Background

Globally, at least one in five children and adolescents experience mental health problems. This number is likely to be even higher in low middle income countries (LMICs) with vulnerable populations that are faced with multiple adversities.

In South Africa, the number of anxiety disorders amongst children and adolescents is high, ranging from 22% to 25.6% amongst seven to 13 year olds. Finding appropriate, cost-effective and efficient ways to intervene with adolescents’ mental health issues is necessary given that, in the short term we know anxiety and depression impacts on daily functioning, disrupts educational attendance and attainment, affects social relationships and interferes with normal development. In the long term, untreated depression is associated with an increased risk of subsequent depression, interpersonal difficulties and suicide in adulthood.

There is convincing evidence, predominantly from high income countries, that treatments - particularly Cognitive Behaviour Therapy (CBT) - are effective in treating anxiety and depression. CBT-based programmes for children and young people with anxiety have been widely used in individual and group-based contexts.

CBT in low middle income countries

There is emerging evidence of the effectiveness of CBT-based approaches in these populations in LMICs. However, in these countries, there is also a lack of trained clinicians, particularly in the most deprived areas, where the vulnerability factors for developing mental health problems are highest. This has led to interest in mental health prevention programmes, but to date, preventive interventions undertaken in LMIC countries are still low.

Whilst nearly 90% of all children live in LMICs, only 10% of randomised trials are undertaken in these countries, with almost all being psychopharmacological trials. This highlights the need to develop and evaluate mental health prevention programmes for children in LMICs with schools providing a promising context for their delivery.

Four Steps to My Future programme

Our research involves adapting preventative interventions so that they are suitable in South Africa. The programme, once finalised, will be called Four Steps to my Future.

The design and adaptation of effective preventive interventions requires:

• community ownership
• cultural flexibility
• an ability to be able to fit with the delivery context to maximise effectiveness
• appropriate training and support to deliver relevance and acceptability to stakeholders

Formative work by co-investigators in this application has demonstrated that existing evidence-based CBT-based programmes, can successfully be adapted to be culturally-sensitive and to fit with the South African context. This research will build on this formative work by developing an effective CBT-based mental health prevention programme for adolescents 11 to 14 years old, to be delivered by NGO counsellors at agreed upon times during regular school hours. The intervention strategy will follow a universal intervention approach that targets all the children within an age group or grade.

Aims of current study

• To develop a counsellor-led prevention programme based on previous evidence-based CBT programmes to target anxiety and depressive symptoms amongst adolescents aged approximately 11 to 14 years) in schools in the Western Cape.
• To explore the acceptability, feasibility and preliminary effectiveness of the counsellor led intervention amongst adolescents using a pre-test, post-test evaluation design with a 10 week follow-up.

Methods

Intervention development

In the first part of the project we have undertaken a systematic review of the literature to identify CBT programs that have been implemented in primary school settings globally and in South Africa. This information will be used to develop a database.

Local adaptation

We will undertake interviews and focus groups with young adolescents, their parents, NGO counsellors and school staff to understand the way that programmes need to be adapted. We’ll then use qualitative software to analyse transcripts from the interviews.

Programme development and feasibility

That information gathered from the first stages of the project will be used to inform the 4 Steps to My Future programme.

The programme will be tested in a randomised feasibility study with a 10 week follow-up. Students attending one school will be randomised to receive the intervention whilst the other school will be the comparator (treatment as usual).

Adolescents will complete pre and post (10 weeks) assessments of anxiety, mood and well-being.

Programme attendance and completion rates and adolescent, NGO and school satisfaction with the programme will be assessed.

Expected outputs

This project will produce a culturally sensitive, practical, user-friendly and structured intervention deliverable by NGO staff during school time which has the potential to be scaled-up in schools across South Africa. Assuming the programme is feasible, acceptable, and appears to be effective, we will subsequently seek a larger grant to conduct a definitive trial of this programme.

Research Team

Chief Investigator

Dr Bronwyne Coetzee, Stellenbosch University

Co-Investigators

• Professor Paul Stallard, University of Bath
• Dr Maria Loades, University of Bath
  
• Gerrit Laning, Community Keepers, Western Cape
• Helene Loxton, Stellenbosch University
• Suzanne Human, Stellenbosch University
• Naomi Myburgh, Stellenbosch University

Funder

Wellcome Trust Seed Award in Science

Project timeline

April to July 2019

Project set-up.

August 2019 to March 2020

Systematic review of school based CBT programmes.

September to December 2019

Formative consultations with stakeholders.

October to December 2019

Intervention manual developed.

December 2019

Train NGOs.

January to March 2020

Finalise systematic review and write up stakeholder feedback.

March 2020

Baseline assessments School 1.

April to June 2020

Intervention at School 1.

July 2020

Follow-up school 1 and baseline assessments School 2.

July to September 2020

Intervention School 2.

October 2020

10 week follow-up School 2.

October 2020 to March 2021

Data analysis and dissemination.