The mental health of adolescents is worthy of attention. Perhaps they are one of our greatest resources as they are the future of a thriving society.  Adolescents are at high risk of developing mental disorders which can be carried forward into their adult lives and the future of their own children. The risk and protective factors for mental health and wellbeing are explored to create an understanding of the challenges faced during adolescence. The health promotion and prevention interventions which consist of the three levels (primary, secondary, and tertiary) are explained, as well as the ecological model as developed by Bronfenbrenner. This model provides a framework that illustrates how each level (microsystem, mesosystem, ecosystem, and macrosystem) exists within a nested system. Adolescents are in a unique phase of life whereby they have biological, social, and psychological changes which can lead to substantial disease burdens such as, inter alia, suicide, violence, pregnancy, and poor academic achievement. It is explored why, despite all of the above the mental health of adolescents has been for the most part neglected by mental health policies. The importance of schools and education is discussed along with the risk and protective factors they provide. The school setting is also important for providing interventions that can impact adolescents. Two interventions namely, classroom-based intervention and a peer-support group intervention, are discussed and explained. Finally, a community collaborative group health promotion namely “The Collaborative HIV Adolescent Mental Health Programme South Africa” (CHAMPSA) is discussed as the intervention, which occurs at microsystem level and group-system intervention, aims to provide education on HIV and empower parents and children.

Mental disorders are the subject of much suffering amongst the population. These disorders affect an individual’s ability to function thus resulting in a diminished quality of life (World Health Organisation (WHO), 2002). The authors also stated that further effects such as stigma, discrimination, alienation, poverty, and social consequences also have devastating effects on an individual’s life. 

There is a relationship that exists between poverty and mental and physical health which decreases an individual's ability in lower and middle-income countries (LMIC) to develop to their full potential (Petersen, 2010). It is suggested that breaking the cycle of poverty and poor mental health outcomes is achieved by mental health promotions and prevention interventions (Petersen, Bhana, & Swartz, 2012). The authors state that this can be done by confronting the risk factors of developing mental illness and then supporting the individuals in overcoming these obstacles. 

Petersen (2010) defines the prevention of mental disorders as “reducing the incidence, prevalence, duration and recurrence of these disorders, as well as their prognosis” (p9). The author then defines promotion as “promoting optimal mental and behavioral health and psycho-physiological development rather than amelioration of symptoms and deficits” (p9). These concepts are interrelated and have complementary outcomes and can be used in the same intervention. Whilst promoting mental health can assist in reducing the prevalence of mental disorders, the prevention of mental disorders may use mental health promotion strategies towards achieving the same goal. 

The prevention of mental disorders takes place at three levels: primary, secondary, and tertiary  (WHO, 2004). Elaborating on these levels, Petersen, Bhana, and Swartz (2012) advise that the goal of primary prevention is to prevent the onset of mental disorders. Secondary prevention relates to the early detection and treatment of mental disorders to manage the severity thereof. The tertiary level is aimed at rehabilitation of those with mental disorders to prevent a relapse in their recovery. The WHO (2004) states that these interventions can be: 1) “universal” which targets the whole population, or 2) “selective” which targets specific groups or individuals who are at risk of developing mental health problems due to specific social, biological or psychological risk factors, or 3) ‘indicated” which targets individuals who display minimal signs of mental disorders. 

The ecological model developed by Bronfenbrenner provides a framework which is important for understanding the prevention and promotion of mental health from a developmental perspective (Petersen, 2010). Petersen (2010) states that within the ecological framework, theory, risk, and protective factors all exist and operate within a nested system comprising of the microsystem, mesosystem, exosystem, and the macrosystem. Petersen states that the microsystem (intrapersonal level) is where an individual interacts directly with another individual (such as a teacher, parent, or friend) which is a basic dyadic relationship. These interactions can also extend out further which would be known as triads, tetrads, and so forth. As part of the ecological understanding these interactions are shared and as such influence the outcome of the interactions. The mesosystem (proximal factors) refers to an individual's accumulated microsystems. Health promotion interventions would look to intervene within the multiple microsystems to enhance the protective factors. Petersen advises that the exosystem impacts the person at a distal level which does not involve them as a participant who is actively pursuing the outcome. This is mostly at a community level and can impact them by, for example, enhancing safety in the neighborhood. The macrosystem (distal factors) refers to the influences of a cultural and societal nature. This can manifest in outcomes like free healthcare, which are embedded in broader socio-economic policies. Cultural beliefs also play a role in this system whereby belief systems can influence outcomes. 

