Effectiveness of Adolescent School-Based Digital Mental Health Interventions: A Systematic Review

Abstract

Purpose: This review aimed to investigate the effectiveness of digital school-based mental health interventions for adolescents in Sub-Saharan Africa. Method: The authors conducted a comprehensive search of digital school-based mental health interventions to identify studies conducted in Sub-Saharan Africa targeting adolescents between the ages of (10–19) years. Peer-reviewed studies published in English between 2009 and May 2023 were obtained through electronic bibliographic databases. Result: Only one study met the full inclusion criteria for this review. The included study tested a digital mental health intervention (“Shamiri Digital”) for treating depression, anxiety, and well-being in adolescents. The “Shamiri Digital” intervention demonstrated positive outcomes on depressive symptoms within the full sample. Discussion: The dearth of studies investigating digital mental health solutions for adolescents in low-income countries demonstrates a critical gap in intervention and research for adolescent mental health in resource constrictive settings

Keywords

adolescents population school-based settings digital mental health interventions adolescent mental health gap Sub-Saharan Africa

There are about 1.3 billion adolescents globally and ∼ 90% currently reside in low- and middle-income countries (United Nations Children Education Fund, 2023). Nearly 14% of adolescents between the ages of 10 and 19 are experiencing a mental health disorder yet many of these disorders remain undetected and untreated (World Health Organization, 2019). Adolescents residing in Sub-Saharan Africa are disproportionately affected by the burden of mental health disorders and experience many challenges associated with social determinants of health that predispose them to mental health problems. Social determinants of health are defined as the non-medical factors affecting health, are risk factors for mental health challenges and they include social, environmental, and economic risk factors such as income instability, food insecurity, unsafe housing, poor education outcomes, limited access to affordable health services and social exclusion (WHO, 2023).

The mental health care gap currently experienced in many Sub-Saharan African countries has been attributed to several factors including the current fragile mental health infrastructure, a limited mental health workforce, more so, in remote and hard to reach places in many Sub-Saharan contexts (Patel et al., 2018). Furthermore, in other contexts, social determinants of health such as poverty, unstable household income, and limited access to high-quality education, have been linked to poor mental health outcomes among adolescents (Alegria et al., 2018). A recent systematic review assessing the prevalence of mental health disorders among adolescents in Sub-Saharan Africa reported depression and anxiety as the most highly prevalent mental health conditions with prevalence estimates at 29% and 19.3%, respectively (Jörns-Presentati et al., 2021). In Kenya, a recent study investigating the prevalence of depression and anxiety among school-going adolescents reported prevalence rates of 28.06% and 30.38%, respectively (Osborn et al., 2022). Similarly, a prevalence rate of 16.35% was reported among school-going girls in South-western Uganda (Nabunya et al., 2020).

The youth mental health crisis has been augmented by the COVID-19 pandemic (Addae, 2021). In Sub-Saharan Africa, these prevalence estimates are considerably higher among adolescents considered as “high risk” such as teenage mothers (Kumar & Huang, 2021), Youth Living With HIV/AIDS (YLWHA) (Dessauvagie et al., 2020), adolescent refugees and adolescents with other comorbid health conditions (Musisi & Kinyanda, 2020). Additionally, most health resources are channeled towards the treatment of other chronic conditions such as HIV/AIDS, malaria, and tuberculosis (WHO, 2021).

Many adolescents who suffer from chronic mental health problems incur expensive out-of-pocket costs associated with mental health assessment and treatment. This is because a universal health insurance system is non-existent in many Sub-Saharan African contexts. In Sub-Saharan African countries where health services are free, the system is set up in such a way that it will only cover specific mental health diagnoses that are more acute and chronic. Moreover, the transportation infrastructure in many remote areas is still underdeveloped. Geographical barriers like distance to treatment areas impede accessibility given individuals must travel considerably long distances to access mental health services, and these journeys are expensive because they require time, temporary support at home like caregiving for a family member, and a mode of transportation.

According to the latest Mental Health Atlas report (2020), 75% of the WHO member states reported having a stand-alone mental health policy or plan. This is an improvement from 68% reported in 2014. Conversely, the level of public expenditure on mental health is still considerably low at a global median of 2.1%. Consequently, this has had a considerable impact on mental health services uptake and availability in many countries (WHO, 2021).

