Youth Forward: Acceptability and Feasibility of Addressing Youth Mental Health Via an Employment Promotion Program in Sierra Leone

Background & Purpose: There is immense inequality in the distribution of skilled practitioners in mental health. The level of untreated mental disorders is especially high in low- and middle-income countries, where war, violence and poverty are commonplace. According to the World Health Organization (WHO), Sierra Leone, with a population of seven million people, has just two psychiatrists, two clinical psychologists, 19 mental health nurses and four nurses specialized in child and adolescent mental health. Given high rates of mental health problems in Sierra Leone, the constraints on the health system and the government’s limited capacity, alternative delivery platforms for evidence-based psychosocial interventions are critical. Youth FORWARD is one such effort to test the integration of the evidence-based Youth Readiness Intervention (YRI) into an existing employment promotion program.

The YRI builds on 15 years of research on the effects of war, violence and other post-conflict adversity on the mental health of young people in Sierra Leone, starting immediately after the end of the brutal civil war in 2002 with the Longitudinal Survey of War-Affected Youth (LSWAY). The study – the first of its kind in Sub-Saharan Africa – found high levels of mental health needs linked to past exposure to violence, manifested for example in poor emotional regulation and anger, depression and hopelessness.

Methods: A three-month feasibility pilot of the integration of the YRI within an Entrepreneurship Training (ENTR) program was conducted. The pilot utilized a cluster randomized three-arm trial (YRI+ENTR, ENTR-only, Control),  targeting 180 youth (50% female, ages 18-30) in one rural district in Sierra Leone (Kailahun) with impairments in emotion regulation and interpersonal functioning.

Results: Study youth (N=171, 62% female) participated in quantitative assessments at baseline and post-intervention. Baseline data indicate male participates had higher mean scores related to emotion dysregulation, functional impairment, anxiety, depression, post-traumatic stress disorder (PTSD), and externalizing behaviors compared to females while females at baseline noted more daily hardships compared to males. Mixed (or multilevel) models were used to assess intervention effects, accounting for treatment arm and time. Preliminary analysis indicate that YRI males had significant improvements in emotion regulation and reductions in PTSD. Females in the YRI, however, demonstrated improvements in functional impairment (non-significant) with a significant increase in externalizing behaviors. 

Conclusion & Implications: While not powered to detect an effect, study outcomes demonstrate improvements for male participants on key study outcomes of interest with female participants noting an increase in externalizing behaviors. Of note, item-response theory was conducted on the externalizing subscale between baseline and endline, negatively impacting internal consistency of the subscale (.76 to .63 at endline). A critical analysis of study results assess appropriateness of delivering an evidence-based mental health intervention within the alternative delivery platform of an employment promotion program. While outcomes demonstrate that delivering the YRI alongside the ENTR is feasible, differential impacts along gender lines indicate  that increased understanding of the sociocultural context is needed to understand the contextual realities facing female youth participants and ways to improve study curriculum to attend to these needs and realities.