Planning a mental health promotion and prevention intervention requires that five distinct stages should occur at each level of the ecological model. (Petersen, Barry, Lund, & Bhana, 2014). The first stage entails the selection of the appropriate theories for guiding the intervention. An example of theories could be cognitive behavioural therapy at an intrapersonal level, or social support theory at a proximal level. The second stage entails the understanding of the socio-cultural context and the factors (risk and protective) impacting on the target group of the intervention to ensure it was culturally appropriate. This could require using an existing intervention and making adjustments to ensure it is culturally appropriate. Community members must be involved as they could provide local knowledge and insight. The third stage entails that interventions are theoretically and contextually informed and that they are delivered in a participatory way, empowering and drawing on existing strengths and competencies. In this stage, it is critical to explore the root causes of social problems and encourage and empower the community to be involved in taking action to address the root cause of mental health issues. The fourth stage requires that the interventions are assessed against the outcomes that were set out and that there is adequate use of scarce resources. The final stage involves the dissemination and scaling up of promotion and prevention interventions. This involves the acceptance of the program by the organisation, and the awareness of the need for the program, and then implementing the program with fidelity.  

Mental health problems in adolescents is an area of concern when one considers that mental disorders are estimated to affect  20% of children and adolescents (Paruk & Karim, 2016). Paruk and Karim (2016) advise that vulnerable environments where there are socio-economic inequalities and lack of social support further exacerbate the risk of mental health problems. Research shows that suicide is the second leading cause of death among adolescents worldwide. Common mental health issues in adolescents that are associated with increased suicide risk are anxiety, trauma, depression, and stressor-related disorders. 

Adolescence is a unique stage of life as it is characterised by a surge in hormones, brain development, and a move from one's family system to a reliance on their peers. A further concern is that mental illness in adolescents often goes undiagnosed and untreated and is, therefore, associated with significant disease burden such as violence, suicide, poor academic achievement, substance use, pregnancy, and increased risk of psychopathology later in life (Casey & Bailey, 2011). 

Adolescents are developing their own identities and learning the skills they will require to take them into adulthood and enable them to live healthy and well-adjusted lives. The mental health of adolescents is also important when considering risk behaviours which pose to be a major challenge (Flisher & Gevers, 2010). Flisher and Gevers (2010) advise that this is a period whereby adolescents are sexually active, and they are likely to experiment with substances and drugs which can result in substance/drug abuse tendencies. Their risky behaviour also transcends into smoking tobacco and even more prevalent is the use of marijuana which can be a contributing factor to mental disorders. The authors also state that adolescents can be both the perpetrators and victims of violent crime, with them being involved in physical fighting and also bullying behaviours, which can be further enhanced by the use of alcohol and drugs. 

Patton et al. (2016) indicate that adolescence is characterised by puberty which means a rise in hormones and brain development. The brain continues to develop during this period and, as the prefrontal cortex develops, there is increased connectivity between brain networks. This development also brings about changes in executive functioning which influences self-regulatory and decision-making skills. 

The factors already mentioned such as hormones, neurological functioning, and environment all play a role in risk factors for adolescents developing mental illness. Adolescents can begin to feel anxious about their appearance and their ability to fit in with their peers which can put them at higher risk of developing eating disorders. Psychosocial factors such as the home environment serve as the primary structure where children grow and develop into adults. Parental neglect, bullying, bereavement, and/or exposure to traumatic life events are linked to poorer outcomes in adolescents. More recently, social media and the online world can expose adolescents and cause changes in their values and identities, also putting them at risk of decreasing mental health. An important consideration is that adolescents, and their mental wellbeing is important as they transition into adulthood, and they also play a crucial role as they raise the next generation. Therefore, the impact will result in healthy adolescents now, healthy adults in the future, and healthy future generations. 

Mental illness in adolescents is related to substantial disease burden, such as suicide, violence, pregnancy, poor academic achievement, substance use, pregnancy, and the risk of poor mental health and the development of psychopathology later in life. Schizophrenia is a mental disorder that could have better outcomes if it is diagnosed and treated earlier in life when the signs and symptoms first manifest. The symptoms for Schizophrenia can be difficult to recognise in the adolescent years along with other disorders because some of the symptoms are also typical of the behaviours during these years. Such as irritability, depressed mood, low motivation, substance use, withdrawal from family/ peers, and strange behaviours. When the symptoms go undiagnosed this can result in poorer mental health outcomes later in life.   