There is minimal funding channeled towards adolescent mental health in many Sub-Saharan African countries and many countries worldwide are still working towards developing effective mental health systems and appropriate mental health legislative frameworks (Patel et al., 2018). Also, few mental health adolescent-friendly services are available, and this impedes mental health services access for many young people (Sequeira et al., 2022). Most mental health interventions that have been developed and implemented in Sub-Saharan Africa have been skewed towards high-risk populations for example, in HIV/AIDS service delivery in clinic-based settings). Few interventions in Sub-Saharan Africa have targeted mental health promotion and prevention initiatives for adolescent populations in community-based settings and school-based settings (Sequeira et al., 2022).

The World Health Organization is pushing forward a mental health agenda that emphasizes the need for mental health practitioners to prioritize nonpharmacological approaches, limit over medicalization, and avoid institutionalization. Digital mental health and dissemination of mental health interventions in community-based settings such as schools are one way through which mental health systems might be adapted to serve the mental needs of adolescents (Patel et al., 2018; Sequeira et al., 2022). Many Saharan African countries are witnessing a youth bulge (Canning et al., 2015), thus, promoting adolescent mental health and well-being is salient for social and economic development. Cognitive, emotional, and social skills development is critical for the transition from childhood to adulthood. Completing secondary and tertiary education enables adolescents to become employable, join the workforce, and contribute significantly to the social and economic development of their countries (Patton et al., 2016)

School-Based Mental Health Interventions for Adolescent Mental Health

Worldwide, research studies have demonstrated the feasibility of conducting mental health promotion and prevention activities in school-based settings (Bradshaw et al., 2021; Fazel Ireri, et al., 2014). School-based mental health interventions are defined as programs, interventions, or services developed to specifically address social, emotional, and behavioral challenges experienced by students within school settings (Rones & Hoagwood, 2000). Schools have become a natural environment for mental health promotion, especially in regions where the traditional routes for mental health services access are deemed “hard to reach.” Also, research conducted in school-based settings in low- and middle-income countries has demonstrated the feasibility of conducting, promoting, and preventing mental health activities within school-based settings as this has been attributed to the fact that many students spend considerably longer periods of time in schools than any other environments (Bradshaw et al., 2021).

A scoping review of mental health interventions for adolescents in Sub-Saharan Africa reported schools as the second most common setting in which mental health interventions have been implemented (Mabrouk et al., 2022). In this review, fewer studies were documented among adolescent populations in Sub-Saharan Africa and were mostly focused on economic-driven interventions (Karimli et al., 2019; Kilburn et al., 2019; Ssewamala et al., 2021) and provision of Cognitive Behavioral Therapy (Betancourt et al. 2014; Ugwuanyi et al., 2020). Some school-based interventions have been effective in reducing mental health symptoms, thereby promoting mental health and well-being (Olowokere & Okanlawon, 2014; Ssewamala et al., 2012). That said, there is still mixed evidence on the effectiveness of such programs within school-based settings (Araya et al., 2013; Ertl et al., 2011; McMullen & McMullen, 2018).

Digital Health and School-Based Mental Health Interventions

Digital health interventions are services that are delivered through digital and mobile technology. These interventions have been categorized into four broad groups, depending on the target users: (1) interventions for clients, 2) interventions for healthcare providers, (3) interventions for health system or resource managers, and (4) interventions for data services. The WHO 2030 Agenda for Sustainable Development supports the implementation of digital health systems in many low-income countries as this has implications for bridging the digital health divide, promoting more knowledgeable societies, and complementing the existing mental health infrastructure in many low-income countries. However, implementing an action plan for digital health strategies in a Sub-Saharan African context is contingent on several factors such as access, cost, quality of service, safety, scalability, and sustainability of these interventions (Huang et al., 2019; Naslund et al., 2017).

