A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries

Mental health is fundamental to good health and wellbeing and influences social and economic outcomes across the lifespan [1‐3]. Childhood and adolescence are crucial periods for laying the foundations for healthy development and good mental health. It is estimated that 10-20% of young people worldwide experience mental health problems [4]. Poor mental health in childhood is associated with health and social problems such as school failure, delinquency and substance misuse, and increases the risk of poverty and other adverse outcomes in adulthood [3]. Interventions that promote positive mental health equip young people with the necessary life skills, supports and resources to fulfill their potential and overcome adversity. Systematic reviews of the international evidence, which come predominantly from high income countries (HICs), show that comprehensive mental health promotion interventions carried out in collaboration with families, schools and communities, lead to improvements not only in mental health but also improved social functioning, academic and work performance, and general health behaviours [5‐13].

Despite the recognition of the importance of mental health promotion for children and adolescents, mental health remains a neglected public health issue, especially in low and middle-income countries (LMICs). Mental health is inequitably distributed as people living in poverty and other forms of social disadvantage bear a disproportionate burden of mental disorders and their adverse consequences [14‐17]. There is increasing recognition of the relevance of mental health to global development strategies, and in particular to the achievement of the Millennium Development Goals (MDGs), including improving child and maternal health, universal education, combating HIV/AIDS and other diseases, and eradicating poverty [18, 19]. As 90% of the world’s children and adolescents live in LMICs, where they constitute up to 50% of the population [20], there is an urgent need to address the mental health of young people as part of the wider health promotion and development agenda.

Schools are one of the most important community settings for promoting the mental health of young people [21]. The school setting provides a forum for promoting emotional and social competence as well as academic learning and offers a means of reaching the significant number of young people who experience mental health problems [22‐25]. Educational opportunities throughout life are associated with improved mental health outcomes. The promotion of emotional health and wellbeing is a core feature of the WHO’s Health Promoting Schools initiative [26]. There is good evidence that mental health promotion programmes in schools, especially those adopting a whole school approach, lead to positive mental health, social and educational outcomes [13, 27‐29]. Programmes incorporating life skills, social and emotional learning and early interventions to address emotional and behavioural problems, produce long-term benefits for young people, including improved emotional and social functioning, positive health behaviours, and improved academic performance [5, 13, 25, 27‐31]. To date there has been comparatively little research on school and community-based mental health promotion interventions for young people in LMIC settings and no systematic attempt to synthesize the evidence from such settings. This is the goal of this paper. The work described here was undertaken in 2011–2012 as part of the World Health Organization Task Force on Mainstreaming Health Promotion. Established on foot of the WHO 7^th Global Conference on Health Promotion [32], the Task Force sought to develop a package of evidence-based health promotion actions addressing priority public health conditions in LMICs.

The objectives of the review were:

The results of the search and study selection are shown in Figure 1. The original search process carried out in 2011 produced 10,471 articles, 188 articles of which were selected for full review and exported to Endnote. Of these, 146 were either contextual articles related to mental health promotion in LMICs or studies that did not meet one of our inclusion criteria. Seven articles were systematic/summary reviews of the evidence base in LMICs, five of which were reviews of interventions for young people. A total of 35 primary studies were selected for review. Of these, 14 studies evaluated school or community-based interventions for young people in LMICs. During the repeated search performed in September 2012, a further eight studies evaluating school-based interventions were identified. The combined searches resulted in a total of 22 studies (14 school and eight community-based studies) undergoing quality assessment. No studies in non-English language specific to school and community based-interventions were identified in the review process.

The five systematic review articles from LMICs that were identified examined the effectiveness of HIV related lifeskills interventions [69, 70] and psychosocial interventions for children and adolescents affected by armed conflict in LMICs [71‐73]. All relevant interventions across the reviews were identified and cross-referenced with the primary articles retrieved through the electronic search. Given the specific focus of this systematic review on mental health promotion and primary prevention, several studies from these systematic reviews did not meet the inclusion criteria for this review.

Regarding the number and percentage of evaluation studies carried out across LMICs, 18.2% (N = 4) of the interventions were carried out in low income countries, 36.4% (N = 8) were carried out in lower middle income countries and 45.4% (N = 10) were carried out in upper middle income countries. Just under one third of the interventions (N = 7) were carried out in South Africa alone.