In light of all the challenges that adolescents face, it is concerning that their mental health has been largely overlooked. Patton et al. (2016) explains that adolescence has been viewed by health professionals as the “healthiest time of life”. The authors explain that this is because, when analysing mortality across the life span in most countries, the peak of mortality is seen in early life, with infant mortality, and again later in adulthood due to chronic disease. Based on this, there is, therefore, a misconception that adolescents have fewer health needs than those in other phases of life, and this has resulted in adolescents attracting little investment and interest in global health policy. It is now being recognised that adolescence is a crucial stage where neurological, physical, and emotional changes are taking place. These changes, although confusing for the adolescent, assist them in developing their autonomy. This, together with education and the safety and security of their environment, is what enables them to enter into adulthood with the skills to undertake employment and enter into lasting relationships. 

When it comes to promoting the mental health of adolescents, Barry, Clarke, Jenkins and Patel (2013) explain that schools are one of the most important settings in the community for promoting mental health.  Further, the school setting provides the opportunity to promote social and emotional competence as well as academic learning to a large number of adolescents who could be experiencing mental health issues. The role of school and education in the life of an adolescent can serve as a risk and protective factor when it comes to mental health outcomes later in life. Research has shown that protective factors that result in better mental health outcomes can be associated with variables such as positive school ethos, school attendance, attainment, positive teacher/student relationships, and supportive policies in place such as anti-bullying policies. There are several risk factors that adolescents face in obtaining an education and therefore having better mental health outcomes. One is the cost of school which may mean that some sectors of the population are unable to afford schooling in a protective environment. Another is the language barrier whereby some schools do not provide lessons that can be understood by all students. Early marriage and pregnancy in adolescents will also hinder their ability to attend school, and children with disabilities are not catered for in some schools, particularly those from lower-income areas. Another factor is the high drop out rate of students, particularly in secondary school, which can be due to students having to repeat grades, the poor interaction and relationships they have with their teachers, a lack of remedial programs for those with particular learning needs, and then early marriage or pregnancy. 

The Ottawa Charter indicates that mental health is rooted in, and influenced by a wider ecology that is made up of social, economic, and cultural factors (World Health Organisation, 2020). The charter was formed from the first International Conference on Health Promotion which took place in Ottawa in 1986. Deriving from this conference, public health actions were set and health was intended to be achieved for all by 2000 and thereafter. The link between people and their environments was acknowledged with a deeper understanding that mental health is rooted within this wider ecology and is impacted by the interplay of risk and protective factors. These risk factors include interpersonal factors, biological, genetic, environmental factors as well as social, cultural, and economic factors.  

Schools provide the ultimate setting for promotion and prevention interventions which are aimed at the mental health of adolescents (Petersen et al., 2014). The idea of “health-promoting schools” is derived from the eco-holistic principles of the Ottawa Charter (World Health Organisation, 2020). This approach aims to strengthen the school system by focusing on school policies and ensuring that the well-being of the students is a priority, for example, anti-bullying and anti-racism policies. The approach also focuses on building student/teacher relationships, providing recreational spaces for the students, and developing a formal and informal curriculum that provides education as well as health-enhancing skills such as life skills and sex education. 

Research shows that school-based interventions implemented across diverse low and middle-income countries (LMIC) have yielded significant results in the way of positive emotional and social well-being in school-going adolescents (Barry, Clarke, Jenkins, & Patel, 2012). 

A systematic review was conducted on school-based programs in LMIC countries (Barry et al., 2013). The evidence from the majority of the studies was positive, with eight of the interventions receiving a strong rating. All the programs were designed for children and adolescents and targeted mental health promotion and universal prevention, two of which will be detailed below. 

A Classroom-Based Intervention (CBI) was conducted in Palestine on adolescents aged 13-16 years of age. It was a school-based psychosocial intervention aimed at increasing resilience and empowerment and reducing distress. The sessions were given at school and implemented by trained CBI counselors. The outcomes showed a strong effect showing a reduction in levels of self-blame, increased ability to trust others, improved communication skills, reduced instances of conduct and peer problems, and decreased levels of hyperactivity (Khamis, Macy, & Coignez, 2004). 

