Adolescents’ reflections on mental health: Key findings from a 13-country qualitative study

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Fine, Joanna Lai, Michelle R.M. Baack, Juliano D. De Oliveira, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6717469/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Adolescence is a sensitive developmental period for the emergence of mental health challenges, but few multi-country qualitative studies explore how adolescents themselves understand these challenges. Through focus group discussions (FGDs) with adolescents across 13 countries, this study aimed to understand adolescents’ perspectives on significant mental health challenges in their age group, key risk and protective factors, and principal coping strategies. Methods: A total of 71 FGDs were conducted between February and June of 2021. Countries were selected to ensure geographic, economic, and cultural diversity, and included: Belgium, Chile, China, the Democratic Republic of the Congo, Egypt, Indonesia, Jamaica, Jordan, Kenya, Malawi, Sweden, Switzerland, and the United States. Within each country, FGDs were stratified by sex and age. FGDs were recorded, transcribed verbatim, and translated into English for analysis. Results: Across countries, adolescents generally described and understood mental health challenges in terms of distress (e.g., sadness, loneliness, anger) rather than disorder (e.g., depression, anxiety). They emphasized the many contexts that drive mental health challenges, including family adversity, peer and school environments, pervasive violence, endemic poverty, and restrictive gender norms. They also discussed significant barriers to help-seeking, which frequently resulted in adolescents coping without what they perceived as sufficient support. Conclusions: Adolescents around the world highlighted numerous social and environmental factors that contribute to mental health challenges, as well as a pressing need for greater formal and informal supports. The non-clinical terminology favored by adolescents suggests that taking a purely diagnostic approach may exclude many adolescents in need of assistance. Psychology Epidemiology Adolescents Youth Mental health Risk and protective factors Help-seeking Low- and middle-income countries Qualitative study Implications and Contribution This 13-country qualitative study explores adolescents’ perceptions of significant mental health challenges among their age group, key risk and protective factors, and principal coping strategies. Findings emphasize that while the presentations, drivers, and coping strategies may differ across geographies, mental health is a pressing issue among adolescents around the world. Introduction Adolescence (ages 10-19) is a period of rapid development marked by dramatic biological, cognitive, social, and emotional changes [1,2]. While adolescence is generally considered to be one of the healthiest periods within the life course, with lower morbidity and mortality relative to other phases of life in most regions of the world, these statistics mask the critical nature of adolescence in influencing life-long health trajectories [2]. Adolescents are vulnerable to a range of risky health-related behaviors, including substance use, interpersonal violence, and early sexual activity, and these behaviors can contribute to myriad negative health outcomes later in life [1]. Additionally, mental health challenges such as depression, anxiety, conduct disorders, and eating disorders commonly emerge during this time, impacting an estimated 14% of adolescents globally [3]. These mental health challenges can persist well into adulthood [4], with multi-country research suggesting that around 50% of all lifetime mental disorders have their first onset by the end of adolescence [5,6]. As such, adolescence offers an essential window for mental health prevention and promotion efforts. The past decade has been characterized by multiple emergent threats to adolescent mental health. The COVID-19 pandemic significantly disrupted adolescents’ lives through infection mitigation strategies such as mobility restrictions, social distancing requirements, and school closures, with documented impacts on depression and anxiety [7,8]. Climate change jeopardizes adolescent mental health through both direct and indirect pathways, including exposure to extreme weather events, increasing temperatures, exacerbation of existing health disparities, and growing awareness of uncertain futures [9]. Global forced displacement has reached record levels, with an estimated 43.3 million children and adolescents in 2022 displaced as a result of persecution, conflict, violence, human rights violations, and other serious disruptions [10], and an estimated 449 million children and adolescents live in areas impacted by armed conflict [11]. Given the growing prominence of digital communications in the daily lives of adolescents around the world, there is substantial concern alongside mounting evidence regarding the ways in which such technologies may be detrimental to adolescent mental health and well-being [12,13]. While the mental health impacts of such complex issues have raised serious alarms worldwide, significant gaps remain in terms of research, services, and policies specifically targeting adolescent mental health. Most notably, despite 90% of the world’s adolescents living in low- and middle-income countries (LMICs), little adolescent mental health research has been conducted in these settings [14,15]. Further, existing evidence suggests that the vast majority of mental health needs among adolescents in LMICs go unrecognized and untreated due to factors such as provider shortages, lack of supportive national policies, and widespread stigma around mental health challenges [16,17]. There is also growing acknowledgment of the need for sustained engagement of adolescents themselves across mental health research and programmatic efforts [18,19]. This includes the incorporation of adolescents with lived experiences of mental health challenges in order to increase the quality, relevance, and practical impact of mental health-related activities [20–22] It is within this greater context that the United Nations Children’s Fund (UNICEF) focused its flagship State of the World’s Children 2021 report around child, adolescent, and caregiver mental health [23,24]. As part of this effort, UNICEF collaborated with investigators from the Johns Hopkins University (JHU) Global Early Adolescent Study (GEAS), alongside global partners, to conduct a series of focus group discussions (FGDs) with adolescents across 13 countries. This qualitative investigation had three central aims: (1) to understand adolescents’ perspectives on significant mental health challenges in their age group; (2) to understand adolescents’ perspectives on what causes and protects them from mental health challenges; and (3) to understand the ways in which adolescents cope with mental health challenges, including barriers and facilitators to help-seeking. In the current study, we will present overarching themes captured by this cross-country qualitative investigation focused around these three aims. It is important to note that while we will synthesize the breadth of topics discussed by adolescents across the 13 participating countries, our intention is not to do so in depth. Rather, our goal is to illustrate overall findings – with a related set of analyses delving into specific salient topics in much greater detail. Methods Study Settings The current study describes results from a collaboration between UNICEF, JHU, and global partners. With the aim of understanding adolescents’ perspectives on mental health across diverse geographic, economic, and cultural environments, qualitative research was conducted by partner organizations in the following country settings: Aalst, Brussels, Couvin, Huy, and Namur, Belgium; Santiago, Chile; Shanghai, China; Kinshasa, Democratic Republic of the the Congo (DRC); Assiut, Egypt; Yogyakarta, Indonesia; Kingston, Jamaica; Amman, Jordan; Nairobi, Kenya; Blantyre, Malawi; Stockholm, Sweden; Lausanne, Switzerland; and New Orleans, United States. Partner organizations across these countries were engaged due to their extensive expertise in conducting adolescent health research. Qualitative data collection within each country largely focused on adolescents living in low- or middle-income, urban or peri-urban areas. The primary exceptions to this are Jamaica, which included several FGDs with adolescents living in rural areas, and Jordan, which focused on Syrian refugees living in a rural refugee camp. Further contextual details across the 13 countries are included in Table 1. Table 1. Adolescent mental health focus group discussions Country Setting Partner Organization FGDs Data Collection Population Belgium Couvin, Huy, and Namur (Francophone) Centre de Référence en Santé Mentale 4 In-person School-based sample from low- and middle-income peri-urban areas Aalst and Brussels (Flemish) Steunpunt Geestelijke Gezondheid 2 In-person School-based sample from middle-income urban and peri-urban areas Chile Santiago Universidad de Santiago de Chile 6 Online Community-based sample from low-income urban areas; largely migrants China Shanghai Shanghai Institute for Biomedical and Pharmaceutical Technologies 6 In-person School-based sample from mixed-income urban areas; included both migrants and local residents Democratic Republic of the Congo Kinshasa Kinshasa School of Public Health 4 In-person School- and community-based sample from mixed-income urban areas Egypt Asyut Assiut University 6 In-person Community-based sample from low-income peri-urban areas Indonesia Yogyakarta Universitas Gadjah Mada 4 In-person School-based sample from middle-income urban areas Jamaica Kingston University of the West Indies 9 Online School- and community-based samples from mixed-income