This review sought to determine the effectiveness of mental health promotion interventions designed for young people (aged 6–18 years) in LMICs. A total of 22 studies evaluating 20 interventions were identified. The majority of interventions were implemented in upper and lower middle income countries, thus highlighting the paucity of evidence from low income countries. Four interventions were carried out in low income countries, three of which were conducted in Uganda. It is encouraging to note, however, the significant increase in publications from LMICs in the last four years, with the majority of interventions identified in this review published since 2008.

With regard to the school-based interventions, the quality of evidence from the 14 studies is moderate to strong. Findings from these studies indicate that there is reasonably robust evidence that school-based programmes implemented across diverse LMICs can have significant positive effects on students’ emotional and behavioural wellbeing, including reduced depression and anxiety and improved coping skills. Promising interventions include the Resourceful Adolescent Program (RAP-A), which was implemented by teachers in Mauritius [42]. This study is an example of an evidence-based intervention adapted from a HIC for implementation in a LMIC and points to the potential of such interventions when adapted to meet the cultural needs of young people in LMICs. Another promising intervention is the teacher led peer-group support intervention for AIDs orphaned children which was implemented in a low-income country [45]. The findings from this study suggest the potential of peer support mental health promotion interventions in optimizing adjustment and decreasing the psychological distress associated with AIDS orphanhood in the adolescent age group. Such interventions may have great potential in addressing the increased risk of depression, peer relationship problems, post-traumatic stress and conduct problems among AIDS orphans [74‐76]. There is also some encouraging evidence that interventions which combine lifeskills with reproductive and sexual health education [37, 38] and physical health and fitness [36] can have a significant positive effect on pupils’ risk-taking and prosocial behaviour. These findings are consistent with the substantive evidence from multiple reviews of school-based interventions in HICs which report the greater effectiveness of multi-component interventions (i.e. interventions that adopt a social competence approach and develop supportive environments), when compared with interventions that focus on specific problem behaviours [8, 28, 77‐79]. The integration of multicomponent programmes within a whole school approach [13] based on generic social and emotional skills training addressing comon risk and protective factors, delivered within a supportive school environment in partnership with parents and the local community, has the potential to reach larger population groups with fewer resources.

The evidence for universal interventions implemented with young people affected by war attests to the important role of the school as an accessible setting for such interventions. Similar to previous reviews [72, 73], the heterogeneity across the studies in terms of programme content, delivery, duration, and study sample makes it difficult to draw general conclusions about the effectiveness of these interventions as a whole. However, there is evidence that the more structured interventions of longer duration can have a significant positive effect on mental health and wellbeing. The results from the Classroom-Based Intervention (CBI) and the school-based Psychosocial Structured Activities intervention (PSSA), which is based on CBI principles, highlight the positive effect of these interventions on young people’s social, emotional and behavioural wellbeing. The differential effects according to gender reported across these interventions, however, calls for further investigation into possible gender specific components. The optimum age for programme implementation also needs further examination. There is evidence from Khamis et al. [48] that CBI did not yield the same significant positive changes with older males (12–16 years) as with the younger group (aged 6–11). This finding is in line with substantive evidence from HICs regarding the need to reach children when they are young in order to sustain their existing resilience and strengthen their coping capabilities [4, 12, 80‐82].

Non-significant findings were also found for a writing intervention implemented with young people aged 12–17 [55] and a CBT intervention implemented with children and adolescents aged 5–16 [54]. It is important to note the initial negative impact of the writing intervention on participants’ depression symptoms, which then subsequently declined at follow-up. Common characteristics of these interventions were their short duration and the broad age range of the intervention participants. This is in contrast to the year long after-school intervention implemented with children and adolescents and their parents living in Gaza and the West Bank, which resulted in significant improvement in participants’ social and emotional wellbeing and parenting behaviours [56]. The results from these studies underscore the importance of understanding optimum programme components in terms of content, duration, and target age range in order to ensure the development of effective school-based interventions in conflict areas. This is in line with recommendations from previous reviews of school-based interventions implemented in war exposed countries [71, 72] including those from secondary prevention interventions, not covered in this review, which also point to the need for more rigorous research on the differential intervention effects related to age, gender and war-related experiences [73, 83]. The studies in this review support previous findings concerning the role of universal school programmes for children living in conflict areas as an effective, accessible and efficient means of enhancing and protecting good mental health alongside more targeted approaches for students at higher risk [84]. The exploration of a whole school approach to interventions in this area carries potential for reaching the wider community through the school setting.