A Peer-Support Group Intervention was developed and implemented for AIDS orphans in Uganda. The age group was children/adolescents aged 10-15 years old who had lost parents due to AIDS. The intervention was aimed at encouraging participants to examine their difficult experiences by challenging and reflecting on them. By facing these difficult experiences the aim was to assist the participants to develop coping skills. The peer support sessions were held in the classroom, twice a week for 10 weeks and the teachers received training to deliver the interventions. The results of the intervention yielded strong outcomes with a significant reduction in scores relating to anxiety, depression, and anger (Kumakech, Cantor-Graae, Maling, & Bajunirwe, 2009). 

Whilst resilience amongst individuals is important in the face of vulnerable environments, there is a risk that microsystem interventions will only provide limited support as they may not have the necessary support from their broader social group (Campbell & Murray, 2004). However, group system interventions provide the opportunity to renegotiate the identity of the group and encourage collective support in addressing the risk factors that can potentially affect the mental health outcomes of adolescents and community members. 

Petersen, Bhana, and Govender (2012) conducted a study “The Collaborative HIV Adolescent Mental Health Programme South Africa” (CHAMPSA), which is a community collaborative health promotion that makes use of both the microsystem and group-system intervention. The study aimed to improve parent-child communication, provide knowledge to parents on HIV/AIDS, and improve parental monitoring of youth.  The microsystem intervention focussed on strengthening and influencing key members, and providing skills and information such as HIV knowledge in parents, assertive and refusal skills in youth, communication skills between parent and child, and participatory psycho-education exercises through role-play. The group-system intervention for parents aimed to assist the participants to challenge norms, understand and renegotiate parental norms and practices, and create a healthy and protective environment for adolescents. 

The CHAMPSA project was an ethnographic study that was conducted in a rural area of South Africa (Petersen et al.,2012). Based on the social construction of the target population it was decided that this needed to be a collective journey and therefore a group approach was used. The topics were introduced using a cartoon based manual which followed a dramatic storyline. The topics included the rights and responsibilities of children, communication, risk management, HIV/AIDS and its stigma, death, and loss and support networks. 

The outcomes of the study showed significant results and the feedback provided by the participants and community members showed the positive impact of the CHAMPSA intervention. On an interpersonal level, a participant commented that the intervention educated them on children’s/parent’s rights and how, as parents, they could be empowered to communicate effectively with their adolescents. Parental empowerment yielded positive results as a result of their increased HIV knowledge. Communication skills improved particularly relating to topics that were difficult to discuss. A participant mentioned that being able to talk to children about difficult topics such as HIV transmission had led to an ability to have more open discussions and build better relationships as a result (Bhana, Petersen, Bell, & McKay, 2020). 

The outcomes relating to the social situation/context resulted in building primary social networks that provide support and social bonding. This was achieved by engaging in critical reflection and engagement which led to empowering parents and renegotiating identities. Participants from the study stated that they realised that they were abusing their position as parents by shouting or engaging in physical punishment, and now realised that it achieved bad results for the children. A further positive outcome was renegotiated social representations regarding HIV and people, which meant that now the community would no longer be scared of those with HIV but would join together to assist those in the community affected by the disease. A further positive outcome was the improved social controls and monitoring of children. There was a togetherness whereby, if a community saw an adolescent who was not at school, they would be actively involved in assisting the child to make the right choice and holding them accountable (Bhana et al., 2020). 

The positive outcomes of CHAMPSA, in terms of the cultural environment, showed improved opportunities for women as their identities had been renegotiated and empowered within the community. Women were now accepted to hold higher positions than men whereas in the past this would have been seen as only a man’s role (Bhana et al., 2020). 

CHAMPSA highlights that, while distal policy interventions are important, the evidence taken from this intervention illustrates that proximal interventions can promote health-enabling contexts at a community level (Petersen, Bhana, & Govender, 2012).    