rural and urban areas Jordan Amman Terre des Hommes 4 In-person Community-based sample of Syrian refugees from low-income, rural refugee camp Kenya Nairobi African Population and Health Research Center 4 In-person Community-based sample from low-income urban informal settlement Malawi Blantyre Kamuzu University of Health Sciences 4 In-person School-based sample from low-income urban areas Sweden Stockholm Karolinska Institutet 10 In-person School-based sample from high- and mixed-income urban areas Switzerland Lausanne Unisanté 4 Online Community-based sample from mixed income urban and peri-urban areas United States New Orleans Institute of Women and Ethnic Studies 4 Online Community-based sample from low-income urban areas Participants and Procedures Each participating country hosted a minimum of four (and up to ten) FGDs with adolescents between February and June 2021. In general, these FGDs were equally divided by sex and age such that there were at least two younger (ages 12-15) and two older (ages 16-19) FGDs held separately with boys and girls in each country. The purpose behind this stratified approach was to allow for the targeted discussion of specific issues that may vary across these groups. Given the salience of mental health in adolescence, four age- and sex-specific FGDs were deemed sufficient in order to achieve theoretical saturation across countries [25]. Country partners in Belgium, Chile, China, Egypt, Jamaica, and Sweden also elected to conduct additional FGDs. In two countries, Belgium and Sweden, one or more of these additional FGDs were held with mixed sex groups. Groups ranged in size from 3 to 12 participants, with an average of 8 participants per group across countries. While participant recruitment strategies varied, adolescents were generally recruited through schools, youth groups, health centers, and community-based organizations. In total, 71 FGDs were held with 554 adolescents across the 13 participating countries. A more detailed description of FGD participants across countries can be found in Appendix A. All FGDs were implemented by experienced local facilitators using a standardized FGD guide (see Appendix B) which was developed collaboratively by UNICEF, JHU, and country partners. In alignment with the study’s aims, this FGD guide included sections focused on: (1) mental health problems faced by young people, (2) risk and protective factors, (3) coping strategies and health-seeking behaviors, and (4) the mental health impacts of the COVID-19 pandemic. In order to train FGD facilitators across countries, qualitative research experts affiliated with JHU hosted a series of three-hour online training sessions which focused on the study’s research questions, data collection processes, qualitative research guidelines, human subjects research ethics, and documentation methods. Following these online training sessions, site coordinators in each country held local trainings with FGD facilitators focused on reviewing and practicing with the FGD guide. FGD facilitators had varied positionality in relation to study participants because of the diversity of country partner organizations; however, the majority were affiliated with academic institutions. Depending on the local COVID-19 restrictions at the time, FGDs including only the facilitator(s) and adolescent participants were either held in-person or online. In-person FGDs took place in “adolescent-friendly” venues (e.g., schools or community-based organizations) in which adolescents were able to be comfortable and their privacy assured. Virtual FGDs took place on the Zoom or Skype platform using the “gallery” view to ensure that all participants were able to see each other. FGDs were conducted in the local language of each study setting and lasted between 60 and 90 minutes. FGDs were audio-recorded and transcribed verbatim, and field notes were written immediately after each session. When necessary, transcribed audio recordings and typed field notes were translated into English for analysis. So as to ensure consistency across countries, both the transcription and translation processes were undertaken using conventions outlined in standardized protocols developed by the JHU investigators. In addition, the site coordinator in each country performed random quality checks of the transcripts to review the accuracy and comprehensibility of the translations. Ethical Approval Prior to data collection, all country partners obtained ethical approval from their local ethical review boards, including structured protocols to respond in the event that a participant experienced distress. In addition, the cross-country research protocol was submitted to the JHU Institutional Review Board, which determined that the role of JHU investigators, including the secondary data analysis of de-identified, qualitative data, did not qualify as human subjects research. For any adolescents under the age of 18, a parent or guardian gave verbal or written informed consent for their child’s participation. In addition, all adolescents gave verbal or written informed consent or assent for their own participation. Data Analysis This study was guided by elements from grounded theory, a methodological approach that allows findings to emerge inductively from qualitative data [26]. Qualitative data, which consisted of the English translations of FGD transcripts and field notes, were coded using inductive thematic analysis focused largely on identifying salient semantic themes across countries [27]. Analysis began with a process of open coding, with lines of data closely examined and descriptive codes generated based on significant content within. The first phase of open coding was carried out by three analysts using data from four of the countries – China, Egypt, Jordan, and Jamaica – which were selected for their contextual diversity. After independently coding transcripts, initial codes were compared and refined, consolidated into broader categories, and organized into a preliminary codebook (see Appendix C). This codebook was further refined throughout the data analysis process, with two analysts working to systematically apply it to the full set of cross-country qualitative data . In order to increase credibility [28], preliminary country-specific findings were presented to local stakeholders in order to obtain feedback on points of agreement or disagreement and any missing information. Two qualitative analysis software programs – ATLAS.ti (Version 9.1) [29] and MAXQDA 2022 [30] – were used to help organize and analyze the data. Results Overarching findings from this 13-country qualitative study are organized along its three aims: namely, understanding adolescents’ perceptions of significant mental health challenges among their age group, key risk and protective factors, and principal coping strategies. Within each of these aims, we propose a key unifying theme which captures the cross-cutting perspectives of adolescents across diverse country settings. More comprehensive discussions related to these themes are presented in separate analyses [31–35]. Key Theme #1: Terms of distress rather than disorder Across participating countries, adolescents reflected upon the most important mental health challenges faced by young people their age. One of the cross-cutting themes that emerged was adolescents’ consistent reliance on a wide array of largely non-clinical terminology in discussing experiences of distress. For example, adolescents around the world mentioned feelings of stress, pressure, sadness, depression, anxiety, anger, irritability, fear, isolation, loneliness, boredom, suicidality, brokenness, hopelessness, despair, and defeat. While some of this language corresponds with mental disorders and their associated symptoms, it was apparent that adolescents more often describe and understand mental health challenges outside of existing diagnostic categories. For instance, in one particularly powerful illustration, an older girl from Egypt described a state of being “tired psychologically”: It means that you feel that you are not living life and [are] unable to do anything and [are] bored, keeping to yourself and you don’t want to deal with anyone...you will not be able to achieve your ambitions because you are psychologically totally defeated. (Older girl, Egypt) Even when adolescents did mention specific clinical terminology such as depression and anxiety, it was clear that they did not always use these labels to denote clinical diagnoses, with their descriptions of both of these terms indicating immense variability in their perceptions and experiences. Most frequently, adolescents across participating countries discussed depression, which ranged from transient sadness to ongoing despair. Likewise, some adolescents characterized anxiety as a commonplace reaction to daily stressors, whereas others described the ways in which it could become completely disabling. Regardless of the specific categorization, it appears that this spectrum of distress and impairment – from the mild to the severe – is widely understood by adolescents around the world. Further, many adolescents articulated a nuanced understanding of mental health that goes beyond the simple presence or absence of disorder. I don’t think you can prevent someone from getting sad…but you can be able to deal with it when it’s at a low level so that it doesn’t grow and spread like wildfire. You know, like it just blossoms out into something as big as depression. (Older girl, Jamaica) I have also been through several crises of anxiety for such minimal issues that maybe people look at them [and don’t understand], and for you it is so strong or complicated that you think the world is ending. (Older girl, Chile) Key Theme #2: Contexts shape mental health Adolescents around the world highlighted the centrality of the contexts in which they live, grow, study, and play in shaping their