Digital platforms are potential avenues for bridging the adolescent mental health gap in low-resource Sub-Saharan African contexts. A scoping review conducted by Huang and colleagues highlights the benefits of telehealth interventions in many low-resource settings. They reported positive impacts across most e-health technologies with potential for adaptation in low-income countries (Huang et al., 2019). However, this study was conducted within the context of a pediatric setting. Telehealth interventions could potentially improve mental health access, promote cost-efficient mental health services provision, broaden the scope of mental health services as well and promote mental health stigma reduction efforts in these contexts (Naslund et al., 2017). If digital interventions are applied in school-based settings, they might promote equitable and universal access to quality healthcare services at the same time addressing issues pertaining to mental health stigma (Naslund et al., 2019).

The current digital health infrastructure in most low-income countries is still under-developed, however, many countries are beginning to prioritize these efforts in line with the WHO 2030 Agenda for sustainable efforts. Recent studies conducted in high-income countries have shown how social media can facilitate social health interaction, improve access to social support networks, and promote engagement with mental health services (Naslund et al., 2020). Similarly, in an adolescent sample with Jamaican adolescents from rural and urban contexts, over 90% of the sample population reported having access to a smartphone and stated their willingness to engage with mHealth interventions (Maloney et al., 2020). Also, a qualitative study conducted with youth in Vietnam demonstrated that internet-based mental health programs incorporating psychoeducation and social networking components would be well received within this context (Sobowale et al., 2016).

This evidence is presented against the backdrop that barriers to implementing digital technology need to be considered carefully when implementing and disseminating digital interventions in Sub-Saharan Africa. Furthermore, creating a user-centric digital mental health ecosystem targeting an adolescent population will require innovative approaches, collaboration with multiple stakeholders, and an evidence base for the feasibility and utility of digital mental health interventions with adolescent populations. Schools are a potential avenue for testing the feasibility and effectiveness of such mHealth interventions. However, to date, a paucity of research still exists on the effectiveness of such mental health interventions in school-based settings within low- and middle-income countries Psychiatry.

Purpose of the Present Study

The purpose was to investigate the effectiveness of digital school-based mental health interventions for adolescents in Sub-Saharan African countries. The specific research question was: Are digital school-based mental health interventions effective in reducing mental health challenges among adolescents in Sub-Saharan Africa?

Method

The search strategies for this review were in line with the PRISMA guidelines for conducting systematic reviews and meta-analyses. The review was conducted using an eligibility criterion that was developed prior to the start of the review by two reviewers, in this case, the two authors of this manuscript. The screening instrument used in the study is available upon request.

Study Eligibility Criteria

The search strategy included searches from peer-reviewed literature conducted in English. The search strategy did not include any gray literature. The inclusion/exclusion criteria focused on adolescents who were defined as individuals between 10 and 19 years of age (WHO, 2021). Digital school-based mental health interventions conducted in a Sub-Saharan African context were considered for this study. That is school-based mental health interventions that utilize telemental, mHealth, mental health apps, video conferencing, or any other digital platforms. The interventions considered applied either quantitative, qualitative, or mixed methods designs and reported any positive or negative mental health-related outcome. Studies published in English between January 2009 and May 2023 were included in the review.

Information Sources and Search Strategy

A comprehensive and systematic search strategy was conducted to identify and retrieve all relevant peer-reviewed studies. The search process was completed in May 2023. The studies were identified through electronic databases and manual searches. The following databases were searched, PubMed, Web of Science, PsycINFO, CINAHL Complete, ERIC, Child Development & Adolescent Studies, SocINDEX, and Academic Search Premier. The following key terms were combined using a Boolean strategy. school AND mental health AND intervention OR program AND adolescent AND Sub-Saharan Africa. The full search syntax is available upon request.

Selection Process

We identified a total of 2,109 records from peer-reviewed literature. All were English studies. A total of 772 duplicate records were removed at the first level of screening for titles and abstracts, and 70 records were sought for retrieval. These were subjected to a second level of screening for full-text review. Thereafter, two reviewers carefully reviewed the 70 articles, and only one article (n = 1) was included in the study. See Figure 1 is the PRISMA flow diagram detailing the selection process.

Figure 1.
Flow diagram of the study selection process.