The majority of the school-based interventions included in this review were implemented with young people age 12–16 years. In view of the paucity of evidence of mental health promotion interventions for young children in primary schools in LMICs (age 5–10 years), there is an urgent need for high quality studies with longitudinal designs to assess the impact of school-based intervention for younger primary school children in order to strengthen the evidence base in this area. Schools are arguably one of the most important settings for reaching out to young children and their families and early intervention is recognised as one of the key principles of effective mental health promotion and prevention interventions [4, 8, 12, 80]. In addition, eight of the interventions were implemented by trained class teachers, with the remaining interventions implemented by psychologists, paraprofessionals and youth workers. As Srikala & Kumar [35] argue, any programme incorporated into the education system in LMICs has to be feasible and cost-effective. The findings from this review suggest that trained teachers can effectively deliver mental health promotion interventions. Similar to findings from HICs, several of the studies reviewed highlighted the importance of teacher training and the provision of ongoing support during programme implementation. Harnessing the skills of teachers and providing support in the school setting offers a sustainable and low cost method of improving children’s emotional and behavioural wellbeing, developing positive coping strategies and promoting school performance. As the Millennium Development Goals have set out as a target that all boys and girls will be able to complete a full course of primary schools by 2015, the integration of social and emotional learning and lifeskills development in the primary school curriculum and the development of a whole school approach to health promotion is an important component of this development agenda.

In terms of the evidence for community-based interventions in LMICs, there are a limited number of very promising youth interventions addressing sexual and emotional health, HIV prevention, substance misuse, violence prevention, functional literacy, economic empowerment and social participation among excluded groups. The results from these multicomponent interventions are impressive given the improvements that were shown across a broad range of adolescent health outcomes. Although limited in number, the three microfinance interventions for young adults and primary school children included in this review, provide encouraging evidence that combined microfinance and training interventions promoting essential lifeskills, asset building and reourcefulness, can result in significant mental health and wellbeing benefits. Further evaluations of such multicomponent community-based interventions are needed to determine the long-term impact on more specific mental health outcomes.

The review findings indicate that mental health promotion interventions for young people can be implemented effectively in LMIC settings. There is good quality evidence regarding the impact of school-based programmes and promising evidence from multicomponent community-based studies that such interventions offer a viable means of promoting the mental health and wellbeing of young people. Notably, the studies reviewed demonstrate the feasibility and effectiveness of integrating mental health promotion interventions into education and community programmes such as community empowerment, poverty reduction, HIV/AIDS prevention, reproductive and sexual health. While the mental health promotion interventions identified in this review have achieved success across a diverse range of countries, relatively few have been systematically scaled up to serve the needs of young people at a regional or national level. Thus, evidence for their sustainability and effectiveness when scaled up through the educational system and community settings in LMICs needs to be strengthened, especially in low-income countries. In addition, the short-term follow-up periods of many of the studies point to the need for future research to evaluate long-term outcomes. Research is also needed to strengthen the evidence-base on the interrelationship between mental health and other health, educational and social wellbeing outcomes. Such research would strengthen the case for mainstreaming the integration of mental health into key health, education and development priorities for young people in LMICs.

The studies reviewed demonstrate the feasibility and potential sustainability of implementing mental health promotion interventions in LMICs through employing existing infrastructures and resources, working with local teachers, community workers, young people and their families. Further research is needed on the contextual factors influencing the adoption and adaptation in LMICs of well-validated interventions that have been developed in low resource settings in HIC countries. In particular, implementation research is needed to ensure the successful adaptation and transfer of school-based interventions for younger primary school children across educational, cultural and socio-economic settings. The development of culturally valid measures of mental health, that will support the evaluation of culturally appropriate interventions in LMICs, is also identified as an area for methodological development. Existing standardized mental health measures from HICs need to be locally validated and the development of culturally sensitive indicators of positive mental health and wellbeing will be particularly important in determining the benefits of mental health promotion interventions delivered in diverse cultural contexts. Developing capacity in LMICs for the implementation and evaluation of mental health promotion policies and practices is fundamental to promoting and sustaining action for positive youth mental health development.