mental health. A primary theme was adolescents’ recognition of the ways in which overlapping social environments could both protect and damage their well-being. Participants described how supportive, attentive, communicative, nonjudgmental, and trusting families formed an essential foundation for psychosocial adjustment. All too often, however, adolescents labeled such qualities as aspirational, and many identified profound risks to their mental health resulting from experiences of abuse and neglect, controlling behaviors, immense pressure, a lack of support, and poor communication within their families. While supportive peer relationships bolstered adolescent well-being and helped them cope with social and emotional challenges, participants also noted that peers could be a damaging source of betrayal, judgment, bullying, and pressure towards risky behaviors. Likewise, although many adolescents recognized schools as a source of support, learning, and socialization, school environments were more frequently discussed in terms of academic pressure, unsupportive or abusive teachers, and barriers to accessing education. Within communities, adolescents highlighted multifaceted vulnerabilities stemming from pervasive violence [31], inequitable gender norms [32], and endemic poverty [33]. Digital environments were portrayed as a “double-edged sword,” strengthening adolescents’ social networks and facilitating greater support while simultaneously engendering harmful social comparisons, cyber harassment, and internet addiction [34]. Across these social environments, adolescents recognized the profound impacts of the COVID-19 pandemic in shaping their exposure to both risk and protective factors. A detailed exploration of these risk and protective factors is beyond the scope of the current analysis – and many have been discussed in greater depth in the related manuscripts cited above, which focus on adolescent mental health in relation to family relationships, violence [31], gender norms [32], poverty [33], and digital communication [34]. It is important to emphasize, however, that adolescents’ discussions revealed important geographic and gender-related differences in the central drivers of mental health and well-being. For example, poverty had the greatest salience in low-income countries [33] while digital technologies arose most prominently in middle- and high-income countries [34]. Likewise, it was clear that there are differences in violence exposures between boys and girls, with girls much more strongly emphasizing the mental health risks stemming from both threatened and experienced sexual violence [31]. Regardless of such variations, participants’ reflections and associated language suggest that adolescents often perceive mental health challenges as inextricably linked to underlying contextual drivers. Key Theme #3: Coping without sufficient support During the FGDs, participants were asked to consider the ways in which adolescents generally coped with emotional and behavioral difficulties, including important sources of support. Adolescents frequently emphasized that they felt the greatest comfort in seeking support from friends their age, although many also mentioned a reliance on family members, particularly when dealing with severe problems [35]. More often, however, adolescents across geographies detailed the many barriers to seeking help: widespread mental health stigma; unavailable, inaccessible, or low-quality services; fears around judgment, misunderstanding, invalidation, or untrustworthiness from friends or family members; and difficulty articulating emotional distress. Such barriers commonly resulted in adolescents choosing to cope on their own, and a resounding theme across countries was the frequency with which adolescents would “hide,” “close off,” “lock up,” “bottle up,” “swallow,” or “keep quiet about” their feelings. While this was seen as a particularly common response among boys – tied to masculine norms which center restrictive emotionality [32] – it was voiced by both boys and girls. I know a lot of people who...have been going through situations where they are depressed...and they don’t tell their stories, they don’t talk to you about it...Every day that you see them, they have a smile on their face...they try to behave as normal as possible so that you don’t ask questions. (Younger girl, Jamaica) Sometimes people just keep it all bottled up inside themselves and they cry because they’re scared that someone’s going to say something. That their problems are not normal. (Younger girl, Belgium) We will keep to ourselves, we will try to keep it all within ourselves and try to hide the problem even if some people see that something is wrong. (Younger boy, Switzerland) In addition to closing themselves off, adolescents described a range of other maladaptive coping mechanisms. The most common of these included drug and alcohol use, which was widely mentioned especially by boys as a method for “releasing” stress, “relieving” distress, and “forgetting” problems. A number of adolescents also discussed turning to self-harm as a cry for attention or, as one younger girl in Jamaica said, as a way of using physical pain to “help block the emotional and mental pain.” Most people nowadays abuse drugs to reduce stress, then little by little you find yourself becoming an addict...when you use them you kind of forget about your worries and the stress. (Older boy, Kenya) This smoking habit causes my stress to go away, even though I know it’s not a good thing to do. So if you ask me in detail as to why I feel stressed, I don’t know. All I know is that I feel lonely and empty. (Older girl, Indonesia) Some cut themselves just because they kind of want to feel something, and they want to hurt themselves because they do not like themselves. (Younger girl, Sweden) While such strategies were somewhat balanced by more positive individual approaches for managing distress – for instance, through relaxation, socialization, self-expression, or exercise – it was clear that all too often, adolescents around the world cope with pressing mental health challenges without sufficient external support. Discussion Adolescents across 13 diverse countries discussed numerous factors which threaten young people’s mental health as well as ongoing struggles to receive sufficient support. To our knowledge, this is the largest cross-country qualitative study to date which has focused on elucidating adolescents’ own perspectives regarding mental health. Findings emphasize that while the presentations, drivers, and coping strategies may differ across geographies, mental health is a pressing issue among adolescents worldwide. A central finding from this study relates to the extensive range of mostly non-clinical terminology favored by adolescents when discussing their mental health, with language that frequently reflected broad symptomatic distress rather than categorical psychopathological disorder. While this is certainly not a surprising finding within a general sample of adolescents, it has important implications for the ways in which we categorize and intervene upon adolescent mental health around the world. There is growing recognition globally regarding the limitations of framing mental health challenges entirely through the presence or absence of discrete diagnostic categories (e.g., major depressive disorder, generalized anxiety disorder) [36,37]. Increasingly, researchers and practitioners have argued that this biomedical approach privileges clinical treatment rather than public health prevention, thereby ignoring substantial evidence regarding the importance of targeting contextual factors throughout the life course [36]. This focus on diagnosis may be particularly problematic among adolescents given evidence that emerging mental health challenges are often characterized by non-specific or transdiagnostic symptomatic manifestations [38,39]. Further, mounting criticism has called into question the cross-cultural relevance, reliability, and validity of Western-constructed psychiatric classification systems [40–42]. Findings from the current study give additional weight to these arguments by emphasizing that categorical diagnoses may not be reflective of the way adolescents themselves understand and discuss their own mental health. Adolescents around the world voiced a spectrum of mental health challenges with tangible impacts on their lives despite not necessarily rising to the level of psychopathology. As such, it is apparent that taking a purely diagnostic approach across both screening and treatment efforts may exclude many adolescents in need of support. Instead, as is increasingly recommended, it is clear that these efforts should take a more dimensional approach which recognizes variable stages in the progression of mental health challenges during this sensitive developmental period [36,37]. Results from this study also underscore the necessity of targeting social and environmental determinants in order to influence adolescent mental health. It was clear that adolescents frequently perceive ongoing states of distress as being inseparable from underlying contextual factors: for example, feeling “psychologically totally defeated” as a result of gender norms which severely restrict girls’ self-realization. Advocates for mental health prevention and promotion approaches have long argued that treatment alone is insufficient, and that upstream strategies are absolutely essential in order to reduce the global burden of mental health challenges [36]. These arguments have particular salience when applied to adolescents, given the potential to mitigate acute and chronic mental health challenges throughout the life course through focused prevention and early intervention efforts during this sensitive developmental period [4,38,43]. There is concrete evidence regarding the impact of such strategies. For example, a large body of research suggests that family-focused prevention approaches targeting parents’ or caregivers’ capacities can significantly improve mental health among adolescents [44–46]. Likewise, there is a growing emphasis on whole school approaches that collectively target classroom settings, school environments, and family and community partnerships in order to promote health and well-being among students [47,48], and recent guidelines released by the World Health Organization (WHO) and United Nations Educational, Scientific and Cultural Organization outline global standards for supporting mental health through health promoting schools [49,50]. Beyond families and schools, the current study suggests the necessity of integrating a mental health prevention focus into efforts targeting a wider range of structural factors: for example, violence, poverty, and gender inequity. Notably, this broad range of suggestions aligns with the WHO’s Global Accelerated Action for the Health of Adolescents agenda, which emphasizes the importance of structural interventions (e.g., policies focused on socioeconomic determinants), organizational interventions (e.g., strengthening health promoting schools), and interpersonal interventions (e.g., increasing parenting skills) in order to address common mental health challenges in adolescence [51]. Finally, it was evident that adolescents around the world need better formal and informal supports to adequately address their mental health needs. A cross-cutting refrain was the deep isolation that can result from distress, with adolescents often masking their struggles from the outside world and instead coping entirely on their own. This aligns with existing evidence regarding acute mental health treatment gaps among adolescents worldwide which suggests that the majority of adolescents are reluctant to seek help for their mental health challenges [52]. According to one systematic review focused on barriers and facilitators of help-seeking, common barriers reported by adolescents included their shame and embarrassment due to perceived mental health stigma as well as their desire to cope with problems by themselves [53]. Further, even when adolescents are willing to seek help, there are many settings around the world in which appropriate services are simply not available [16]. This evidence, alongside findings from the current study, emphasizes the need for multi-level stigma reduction and mental health literacy strategies that encourage adolescents to openly discuss their mental health concerns while equipping peers, caregivers, and other trusted individuals with the skills to help. In addition, where more intensive support is needed, it is critical to ensure that adolescents have access to appropriate mental health and psychosocial support services. Several limitations to this study should be noted. The inclusion of 13 countries with different geographic, economic, and cultural environments was intended to reflect the viewpoints of a diverse group of adolescents. It is important to emphasize, however, that these results cannot be considered transferable either within or across countries. For example, as most adolescents were drawn from urban environments, findings may not adequately capture the perspectives of those living in rural areas. Further research should endeavor to replicate these efforts with adolescents living in additional contexts. Data analysis relied on English translations of original language transcripts and was primarily conducted by two English-speaking analysts based at an academic institution in the United States. While efforts were made to reduce translation issues through review by bilingual researchers in each country, the large number of included countries increases the likelihood that pertinent information was lost in translation. Further, while local stakeholders were involved in preliminary analysis efforts in order to triangulate findings, the positioning of the data analysts may have influenced the interpretation of results. Young people around the world are reshaping the conversation around mental health and driving positive changes related to how society views and addresses mental health challenges. Through listening to their voices, we can better understand a spectrum of mental health challenges which extend beyond existing diagnostic categories, the complex social and environmental conditions which give rise to these challenges, and the difficulties many young people face in receiving adequate assistance. It is clear that active listening and engagement with young people is essential for guiding mental health prevention and promotion efforts, and for making mental health and psychosocial supports more relevant, accessible, destigmatized, and inclusive across sectors. Abbreviations LMICs low- and middle-income countries UNICEF United Nations Children’s Fund JHU Johns Hopkins University GEAS Global Early Adolescent Study FGD focus group discussion DRC Democratic Republic of the Congo WHO World Health Organization Declarations Funding Information: This work was supported by Wellcome Trust through a contract with UNICEF Headquarters for the preparation of the State of the World’s Children 2021 report, On My Mind: Promoting, protecting and caring for children’s mental health. Acknowledgements: This study was developed in conjunction with UNICEF’s State of the World’s Children 2021 report, On My Mind: Promoting, protecting and caring for children’s mental health . The study was initiated by UNICEF Headquarters in collaboration with the Johns Hopkins University Global Early Adolescent Study, and was made possible through partnerships with organizations across 13 countries. In particular, we would like to acknowledge the following individuals: in Belgium, Eveline Couck and Maud Dominicy from UNICEF Belgium, Léa Tilkens and Alexis Vanderlinden from Centre de Référence en Santé Mentale, and Stefaan Plysier from Steunpunt Geestelijke Gezondheid; in Chile, Francisca Dávalos, Pablo Villalobos, Jorge Puga, and Matilde Maddaleno from Universidad de Santiago de Chile; in China, Xiayun Zuo, Chaohua Lou, Chunyan Yu, and Qiguo Lian from the Shanghai Institute for Biomedical and Pharmaceutical Technologies; in the Democratic Republic of the Congo, Aimée Lulebo, Benito Kazenza, and Eric Mafuta from the Kinshasa School of Public Health; in Egypt, Omaima El Gibaly and Doaa Mohammed Mohammed from Assiut University; in Indonesia, Siswanto Wilopo and Amira Wahdi from Universitas Gadjah Mada; in Jamaica, Abigail Harrison, Caryl James, Donna Kamicka, Georgia Satchwell, and Christina Silvera from the University of the West Indies; in Jordan, Marta Alberici, Sana Alhyari, Maria Bray, and Meilaa Khateeb from Terre des Hommes; in Kenya, Caroline Kabiru and Beatrice Maina from the African Population and Health Research Center; in Malawi, Effie Chipeta, William Stones, Princess Kayira, and Razak Mussa from the Kamuzu University of Health Sciences; in Sweden, Anna Mia Ekström, Carl Fredrik Sjöland, Leo Ziegel, and Maria Stålgren from Karolinska Institutet; in Switzerland, Yara Barrense-Dias, Lorraine Chok, Joan Carles Suris Granell, and Sophie Stadelmann from Unisanté; in the United States, Denese Shervington, Lisa Richardson, Jakevia Green, Gabrielle Roude, Jennifer Latimer, and Tylar Williams from the Institute of Women and Ethnic Studies. We are immensely grateful to these researchers and program specialists who helped to shape the research questions and then organized, facilitated, recorded, transcribed, and translated focus group discussions with adolescents. We would also like to gratefully acknowledge the support from the Wellcome Trust and from UNICEF country offices. Above all, we are thankful for the young people around the world who gave their candid insights during 71 focus groups discussions. Conflicts of Interest: The authors have no conflicts of interest to disclose. References Sawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. The Lancet 2012;379:1630–40. Patton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet commission on adolescent health and wellbeing. The Lancet 2016;387:2423–78. Institute for Health Metrics and Evaluation. GBD Results. Available at: https://vizhub.healthdata.org/gbd-results/. Patel V, Flisher AJ, Hetrick S, et al. Mental health of young people: a global public-health challenge. The Lancet 2007;369:1302–13. McGrath JJ, Al-Hamzawi A, Alonso J, et al. Age of onset and cumulative risk of mental disorders: a cross-national analysis of population surveys from 29 countries. Lancet Psychiatry 2023. Solmi M, Radua J, Olivola M, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 2022;27:281–95. Harrison L, Carducci B, Klein JD, et al. Indirect effects of COVID-19 on child and adolescent mental health: an overview of systematic reviews. BMJ Glob Health 2022;7:e010713. Deng J, Zhou F, Hou W, et al. Prevalence of mental health symptoms in children and adolescents during the COVID-19 pandemic: A meta-analysis. Ann N Y Acad Sci 2023;1520:53–73. van Nieuwenhuizen A, Hudson K, Chen X, et al. The Effects of Climate Change on Child and Adolescent Mental Health: Clinical Considerations. Curr Psychiatry Rep 2021;23:88. United Nations High Commissioner for Refugees. Global Trends: Forced Displacement in 2022. Copenhagen: United Nations High Commissioner for Refugees; 2023. Save the Children. Stop the War on Children: The Forgotten Ones. Save the Children; 2022. Santos RMS, Mendes CG, Sen Bressani GY, et al. The associations between screen time and mental health in adolescents: a systematic review. BMC Psychol 2023;11:127. Valkenburg PM, Meier A, Beyens I. Social media use and its impact on adolescent mental health: An umbrella review of the evidence. Curr Opin Psychol 2022;44:58–68. Kieling C, Baker-Henningham H, Belfer M, et al. Child and adolescent mental health worldwide: evidence for action. The Lancet 2011;378:1515–25. Erskine HE, Baxter AJ, Patton G, et al. The global coverage of prevalence data for mental disorders in children and adolescents. Epidemiol Psychiatr Sci 2017;26:395–402. Morris J, Belfer M, Daniels A, et al. Treated prevalence of and mental health services received by children and adolescents in 42 low-and-middle-income countries. J Child Psychol Psychiatry 2011;52:1239–46. Juengsiragulwit D. Opportunities and obstacles in child and adolescent mental health services in low- and middle-income countries: a review of the literature. WHO South-East Asia J Public Health 2015;4:110–22. McCabe E, Amarbayan MM, Rabi S, et al. Youth engagement in mental health research: A systematic review. Health Expect Int J Public Particip Health Care Health Policy 2023;26:30–50. Yamaguchi S, Bentayeb N, Holtom A, et al. Participation of Children and Youth in Mental Health Policymaking: A Scoping Review [Part I]. Adm Policy Ment Health Ment Health Serv Res 2023;50:58–83. Ali AZ, Wright B, Curran JA, et al. Review: Patient engagement in child, adolescent, and youth mental health care research – a scoping review. Child Adolesc Ment Health n.d.;n/a. Faithfull S, Brophy L, Pennell K, et al. Barriers and enablers to meaningful youth participation in mental health research: qualitative interviews with youth mental health researchers. J Ment Health Abingdon Engl 2019;28:56–63. Sheikhan NY, Kuluski K, McKee S, et al. Exploring the impact of engagement in mental health and substance use research: A scoping review and thematic analysis. Health Expect n.d.;n/a. United Nations Children’s Fund. The State of the World’s Children 2021: On My Mind – Promoting, protecting and caring for children’s mental health. New York: UNICEF; 2021. Johns Hopkins Bloomberg School of Public Health, United Nations Children’s Fund. On My Mind: How adolescents experience and perceive mental health around the world. Baltimore and New York: JHU and UNICEF; 2022. Sandelowski M. Sample size in qualitative research. Res Nurs Health 1995;18:179–83. Charmaz K. Constructing grounded theory: A practical guide through qualitative analysis. London: Sage Publications; 2006. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park: Sage Publications; 1985. ATLAS.ti Version 9.1. ATLAS.ti Scientific Software Development GmbH 2013. VERBI Software. MAXQDA 2020 2019. Ramaiya A, Wheeler J, Stones W, et al. Understanding adolescents’ perceptions and experiences of violence victimization and its perceived impact on mental health: a qualitative study across 13 countries. Under review. Fine SL, Harrison A, Rykiel NA, et al. Adolescents’ perceptions of gendered influences on mental health: Results from a 13-country qualitative study. Under review. Maina BW, Athero S, Ziegel L, et al. Poverty as a social determinant of mental health among young people: Qualitative findings across 13 countries. Under review. Ziegel L, Sjöland CF, Xiayun Z, et al. "It depends (on what you do with it)”: Adolescent perspectives on digital communication and mental health in 11 countries. Under review. Wahdi AE, James C, Nadhira DA, et al. Barriers and facilitators of seeking help for mental health challenges among adolescents across 13 countries: A qualitative investigation Under review. Patel V, Saxena S, Lund C, et al. Transforming mental health systems globally: principles and policy recommendations. Lancet Lond Engl 2023;402:656–66. Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development. The Lancet 2018;392:1553–98. Uhlhaas PJ, Davey CG, Mehta UM, et al. Towards a youth mental health paradigm: a perspective and roadmap. Mol Psychiatry 2023:1–11. McElroy E, Belsky J, Carragher N, et al. Developmental stability of general and specific factors of psychopathology from early childhood to adolescence: dynamic mutualism or p-differentiation? J Child Psychol Psychiatry 2018;59:667–75. Malott KM, Barraclough S, Yee T. Towards Decolonizing Diagnosis: a Critical Review and Suggested Alternatives. Int J Adv Couns 2023;45:1–17. Bemme D, Kirmayer LJ. Global Mental Health: Interdisciplinary challenges for a field in motion. Transcult Psychiatry 2020;57:3–18. Summerfield D. How scientifically valid is the knowledge base of global mental health? BMJ 2008;336:992–4. World Health Organization. Guidelines on mental health promotive and preventive interventions for adolescents: Helping adolescents thrive. Geneva: World Health Organization; 2020. Yap MBH, Morgan AJ, Cairns K, et al. Parents in prevention: A meta-analysis of randomized controlled trials of parenting interventions to prevent internalizing problems in children from birth to age 18. Clin Psychol Rev 2016;50:138–58. Kuhn ES, Laird RD. Family support programs and adolescent mental health: review of evidence. Adolesc Health Med Ther 2014;5:127–42. Healy EA, Kaiser BN, Puffer ES. Family-based youth mental health interventions delivered by nonspecialist providers in low- and middle-income countries: A systematic review. Fam Syst Health J Collab Fam Healthc 2018;36:182–97. Goldberg JM, Sklad M, Elfrink TR, et al. Effectiveness of interventions adopting a whole school approach to enhancing social and emotional development: a meta-analysis. Eur J Psychol Educ 2019;34:755–82. Shackleton N, Jamal F, Viner RM, et al. School-Based Interventions Going Beyond Health Education to Promote Adolescent Health: Systematic Review of Reviews. J Adolesc Health 2016;58:382–96. World Health Organization, United Nations Children’s Fund, United Nations Educational, Scientific and Cultural. How school systems can improve health and well-being: topic brief: mental health. Geneva: World Health Organization; 2023. World Health Organization, United Nations Educational, Scientific and Cultural. Making every school a health-promoting school: implementation guidance. Geneva: World Health Organization and United Nations Educational, Scientific and Cultural; 2021. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation, second edition. Geneva: 2023. Aguirre Velasco A, Cruz ISS, Billings J, et al. What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review. BMC Psychiatry 2020;20:293. Radez J, Reardon T, Creswell C, et al. Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. Eur Child Adolesc Psychiatry 2020. Additional Declarations The authors declare no competing interests. Supplementary Files PreprintsAdolescentMHSupplementalFiles.docx Adolescent Mental Health Key Themes: Supplementary Files Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6717469","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":459967283,"identity":"457b28c5-b4c2-4b83-b1f5-266f135f2923","order_by":0,"name":"Shoshanna L. Fine","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYDACdsYHBxgYbJgNQBweorQwMxsAtaSRqAVIHmYgXot8MzPj4YKK8+zmEgmMD962EaHF4DAzw+EZZ24zW85IYDacS5QWZv4Dh3nbbjMb3Ehgk+YlRgvQYQyHef+dA2lh/02UFgaQw3gbDoBtYSZKC9gvPMeSmQ3OPGyWnHOOGIe1NzN/5qmxSzY4nnzww5syYhwGBckMDIwNJKgHAjvSlI+CUTAKRsGIAgCDnjG8qjv6vAAAAABJRU5ErkJggg==","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Shoshanna","middleName":"L.","lastName":"Fine","suffix":""},{"id":459967284,"identity":"4d53d900-2514-465a-b3dc-085156fc5384","order_by":1,"name":"Joanna Lai","email":"","orcid":"","institution":"UNICEF Headquarters","correspondingAuthor":false,"prefix":"","firstName":"Joanna","middleName":"","lastName":"Lai","suffix":""},{"id":459967285,"identity":"3f6abf33-547f-4a9b-a03a-c7bdae622be7","order_by":2,"name":"Michelle R.M. Baack","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"R.M.","lastName":"Baack","suffix":""},{"id":459967286,"identity":"9e3cefce-0e99-417d-abdf-e5ee9946537f","order_by":3,"name":"Juliano D. De Oliveira","email":"","orcid":"","institution":"UNICEF Headquarters","correspondingAuthor":false,"prefix":"","firstName":"Juliano","middleName":"D.","lastName":"De Oliveira","suffix":""},{"id":459967287,"identity":"66b29d50-a453-4554-a9c0-9303a1ef7168","order_by":4,"name":"Robert W. Blum","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"W.","lastName":"Blum","suffix":""}],"badges":[],"createdAt":"2025-05-21 14:27:53","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6717469/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6717469/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83435578,"identity":"7be506ae-7733-4a6f-8601-c3df132960a9","added_by":"auto","created_at":"2025-05-26 08:25:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":570637,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6717469/v1/dce3ebde-44c8-4f7e-b23f-22e7ff8c88da.pdf"},{"id":83434922,"identity":"d2ac1f59-ce1c-487f-9e92-39b2a63e6066","added_by":"auto","created_at":"2025-05-26 08:17:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":40919,"visible":true,"origin":"","legend":"\u003cp\u003eAdolescent Mental Health Key Themes: Supplementary Files\u003c/p\u003e","description":"","filename":"PreprintsAdolescentMHSupplementalFiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-6717469/v1/bf08cf35e578d4e33966542f.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAdolescents’ reflections on mental health: Key findings from a 13-country qualitative study\u003c/p\u003e","fulltext":[{"header":"Implications and Contribution","content":"\u003cp\u003eThis 13-country qualitative study explores adolescents\u0026rsquo; perceptions of significant mental health challenges among their age group, key risk and protective factors, and principal coping strategies. Findings emphasize that while the presentations, drivers, and coping strategies may differ across geographies, mental health is a pressing issue among adolescents around the world.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAdolescence (ages 10-19) is a period of rapid development marked by dramatic biological, cognitive, social, and emotional changes\u0026nbsp;[1,2]. While adolescence is generally considered to be one of the healthiest periods within the life course, with lower morbidity and mortality relative to other phases of life in most regions of the world, these statistics mask the critical nature of adolescence in influencing life-long health trajectories [2].\u0026nbsp;Adolescents are vulnerable to a range of risky health-related behaviors, including substance use, interpersonal violence, and early sexual activity, and these behaviors can contribute to myriad negative health outcomes later in life [1].\u0026nbsp;Additionally, mental health challenges such as depression, anxiety, conduct disorders, and eating disorders commonly emerge during this time, impacting an estimated 14% of adolescents globally [3]. These mental health challenges can persist well into adulthood [4], with multi-country research suggesting that around 50% of all lifetime mental disorders have their first onset by the end of adolescence [5,6]. As such, adolescence offers an essential window for mental health prevention and promotion efforts.\u003c/p\u003e\n\u003cp\u003eThe past decade has been characterized by multiple emergent threats to adolescent mental health. The COVID-19 pandemic significantly disrupted adolescents\u0026rsquo; lives through infection mitigation strategies such as mobility restrictions, social distancing requirements, and school closures, with documented impacts on depression and anxiety [7,8]. Climate change jeopardizes adolescent mental health through both direct and indirect pathways, including exposure to extreme weather events, increasing temperatures, exacerbation of existing health disparities, and growing awareness of uncertain futures [9]. Global forced displacement has reached record levels, with an estimated 43.3 million children and adolescents in 2022 displaced as a result of persecution, conflict, violence, human rights violations, and other serious disruptions [10], and an estimated 449 million children and adolescents live in areas impacted by armed conflict [11]. Given the growing prominence of digital communications in the daily lives of adolescents around the world, there is substantial concern alongside mounting evidence regarding the ways in which such technologies may be detrimental to adolescent mental health and well-being [12,13].\u003c/p\u003e\n\u003cp\u003eWhile the mental health impacts of such complex issues have raised serious alarms worldwide, significant gaps remain in terms of research, services, and policies specifically targeting adolescent mental health. Most notably, despite 90% of the world\u0026rsquo;s adolescents living in low- and middle-income countries (LMICs), little adolescent mental health research has been conducted in these settings [14,15]. Further, existing evidence suggests that the vast majority of mental health needs among adolescents in LMICs go unrecognized and untreated due to factors such as provider shortages, lack of supportive national policies, and widespread stigma around mental health challenges [16,17]. There is also growing acknowledgment of the need for sustained engagement of adolescents themselves across mental health research and programmatic efforts [18,19]. This includes the incorporation of adolescents with lived experiences of mental health challenges in order to increase the quality, relevance, and practical impact of mental health-related activities [20\u0026ndash;22]\u003c/p\u003e\n\u003cp\u003eIt is within this greater context that the United Nations Children\u0026rsquo;s Fund (UNICEF) focused its flagship \u003cem\u003eState of the World\u0026rsquo;s Children 2021\u0026nbsp;\u003c/em\u003ereport around child, adolescent, and caregiver mental health [23,24]. As part of this effort, UNICEF collaborated with investigators from the Johns Hopkins University (JHU) Global Early Adolescent Study (GEAS), alongside global partners, to conduct a series of focus group discussions (FGDs) with adolescents across 13 countries. This qualitative investigation had three central aims: (1) to understand adolescents\u0026rsquo; perspectives on significant mental health challenges in their age group; (2) to understand adolescents\u0026rsquo; perspectives on what \u0026nbsp;causes and protects them from mental health challenges; and (3) to understand the ways in which adolescents cope with mental health challenges, including barriers and facilitators to help-seeking. In the current study, we will present overarching themes captured by this cross-country qualitative investigation focused around these three aims. It is important to note that while we will synthesize the breadth of topics discussed by adolescents across the 13 participating countries, our intention is not to do so in depth. Rather, our goal is to illustrate overall findings \u0026ndash; with a related set of analyses delving into specific salient topics in much greater detail.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Settings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current study describes results from a collaboration between UNICEF, JHU, and global partners. With the aim of understanding adolescents\u0026rsquo; perspectives on mental health across diverse geographic, economic, and cultural environments, qualitative research was conducted by partner organizations in the following country settings: Aalst, Brussels, Couvin, Huy, and Namur, Belgium; Santiago, Chile; Shanghai, China; Kinshasa, Democratic Republic of the the Congo (DRC); Assiut, Egypt; Yogyakarta, Indonesia; Kingston, Jamaica; Amman, Jordan; Nairobi, Kenya; Blantyre, Malawi; Stockholm, Sweden; Lausanne, Switzerland; and New Orleans, United States. Partner organizations across these countries were engaged due to their extensive expertise in conducting adolescent health research. Qualitative data collection within each country largely focused on adolescents living in low- or middle-income, urban or peri-urban areas. The primary exceptions to this are Jamaica, which included several FGDs with adolescents living in rural areas, and Jordan, which focused on Syrian refugees living in a rural refugee camp. Further contextual details across the 13 countries are included in Table 1. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Adolescent mental health focus group discussions\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePartner Organization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGDs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePopulation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eBelgium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eCouvin, Huy, and Namur (Francophone)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eCentre de R\u0026eacute;f\u0026eacute;rence en Sant\u0026eacute; Mentale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSchool-based sample from low- and middle-income peri-urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eAalst and Brussels (Flemish)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eSteunpunt Geestelijke Gezondheid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSchool-based sample from middle-income urban and peri-urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eChile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eSantiago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eUniversidad de Santiago de Chile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eCommunity-based sample from low-income urban areas; largely migrants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eShanghai\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eShanghai Institute for Biomedical and Pharmaceutical Technologies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSchool-based sample from mixed-income urban areas; included both migrants and local residents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eDemocratic Republic of the Congo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eKinshasa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eKinshasa School of Public Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSchool- and community-based sample from mixed-income urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eEgypt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eAsyut\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eAssiut University\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eCommunity-based sample from low-income peri-urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIndonesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eYogyakarta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eUniversitas Gadjah Mada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSchool-based sample from middle-income urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eJamaica\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eKingston\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eUniversity of the West Indies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSchool- and community-based samples from mixed-income rural and urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eJordan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eAmman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eTerre des Hommes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eCommunity-based sample of Syrian refugees from low-income, rural refugee camp\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eKenya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNairobi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eAfrican Population and Health Research Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eCommunity-based sample from low-income urban informal settlement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eMalawi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eBlantyre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eKamuzu University of Health Sciences\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSchool-based sample from low-income urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eSweden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eStockholm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eKarolinska Institutet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eIn-person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSchool-based sample from high- and mixed-income urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eSwitzerland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eLausanne\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eUnisant\u0026eacute;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eCommunity-based sample from mixed income urban and peri-urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eUnited States\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eNew Orleans\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eInstitute of Women and Ethnic Studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eCommunity-based sample from low-income urban areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach participating country hosted a minimum of four (and up to ten) FGDs with adolescents between February and June 2021. In general, these FGDs were equally divided by sex and age such that there were at least two younger (ages 12-15) and two older (ages 16-19) FGDs held separately with boys and girls in each country. The purpose behind this stratified approach was to allow for the targeted discussion of specific issues that may vary across these groups. Given the salience of mental health in adolescence, four age- and sex-specific FGDs were deemed sufficient in order to achieve theoretical saturation across countries [25]. Country partners in Belgium, Chile, China, Egypt, Jamaica, and Sweden also elected to conduct additional FGDs. In two countries, Belgium and Sweden, one or more of these additional FGDs were held with mixed sex groups. Groups ranged in size from 3 to 12 participants, with an average of 8 participants per group across countries. While participant recruitment strategies varied, adolescents were generally recruited through schools, youth groups, health centers, and community-based organizations. In total, 71 FGDs were held with 554 adolescents across the 13 participating countries. A more detailed description of FGD participants across countries can be found in Appendix A.\u003c/p\u003e\n\u003cp\u003eAll FGDs were implemented by experienced local facilitators using a standardized FGD guide (see Appendix B) which was developed collaboratively by UNICEF, JHU, and country partners. In alignment with the study\u0026rsquo;s aims, this FGD guide included sections focused on: (1) mental health problems faced by young people, (2) risk and protective factors, (3) coping strategies and health-seeking behaviors, and (4) the mental health impacts of the COVID-19 pandemic. In order to train FGD facilitators across countries, qualitative research experts affiliated with JHU hosted a series of three-hour online training sessions which focused on the study\u0026rsquo;s research questions, data collection processes, qualitative research guidelines, human subjects research ethics, and documentation methods. Following these online training sessions, site coordinators in each country held local trainings with FGD facilitators focused on reviewing and practicing with the FGD guide. FGD facilitators had varied positionality in relation to study participants because of the diversity of country partner organizations; however, the majority were affiliated with academic institutions.\u003c/p\u003e\n\u003cp\u003eDepending on the local COVID-19 restrictions at the time, FGDs including only the facilitator(s) and adolescent participants were either held in-person or online. In-person FGDs took place in \u0026ldquo;adolescent-friendly\u0026rdquo; venues (e.g., schools or community-based organizations) in which adolescents were able to be comfortable and their privacy assured. Virtual FGDs took place on the Zoom or Skype platform using the \u0026ldquo;gallery\u0026rdquo; view to ensure that all participants were able to see each other. FGDs were conducted in the local language of each study setting and lasted between 60 and 90 minutes.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eFGDs were audio-recorded and transcribed verbatim, and field notes were written immediately after each session. When necessary, transcribed audio recordings and typed field notes were translated into English for analysis. So as to ensure consistency across countries, both the transcription and translation processes were undertaken using conventions outlined in standardized protocols developed by the JHU investigators. In addition, the site coordinator in each country performed random quality checks of the transcripts to review the accuracy and comprehensibility of the translations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to data collection, all country partners obtained ethical approval from their local ethical review boards, including structured protocols to respond in the event that a participant experienced distress. In addition, the cross-country research protocol was submitted to the JHU Institutional Review Board, which determined that the role of JHU investigators, including the secondary data analysis of de-identified, qualitative data, did not qualify as human subjects research. For any adolescents under the age of 18, a parent or guardian gave verbal or written informed consent for their child\u0026rsquo;s participation. In addition, all adolescents gave verbal or written informed consent or assent for their own participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was guided by elements from grounded theory, a methodological approach that allows findings to emerge inductively from qualitative data [26]. Qualitative data, which consisted of the English translations of FGD transcripts and field notes, were coded using inductive thematic analysis focused largely on identifying salient semantic themes across countries [27]. Analysis began with a process of open coding, with lines of data closely examined and descriptive codes generated based on significant content within. The first phase of open coding was carried out by three analysts using data from four of the countries \u0026ndash; China, Egypt, Jordan, and Jamaica \u0026ndash; which were selected for their contextual diversity. After independently coding transcripts, initial codes were compared and refined, consolidated into broader categories, and organized into a preliminary codebook (see Appendix C). This codebook was further refined throughout the data analysis process, with two analysts working to systematically apply it to the full set of cross-country qualitative data\u003cem\u003e.\u0026nbsp;\u003c/em\u003eIn order to increase credibility [28], preliminary country-specific findings were presented to local stakeholders in order to obtain feedback on points of agreement or disagreement and any missing information. Two qualitative analysis software programs \u0026ndash; ATLAS.ti (Version 9.1) [29] and MAXQDA 2022 [30] \u0026ndash; were used to help organize and analyze the data.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOverarching findings from this 13-country qualitative study are organized along its three aims: namely, understanding adolescents\u0026rsquo; perceptions of significant mental health challenges among their age group, key risk and protective factors, and principal coping strategies. Within each of these aims, we propose a key unifying theme which captures the cross-cutting perspectives of adolescents across diverse country settings. More comprehensive discussions related to these themes are presented in separate analyses [31\u0026ndash;35]. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey Theme #1: Terms of distress rather than disorder\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross participating countries, adolescents reflected upon the most important mental health challenges faced by young people their age. One of the cross-cutting themes that emerged was adolescents\u0026rsquo; consistent reliance on a wide array of largely non-clinical terminology in discussing experiences of distress. For example, adolescents around the world mentioned feelings of stress, pressure, sadness, depression, anxiety, anger, irritability, fear, isolation, loneliness, boredom, suicidality, brokenness, hopelessness, despair, and defeat. While some of this language corresponds with mental disorders and their associated symptoms, it was apparent that adolescents more often describe and understand mental health challenges outside of existing diagnostic categories. For instance, in one particularly powerful illustration, an older girl from Egypt described a state of being \u0026ldquo;tired psychologically\u0026rdquo;: \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt means that you feel that you are not living life and [are] unable to do anything and [are] bored, keeping to yourself and you don\u0026rsquo;t want to deal with anyone...you will not be able to achieve your ambitions because you are psychologically totally defeated. (Older girl, Egypt)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEven when adolescents did mention specific clinical terminology such as depression and anxiety, it was clear that they did not always use these labels to denote clinical diagnoses, with their descriptions of both of these terms indicating immense variability in their perceptions and experiences. Most frequently, adolescents across participating countries discussed depression, which ranged from transient sadness to ongoing despair. Likewise, some adolescents characterized anxiety as a commonplace reaction to daily stressors, whereas others described the ways in which it could become completely disabling. Regardless of the specific categorization, it appears that this spectrum of distress and impairment \u0026ndash; from the mild to the severe \u0026ndash; is widely understood