Results

Study Characteristics

The study included in this review was a randomized controlled trial of Shamiri Digital, an intervention developed and implemented to treat depression, anxiety, and well-being among secondary school-going adolescents in Kenya (Osborn et al., 2020a). The Shamiri Digital was adapted from the previous face-to-face group administered Shamiri intervention conducted among adolescents attending a secondary school in Kibera, Nairobi (Osborn et al., 2020c). The participants in the included study for review were from a mixed-gender secondary school, serving predominantly low-income families from all around Kenya. This school was in Kiambu County, an area found on the outskirts of Nairobi.

A total number of 103 adolescents between the ages of 13 and 18 years of age were randomized into two treatment arms, that is, the Shamiri-Digital Wellness arm which was the treatment arm of the study, and the Study Skills arm which was the control arm of the study (n = 50; n = 53). The participants’ mean age for the Shamiri Digital group was 15.6 years and 15.72 years for the Study Skills group. At baseline, the number of females was more than that of males in both the Shamiri-Digital intervention and Study skills group at (n = 35) and (n = 31), respectively.

The intervention was delivered over a two-week period with each session taking ∼ 90 min to complete, with two time points, at baseline and after two weeks. The intervention was delivered in a computer lab situated in a Kenyan secondary school. The Shamiri-Digital intervention utilized components of Wise Interventions. Contrary to other traditional evidence-based interventions, Wise Interventions are often briefer and shorter, often lasting one to three sessions. They are not specifically administered in clinic-based settings and they can be administered by trained lay workers or peers, as the case with this study (Schleider et al., 2022). Wise Interventions (WIs) are defined as psychological interventions that focus on meanings and inferences that people make of themselves, and their world, and how these approaches can be used by individuals to make meaningful decisions, face adversity, approach social problems, and accomplish their goals (Walton & Wilson, 2018). They tackle one belief strategy at a time and most often these belief strategies are embedded in real-life situations. They can be delivered digitally, they focus less on labeling and because of this, they are less stigmatizing (Walton & Wilson, 2018). These qualities endear them to many culturally diverse contexts, as one can adapt them to context-specific situations.

Wise interventions were used specifically for the intervention group (Shamiri Digital).

The following modules applying Wise Interventions were included in the Shamiri-Digital intervention, a growth mindset intervention, a gratitude intervention, and a value-affirmation intervention. On the other hand, the control arm of the study (study skills group) comprised two modules, that is, note-taking skills and effective study habits. The primary outcomes in this study were depression, anxiety, and well-being that were operationalized by the Patient Health Questionnaire-8 (PHQ-8), Generalized Anxiety Disorder (GAD)-7, and the shortened version of Warwick-Edinburg Mental Health Well-Being Scale (SWEM-WBS), respectively. A cut-off score of ≥ 10 was applied to the PHQ-8 and GAD-7. Other secondary outcomes that were assessed in the study were optimism and happiness.

Primary and Secondary Outcomes

The primary outcomes in this study were Depressive symptoms which were assessed using the Patient Health Questionnaire-8 (PHQ-9), anxiety symptoms assessed using the Generalized Anxiety Disorder-7 (GAD-7) and adolescent mental health and well-being which was assessed using the shortened version of the Warwick-Edinburgh Mental Well-Beig Scale (SWEM-WBS). The Cronbach's alpha for the PHQ-9, GAD-7, and SWEMWBS in the included study was 0.73, 0.82, and 0.70, respectively. The secondary outcomes of the study were self-reported happiness and optimism that were assessed using the Happiness and Optimism sub-scales of the Engagement, Perseverance, Optimism, Connectedness and Happiness Measure of Adolescent Well-Being. In this study, the Cronbach alpha for the Happiness scale was 0.76 and the Optimism scale was 0.69.

Feasibility and Acceptability

On a scale of 1 to 5, when asked to rate the degree to which participants understood or comprehended the intervention, an independent samples t-test showed high mean ratings of the Shamiri-Digital intervention (M = 4.77, SD = 0.49) as well as the study skills intervention (M = 4.57, SD = 0.94), groups t(41.91) = 1.01, p = .321. The authors reported a high mean and no statistically significant differences across both groups. Most participants reported that they found that lessons learned in the program could be applicable (M = 4.84, SD = 0.50) and study skills group (M = 4.74, SD = 0.81) groups, t(40.17) = 0.55, p = .586. Lastly, the participants were able to rate whether they found this program useful, and many reported high mean ratings though the differences were not statistically significant (M = 4.73, SD = 0.65) and study skills group (M = 4.76, SD = 0.83) groups, t(52.12) = 1.01, p = .878.

Effect Sizes

The main method and design applied in the parent study and subsequent single-session digital intervention was a randomized controlled trial (RCT). The type of e-health technology that was used focused on a brief computerized single session. The Shamiri-Digital intervention produced significant effects on depressive symptoms within the full sample. After two weeks, adolescents in the Shamiri-Digital group had greater improvement levels in comparison to their study skills counterparts, p = .028, d = 0.50, 95% confidence interval (CI) [.00, 1.06]. The number of adolescents reporting depressive symptoms at follow-up was significantly reduced to 46% in comparison to 56% who reported depressive symptoms at baseline, thus demonstrating the effectiveness of the Shamiri-Digital interventions.

The authors reported nonsignificant differences in anxiety between the Shamiri-Digital and study skills control groups, p = .028, d = .29, 95% CI [−.20, .79]. Younger adolescents reportedly experienced improvements in mental health well-being scores from baseline to 2-week follow-up compared with older adolescents. At 40%, there was a decline in the number of adolescents who reported anxiety symptoms at follow-up in comparison to 48% who reported anxiety symptoms at baseline. However, the authors did not report any differences in self-reported well-being between adolescents in the intervention and control groups, p = .028, d = −.04, 95% CI [−.54, .46]. Also, the authors reported that no differences were evident in self-reported happiness between adolescents in the intervention and control groups. The optimism scale was subsequently dropped out of further analysis based on a lower Cronbach alpha at 0.69.

Risk of Bias

Overall methodological quality of the included study was strong. It was an RCT exhibiting low risk. The risk of bias was assessed for the randomization, baseline, blinding, and withdrawals (Boland et al., 2017). Study participants were randomized using a random generator included within the website. They were clearly allocated into two treatment arms, that is, the Shamiri-Digital wellness group and the study skills group. Adolescents between 13 and 18 years old were eligible to participate in the study. No exclusion criteria were applied because the intervention was designed to improve wellness and academic functioning for adolescents in a school-based setting, thus, it was open to any adolescents who wished to participate in the study. There were outcomes of over 80% of the study participants with the intention to treat approach being utilized in this study. See Table 1 for details.

Table 1.
Risk of Bias of Included Study.

Type of Bias Category Support for Judgement

Randomization Truly random ✓
Allocation concealment✓
Number stated✓ Low-risk-random assignment of study participants

Baseline comparability Presented✓
Achieved✓
Inclusion criteria specified✓
Co-interventions identified✓ Low-risk adolescents between 13 and 18 years were eligible. No exclusion criteria were applied. The authors justify this by stating that the program was designed to improve wellness and academic functioning in a school-based setting

Blinding Assessors✓
Administration✓
Participants NS
Procedure assessed✓ Low risk

Withdrawals > 80% in final analysis✓
Reason stated✓
Intention to treat✓
Other outcomes✓ Low risk
Primary outcomes of depression anxiety and mental health well-being reported. Additionally, secondary outcomes on adolescent happiness and optimism reported

Note. ✓ Yes (item adequately addressed); ✗ No (item not adequately addressed); ✓✗ Partially (item partially addressed); NS = not stated; NA = not applicable.

Results of the Included Study

There was an improvement in total scores recorded for participants in the Shamiri-Digital intervention group. The lower scores recorded at the 2-week follow-up for depressive and anxiety symptoms show an improvement in functioning. There were no reported changes between adolescent mental health well-being at baseline and at 2-week follow-up. See Table 2 for details.

Table 2.
Symptom Reduction and Well-Being Improvement From Baseline to 2-Week Follow-Up for Both Shamiri-Digital Wellness Group and Study Skills Group.

Outcome Variable Shamiri-Digital Intervention Group Study Skills Control Group Cohen's d (Baseline to 2-week Follow-Up)

Baseline (M [SD]) 2-Week Follow-Up (M [SD]) Baseline (M [SD]) 2-Week Follow-Up M [SD])

Primary outcomes

Depressive symptoms 10.60 (5.37) 8.35 (4.69) 9.68 (4.75) 10.00 (4.65) .50 [.00, 1.06]

Anxiety symptoms 8.98 (5.12) 7.92 (4.48) 8.74 (5.30) 9.00 (4.45) .29 [–.20, .79]

Mental well-being 25.78 (4.43) 25.58 (4.00) 24.79 (4.51) 24.77 (4.59) –.04 [–.54, .46]

Discussion and Applications to Practice

We searched across eight databases and obtained only one article that met the eligibility criteria for digital school-based mental health interventions that have been conducted in a Sub-Saharan African context. There is a dearth of studies on school-based mental health intervention studies (Mabrouk et al., 2022), more so, among adolescent populations in Sub-Saharan Africa therefore this finding was not surprising. Also, research documenting the application of technology for the delivery of mental health services and interventions is only just beginning to gain momentum in Sub-Saharan Africa (Naslund et al., 2019).

The findings of this systematic review documented a randomized controlled trial intervention that has been developed and adapted for a Sub-Saharan African context. The computerized single-session intervention (Shamiri Digital) demonstrated positive outcomes for depression among adolescents in a school-based Sub-Saharan context (Osborn et al., 2020a), however, no academic outcomes in this school were observed or reported. A separate study was designed to evaluate the costs and cost-effectiveness of the Shamiri-Digital the same study team that developed the randomized control trial single session digital intervention (Wasil et al., 2021). The authors reported that the single-session intervention was cost-effective in treating depressive symptoms among adolescents in Sub-Saharan Africa (Wasil et al., 2021). Similarly, the feasibility of conducting digital mental health interventions in treating depression among adolescents has been well-received in other contexts such as India (Wasil et al., 2020), Jamaica (Maloney et al., 2020), and Vietnam (Sobowale et al., 2016).

Digital mental health technology has the capacity to complement task-shifting or sharing initiatives in many low-resource contexts. In Sub-Saharan Africa, school-based social workers are a scarce resource, and therefore a sound digital eco-system has the potential to strengthen the existing mental health workforce, thus bridging the adolescent mental health gap. Some studies in Sub-Saharan Africa have applied digital mental health technology in other contexts other than school settings though evidence on the effectiveness of these interventions remains limited (Chibanda et al., 2015; Gureje et al., 2015). That said, there is a need for more research on the different ways technology could potentially augment the role played by mental health paraprofessionals such as teachers and peer mentors in the delivery of mental health services.

Digital school-based mental health interventions that are brief, affordable, and feasible can be adapted further across diverse adolescent sub-populations especially if the “mental health task” can be easily shared between trained mental health professionals—in this case, the social workers and lay health workers or peer mentors. The use of precise theory—and research-based techniques as those observed in the wise interventions judiciously applied in the study included in this systematic review require more evidence for their feasibility, utility, and translation in other Sub-Saharan contexts (Osborn et al., 2020a, 2020c). The use of WIs as opposed to traditional evidence-based interventions (Osborn et al., 2020a, 2020c) presents an opportunity for debate and further research for mental health theory and practice particularly the cultural or contextual implications in low-resource school-based settings in Sub-Saharan contexts.

Furthermore, evidence-based interventions are highly structured and require trained mental health individuals to deliver, therefore digitalizing these interventions necessitates careful clinical implementation. Additionally, these mental health interventions ought to be accessible and equitable since many low-resource contexts globally grapple with a lean mental health workforce of social workers and other specialized mental health professionals (Iversen et al., 2021; Sequeira et al., 2022). Also, multiple level factors at policy, organizational, and individual levels must be considered when integrating technology into the mental health infrastructure (Graham et al., 2020).

For example, at an individual level, issues such as stigma, low digital literacy rate, preference for traditional face-to-face interventions, privacy, and confidentiality might discourage many people from opting for digital interventions. Similarly, organizational-level barriers such as lack of sufficient funding, low technical support, the perceived negative practitioner's attitude toward the digital intervention, and a recurring issue that many mental health interventions already grapple with—the lack of culturally sensitive and pluralistic elements embedded within the digital mental health intervention. These barriers affect the uptake and utilization of digital mental health interventions (Orsolini et al., 2021). That said, more evidence will be needed to demonstrate the feasibility and effectiveness of digital mental health interventions in school-based settings.

Involving multiple key community stakeholders in the development of these interventions is critical to the implementation of adolescent digital mental health interventions. In many low-resource contexts globally, the first step in this process would be to conduct a grassroots needs assessment of what is required, posing new research questions and establishing the contextual fit, exploring and brainstorming the different ways these challenges might be tackled. Another important step in this process would be to conduct feasibility and qualitative studies for digital mental health interventions especially when transporting and translating interventions from one context to another. Lastly, the co-production of knowledge with key community stakeholders should not be overlooked, especially, if policy makers, practitioners, and researchers are to actively seek out the knowledge for what mental health interventions might work for respective populations (Park et al., 2022). That is, multiple stakeholders hold diverse views and these views are important in developing digital solutions aimed at promoting user-friendly mental health services, especially for adolescents in low-resource school-based settings.

Conclusively, as scholars we are taught to acknowledge the reflexivity that we bring into our research work. Similarly, when developing interventions, especially those pertaining to mental health in low-resource contexts, it is helpful to be mindful of the cultural and contextual limitations of many current mental health interventions, as most of them have been developed and normed within predominantly Western cultures and contexts. Digital mental health interventions have the potential to work and bridge the current adolescent mental health gap. However, for them to work effectively, we need to revert to the drawing board, retrospectively analyze what has worked and not worked, pose new questions, answer these, and develop digital mental health interventions embodying the values of cultural sensitivity and pluralistic care. This is key to promoting their uptake and utility in many low-resource contexts worldwide while at the same time tackling mental health stigma among the adolescent population.

Type of Bias	Category	Support for Judgement
Randomization	Truly random ✓ Allocation concealment✓ Number stated✓	Low-risk-random assignment of study participants
Baseline comparability	Presented✓ Achieved✓ Inclusion criteria specified✓ Co-interventions identified✓	Low-risk adolescents between 13 and 18 years were eligible. No exclusion criteria were applied. The authors justify this by stating that the program was designed to improve wellness and academic functioning in a school-based setting
Blinding	Assessors✓ Administration✓ Participants NS Procedure assessed✓	Low risk
Withdrawals	> 80% in final analysis✓ Reason stated✓ Intention to treat✓ Other outcomes✓	Low risk Primary outcomes of depression anxiety and mental health well-being reported. Additionally, secondary outcomes on adolescent happiness and optimism reported

Outcome Variable	Shamiri-Digital Intervention Group	Study Skills Control Group	Cohen's d (Baseline to 2-week Follow-Up)
Primary outcomes
Depressive symptoms	10.60 (5.37)	8.35 (4.69)	9.68 (4.75)	10.00 (4.65)	.50 [.00, 1.06]
Anxiety symptoms	8.98 (5.12)	7.92 (4.48)	8.74 (5.30)	9.00 (4.45)	.29 [–.20, .79]
Mental well-being	25.78 (4.43)	25.58 (4.00)	24.79 (4.51)	24.77 (4.59)	–.04 [–.54, .46]

Footnotes

Author Note

Gloria Akello Abura-Meerdink is a PhD candidate in the Social Work PhD program at The University of Alabama, Tuscaloosa, Alabama. School of Social Work, The University of Alabama.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Gloria Akello Abura-Meerdink

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Outcome Variable	Shamiri-Digital Intervention Group		Study Skills Control Group		Cohen's d (Baseline to 2-week Follow-Up)
Outcome Variable	Baseline (M [SD])	2-Week Follow-Up (M [SD])	Baseline (M [SD])	2-Week Follow-Up M [SD])	Cohen's d (Baseline to 2-week Follow-Up)
Primary outcomes
Depressive symptoms	10.60 (5.37)	8.35 (4.69)	9.68 (4.75)	10.00 (4.65)	.50 [.00, 1.06]
Anxiety symptoms	8.98 (5.12)	7.92 (4.48)	8.74 (5.30)	9.00 (4.45)	.29 [–.20, .79]
Mental well-being	25.78 (4.43)	25.58 (4.00)	24.79 (4.51)	24.77 (4.59)	–.04 [–.54, .46]