In conclusion, it has been acknowledged that adolescents have been overlooked in health and social policies worldwide and, therefore, have had fewer health gains than any other age group. As discussed, although adolescence may appear to be a healthy life phase, research shows that this is a critical phase of life where they are undergoing social, biological, and psychological changes that put them at higher risk for developing mental disorders. In addition, mental disorders overlooked in adolescence can then be carried forward into adulthood thus making them harder to treat. The promotion and prevention interventions outlined herein demonstrate how the use of the ecological model developed by Bronfenbrenner assists in intervening within the multiple microsystems to enhance protective factors. The school setting is important in the life of an adolescent as, not only does it provide them with an education which is vital in the skill set required to succeed, it also provides a platform whereby intervention can reach many adolescents at once. The CBI conducted in Palestine as a psychosocial intervention to increase resilience showed significant improvements such as increased levels of trust, communication skills, and improved peer relationships. A further peer support program implemented in Uganda for AIDS orphans also showed significant improvement in reduced anxiety, depression, and feelings of anger.  CHAMPSA conducted in South Africa as a community collaborative health promotion making use of the microsystem and group-system intervention showed marked improvement to parent-child relationships, communication skills, and HIV-related knowledge, thus highlighting the effectiveness of proximal interventions. 

The spotlight is finally turning towards adolescents as the importance of this phase of life is being recognised and that the investment in them brings a triple benefit. Healthy adolescents now mean healthy adults in the future and therefore healthy future generations. 

References

 Barry, M., Clarke, A., Jenkins, R., & Patel, V. (2012). Rapid review of the evidence on the effectiveness of mental health promotion in low and middle-income countries. Mainstreaming health promotion: Reviewing the health promotion actions on priority public health conditions. Geneva: World Health Organisation. 

Barry, M., Clarke, A., Jenkins, R., & Patel, V. (2013). A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle-income countries. BMC Public Health, 1-19. 

Bhana, A., Petersen, I., Bell, C., & McKay, M. (2020, June 20). Outcome and process evaluation of the CHAMP South Africa (AMAQHAWE) Family-Based HIV Prevention Intervention 2007. Retrieved from Human Sciences Research Council: http://www.hsrc.ac.za/en/research-outputs/view/3450 

Campbell, C., & Murray, M. (2004). Community health psychology: Promoting analysis and action for social change. Journal of Health Psychology, 187-195. 

Casey, P., & Bailey, S. (2011). Adjustment Disorders: The state of the art. World Psychiatry, 11-18. 

Flisher, A., & Gevers, A. (2010). Adolescence. In I. Petersen, A. Bhana, A. Flisher, L. Swartz, & L. Richter, Promoting mental health in scarce-resource contexts: Emerging evidence and practice. Cape Town, South Africa: HSRC Press. 

Khamis, V., Macy, R., & Coignez, V. (2004). The Impact of the Classroom/Community/Camp-Based Intervention (CBI) Program on Palestinian Children. USA: Save the Children. 

Kumakech, E., Cantor-Graae, E., Maling, S., & Bajunirwe, F. (2009). Peer-group support intervention improves the psychosocial well-being of AIDS orphans: Cluster randomized trial. Soc Sci Med 2009, 1038-1043. 

Paruk, S., & Karim, E. (2016). Update on adolescent mental health. SAMJ CME, 548-550.

Patton, G., Sawyer, S., Santelli, J., Ross, D., Afifi, R., Allen, N., & Viner, R. (2016). Our future: a Lancet commission on adolescent health and wellbeing. The Lancet, 1-57. 

Petersen, I. (2010). At the heart of development: an introduction to mental health promotion and the prevention of mental disorders in scarce-resource contexts. In I. Petersen, A. Bhana, A. Flisher, L. Swartz, & L. Richter, Promoting mental health in scarce-resource contexts (pp. 3-20). Cape Town, South Africa: HSRC Press. 

Petersen, I., Barry, M., Lund, C., & Bhana, A. (2014). Mental Health Promotion and the Prevention of Mental Disorders. In Global Mental Health Principles and Practice (pp. 245-275). New York: Oxford University Press. 

Petersen, I., Bhana, A., & Govender, K. (2012). Beyond the Individual: Promoting Mental and Behavioural Health in Low and MIddle-income Countries. Journal of Psychology in Africa 2012, 559-569. 

Petersen, I., Bhana, A., & Swartz, L. (2012). Mental Health Promotion and the Prevention of Mental Disorders in South Africa. Afr J Psychiatry, 411-416. 

World Health Organisation. (2002). Prevention and Promotion in Mental Health. Geneva, Switzerland: 

World Health Organisation. World Health Organisation. (2004). Prevention of mental disorders. Geneva: 

WHO. World Health Organisation. (2020, June 19). Ottawa Charter for Health Promotion. 1986. Retrieved from World Health Organisation: https://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf