized in the region85. All these factors, along with having fewer researchers per capita86, mean that research
publications in the region would be scarce. The lower concentration of researchers is also linked to lower investment in
education and research and the current brain drain is further exacerbating the issue87. In addition, the social stigma
associated with mental health issues may represent further obstacles to research. Several studies including those from
the literature review have highlighted the intense stigma associated with mental issues and its negative impact
diagnosis and health-seeking behaviour25, 27, 28, 73. This obstacle may manifest in a bias limiting research interest and
funding for mental health research. It is, however, more evidenced in the reduced participation as parents and guardians
are less likely to permit their wards to avoid the associated shame – and several studies in the sample took steps to
remedy it76, 80, 81. This phenomenon represents a social obstacle to mental health research that may explain the dearth
of studies on this topic.
Nearly all the studies reported positive outcomes when schools were adopted as the setting for delivering depressive
disorder interventions for adolescents. While even the studies exploring novel or adapted treatment methods reported
positive outcomes, two studies reported somewhat negative conclusions. Two studies78, 79 reported statistically
insignicant improvements in mental health outcomes. While Unterhitzenberger and Rosner79 blamed the effectiveness
of their intervention methods (unstructured writing) and their effectiveness at preparing the participants, Tol et al.78
Page 15/24
concluded that the school setting might not be appropriate for handling depressive disorders that are connected to
bereavement and PTSD. In contrast, all the other authors had glowed praise for the opportunities created by the
educational institution for reaching vulnerable children. The studies reporting positive outcomes were able to determine
that school-based interventions contributed to the positive results acquired. These include improvements in depressive
symptoms and general well-being75, 76, 80, preventing worsening mental health outcomes72, and even resolving similar
issues such as anxiety-like conditions73, 74, 81. Osborn et al.73, 74 also credit the school channel as responsible for the
unexpected and positive improvement in mental health outcomes for even their control groups that had been put on
study skill training. These positive results reinforce the effectiveness of the school-based channels and, combined with
the study limitations reported by Tol et al78, increases the likelihood that an extraneous factor other than setting is
responsible inuenced their negative results.
Many studies have identied the factors in the school setting increased the team’s reach and contributed to improved
access and participation of adolescents in the mental health interventions. The rst advantage and opportunity
identied by all the studies was the school’s ability to increase the program’s reach and students’ accessibility to
healthcare. Intervention teams are often limited by their ability to reach adolescents and potential participants in their
homes. Since adolescents already gather in this location, the school represents an ecient meeting place for
intervention teams to meet adolescents. Are et al.75 emphasised this issue, noting the school-based intervention as a
solution to the relatively high rate of enrolment in low- and medium-income countries. They also added that the cost of
transportation and the need for parents to accompany the adolescent were previously obstacles to accessing healthcare
but could be eliminated by using the school as a channel. These issues are solved by the school setting as the
intervention adds no new transport cost and parents do not need to follow the participants who already attend school
alone and can be managed by their teachers. In addition, Osborn et al.73, 81, Thurman et al.80, and Bella-Awusah et al.76
reported that peer support and encouragement can also be used to increase participation and minimise the stigma that
prevents access. The interventions can, thus, rely on positive peer pressure to boost participation. Shy or hesitant
adolescents are also likely to mimic their peers reducing the likelihood of dropping out of the program. Participation in a
large group could, furthermore, minimise stigma. The school setting is, therefore, useful in resolving the issue of stigma
and its negative impact on health-seeking behaviour25 and participation in medical health research80, 81, especially with
adolescents in SSA. Lastly, the positive relationship and trust existing between guardians and their wards’ teachers
would make it easier to gain their permission48. Participation in research could be undermined by guardians’ concern for
the wellbeing of their wards and the trustworthiness of researchers who would often be strangers. The school setting
will position the researchers to leverage the existing relationship between teachers and guardians. Building on that trust,
parents would be more willing to trust researchers who are well-regarded by the teachers – especially because the
teachers would be present and potentially part of the intervention.
In addition, the school setting can minimise the cost of mental health programs by sharing resources. Mental health
intervention teams, to reduce the intervention’s cost, can leverage existing buildings, furniture, equipment, and
manpower. The use of the school’s facilities is obvious but could represent a signicant reduction in the cost of storage,
oce space, security, and other services. Also, the use of school teachers and students to provide mental health
treatments was common among the studies, with at least ve of the studies explicitly reporting its positive impact73–75,
81. Others75, 80 reported their adoption of the strategy following its recommendation in WHO’s potent strategy for driving
mental health programs in low- and medium-income countries where professionals are insucient. This strategy is,
thus, a contemporary and effective response to the constraints of human and material resources which is a crucial issue
in the SSA.
However, the advantage of the school as a meeting point is counterbalanced by other issues such as transportation
costs and school dropout. Two of the studies72, 79 directly identied participants dropping out of school or lacking
Page 16/24
transportation funds as main reasons that some of its participants did not complete the intervention program. Green et
al.72, therefore, suggested that nancial support for participants would reduce the number of dropouts from the program
and increase accessibility. Bella-Awusah et al.76 added that providing childcare for those tasked with caring for their
siblings could also help increase attendance and participation. The socioeconomic condition of the region is a primary
contributor to school dropout and insucient transport funds. The school setting is already minimizing the cost of
transportation but that cost can only be eliminated by the community-based approach –i.e. meeting participants in their
home community. Depending on the income level of the specic area, school dropout would not be a signicant issue
and a stipend covering transportation may be sucient to minimize this issue.
As previously mentioned, the use of lay-persons (or task shifting strategy) was adopted by about half (6 of 11) of the
studies in this sample. While some studies used teachers50, 75 and social workers80, the three Osborn et al.73, 74, 81
employed other adolescents. All of these studies, despite the use of lay-persons, reported positive outcomes for the
participants' mental health, conrming the effectiveness of task shifting and sharing. This report reveals the immense
potential of the school setting and school-based interventions. Are et al.75 added that concerns of condentiality were
unfounded, as emphasizing it during training was sucient. They, however, suggested that training costs could present
an obstacle to this cost-saving strategy. Consequently, lay-persons (including peers) could be leveraged as support staff
for facilitating mental health interventions. There are several potential advantages hidden here including the enhancing
the public’s knowledge of mental health issues and proper treatment, reducing stereotyping and stigma, equipping more
lay individuals in supporting mental health patients, and increasing interest in mental health interventions and research
in the region.
Generally, the intervention studies in the sample were mostly short, lasting an average of four weeks, and mostly used
the group approach. This is in contrast to the longer terms employed by studies in the West. The longest intervention
periods in this sample were those reported by 75, 78, whose programs ran for ve weeks. Others commonly ran for four
weeks, with Osborn et al.74 (2023) being the shortest lasting only a week. The length of the intervention programs was
not a signicant determinant in their effectiveness. Certain authors73–76 specically noted that the effectiveness and
results of their studies were comparable to those of longer interventions. These ndings suggest that future mental
health interventions could optimise their intervention design to increase eciency. Such is welcome for mental health
researchers in SSA as the minimized cost from reducing the program’s length would make it possible for more
interventions to be performed at a cheaper rate. Similarly, it was noted that the use of a group-based approach was
common in the sample, with one study50 arguing that their results demonstrated the scalability of the classroom
approach. This recommendation could further reduce the cost of mental health interventions and allow for more
research in the region. Additionally, a short group-based intervention design would allow researchers to integrate their
programs with the school’s timetable74 enhancing the team’s ability to leverage the school setting. It also suggests that
active prevention and detection programs could be integrated into school curricula, enabling educational institutions to
constantly provide mental health intervention throughout the school’s calendar.
More importantly, the sample studies show that SSA researchers have been taking steps to localize their intervention
programs. All the studies made certain modications to their intervention plans ensuring that it was tailored to the
participants’ sociocultural and religious backgrounds. While some of the studies73, 80, 81 had unique interventions based
on the local culture, other studies took steps to adapt their interventions to their group. These adaptations included
translation into the local language76, replacing terms, phrases, and examples with local equivalents77, 79, and using
strategies that align with local religious practices75. These steps were taken to circumvent the cultural and language
barriers that would have impaired understanding and effectiveness. In this vein, Osborn et al.74, 81 argued for the need
for non-Western tools for measuring mental health disorders, as the current tools fail to capture culture-specic
symptoms. The cultural disconnect may impair diagnosis, treatment, monitoring, and evaluation – thus, making the
Page 17/24
interventions counterproductive. The need for more local studies is, hereby, stressed as a critical measure for improving
mental health treatments and outcomes in SSA. It may also be necessary to evaluate the modications performed by
local intervention studies to conrm that they produced only positive effects on the participants.
In conclusion, these ndings show decisively that schools were an effective channel for providing mental health
interventions. The school setting provided several advantages for mental health interventions in SSA including boosting
participation, reducing cost by leveraging the school’s resources and manpower, and several other advantages pursuant
for the prior two. The school setting was especially important for combating stigma and raising awareness of mental
health issues while equipping students and teachers to provide support for mental health patients. With these
advantages, school-based mental health interventions would provide far-reaching advantages for the general SSA public
in addition to being cheaper for the researcher and more effective for participating adolescents. This potential is
especially crucial to low and middle-income countries, as insucient nancial resources and personnel along with
superstitious and stigmatising cultures undermine the mental health system. In addition, the school-based intervention
remained effective even while being brief (1–5 weeks) providing the potential to be integrated with the educational
calendar while providing synergistic opportunities with scalability in larger schools. However, the channel still
experienced limitations in providing the mental health interventions. The limitations were resulting from the potential for
school dropout and insucient transportation fare. Insucient resources remain a constraint in providing interventions
and the cost of properly training lay providers may be restrictive8, 21, 35, 45. The need for mental health evaluation tools
and treatment programs designed to t the local culture remains an issue in the present. While researchers are already
being proactive in localising their interventions, further studies need to establish its impact on the participants. Also,
future studies need to compare the effectiveness of school-based interventions to those in other settings. Determining
the optimal length and dosage of interventions is also necessary for optimizing the results of future interventions.
Declarations
Consent to Publish declaration: not applicable
Author Contribution
All authors reviewed the manuscript. B.A. wrote the main manuscript. N.Q.W developed and supported B.A.
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Figures
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Figure 1
PRISMA diagram of the selection process
*Relevant sources for Zendaya; the total number of registers was 964,656