by adolescents around the world. Further, many adolescents articulated a nuanced understanding of mental health that goes beyond the simple presence or absence of disorder. \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI don\u0026rsquo;t think you can prevent someone from getting sad\u0026hellip;but you can be able to deal with it when it\u0026rsquo;s at a low level so that it doesn\u0026rsquo;t grow and spread like wildfire. You know, like it just blossoms out into something as big as depression. (Older girl, Jamaica)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI have also been through several crises of anxiety for such minimal issues that maybe people look at them [and don\u0026rsquo;t understand], and for you it is so strong or complicated that you think the world is ending. (Older girl, Chile)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey Theme #2: Contexts shape mental health\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdolescents around the world highlighted the centrality of the contexts in which they live, grow, study, and play in shaping their mental health. A primary theme was adolescents\u0026rsquo; recognition of the ways in which overlapping social environments could both protect and damage their well-being. Participants described how supportive, attentive, communicative, nonjudgmental, and trusting families formed an essential foundation for psychosocial adjustment. All too often, however, adolescents labeled such qualities as aspirational, and many identified profound risks to their mental health resulting from experiences of abuse and neglect, controlling behaviors, immense pressure, a lack of support, and poor communication within their families. While supportive peer relationships bolstered adolescent well-being and helped them cope with social and emotional challenges, participants also noted that peers could be a damaging source of betrayal, judgment, bullying, and pressure towards risky behaviors. Likewise, although many adolescents recognized schools as a source of support, learning, and socialization, school environments were more frequently discussed in terms of academic pressure, unsupportive or abusive teachers, and barriers to accessing education. Within communities, adolescents highlighted multifaceted vulnerabilities stemming from pervasive violence [31], inequitable gender norms [32], and endemic poverty [33]. Digital environments were portrayed as a \u0026ldquo;double-edged sword,\u0026rdquo; strengthening adolescents\u0026rsquo; social networks and facilitating greater support while simultaneously engendering harmful social comparisons, cyber harassment, and internet addiction [34]. Across these social environments, adolescents recognized the profound impacts of the COVID-19 pandemic in shaping their exposure to both risk and protective factors. \u003c/p\u003e\n\u003cp\u003eA detailed exploration of these risk and protective factors is beyond the scope of the current analysis \u0026ndash; and many have been discussed in greater depth in the related manuscripts cited above, which focus on adolescent mental health in relation to family relationships, violence [31], gender norms [32], poverty [33], and digital communication [34]. It is important to emphasize, however, that adolescents\u0026rsquo; discussions revealed important geographic and gender-related differences in the central drivers of mental health and well-being. For example, poverty had the greatest salience in low-income countries [33] while digital technologies arose most prominently in middle- and high-income countries [34]. Likewise, it was clear that there are differences in violence exposures between boys and girls, with girls much more strongly emphasizing the mental health risks stemming from both threatened and experienced sexual violence [31]. Regardless of such variations, participants\u0026rsquo; reflections and associated language suggest that adolescents often perceive mental health challenges as inextricably linked to underlying contextual drivers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey Theme #3: Coping without sufficient support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the FGDs, participants were asked to consider the ways in which adolescents generally coped with emotional and behavioral difficulties, including important sources of support. Adolescents frequently emphasized that they felt the greatest comfort in seeking support from friends their age, although many also mentioned a reliance on family members, particularly when dealing with severe problems [35]. More often, however, adolescents across geographies detailed the many barriers to seeking help: widespread mental health stigma; unavailable, inaccessible, or low-quality services; fears around judgment, misunderstanding, invalidation, or untrustworthiness from friends or family members; and difficulty articulating emotional distress. Such barriers commonly resulted in adolescents choosing to cope on their own, and a resounding theme across countries was the frequency with which adolescents would \u0026ldquo;hide,\u0026rdquo; \u0026ldquo;close off,\u0026rdquo; \u0026ldquo;lock up,\u0026rdquo; \u0026ldquo;bottle up,\u0026rdquo; \u0026ldquo;swallow,\u0026rdquo; or \u0026ldquo;keep quiet about\u0026rdquo; their feelings. While this was seen as a particularly common response among boys \u0026ndash; tied to masculine norms which center restrictive emotionality [32] \u0026ndash; it was voiced by both boys and girls. \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI know a lot of people who...have been going through situations where they are depressed...and they don\u0026rsquo;t tell their stories, they don\u0026rsquo;t talk to you about it...Every day that you see them, they have a smile on their face...they try to behave as normal as possible so that you don\u0026rsquo;t ask questions. (Younger girl, Jamaica) \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSometimes people just keep it all bottled up inside themselves and they cry because they\u0026rsquo;re scared that someone\u0026rsquo;s going to say something. That their problems are not normal. (Younger girl, Belgium) \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe will keep to ourselves, we will try to keep it all within ourselves and try to hide the problem even if some people see that something is wrong. (Younger boy, Switzerland)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to closing themselves off, adolescents described a range of other maladaptive coping mechanisms. The most common of these included drug and alcohol use, which was widely mentioned especially by boys as a method for \u0026ldquo;releasing\u0026rdquo; stress, \u0026ldquo;relieving\u0026rdquo; distress, and \u0026ldquo;forgetting\u0026rdquo; problems. A number of adolescents also discussed turning to self-harm as a cry for attention or, as one younger girl in Jamaica said, as a way of using physical pain to \u0026ldquo;help block the emotional and mental pain.\u0026rdquo; \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMost people nowadays abuse drugs to reduce stress, then little by little you find yourself becoming an addict...when you use them you kind of forget about your worries and the stress. (Older boy, Kenya) \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis smoking habit causes my stress to go away, even though I know it\u0026rsquo;s not a good thing to do. So if you ask me in detail as to why I feel stressed, I don\u0026rsquo;t know. All I know is that I feel lonely and empty. (Older girl, Indonesia)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSome cut themselves just because they kind of want to feel something, and they want to hurt themselves because they do not like themselves. (Younger girl, Sweden)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile such strategies were somewhat balanced by more positive individual approaches for managing distress \u0026ndash; for instance, through relaxation, socialization, self-expression, or exercise \u0026ndash; it was clear that all too often, adolescents around the world cope with pressing mental health challenges without sufficient external support.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAdolescents across 13 diverse countries discussed numerous factors which threaten young people\u0026rsquo;s mental health as well as ongoing struggles to receive sufficient support. To our knowledge, this is the largest cross-country qualitative study to date which has focused on elucidating adolescents\u0026rsquo; own perspectives regarding mental health. Findings emphasize that while the presentations, drivers, and coping strategies may differ across geographies, mental health is a pressing issue among adolescents worldwide.\u003c/p\u003e\n\u003cp\u003eA central finding from this study relates to the extensive range of mostly\u0026nbsp;non-clinical terminology favored by adolescents when discussing their mental health, with language that frequently reflected broad symptomatic distress rather than categorical psychopathological disorder. While this is certainly not a surprising finding within a general sample of adolescents, it has important implications for the ways in which we categorize and intervene upon adolescent mental health around the world. There is growing recognition globally regarding the limitations of framing mental health challenges entirely through the presence or absence of discrete diagnostic categories (e.g., major depressive disorder, generalized anxiety disorder) [36,37]. Increasingly, researchers and practitioners have argued that this biomedical approach privileges clinical treatment rather than public health prevention, thereby ignoring substantial evidence regarding the importance of targeting contextual factors throughout the life course [36]. This focus on diagnosis may be particularly problematic among adolescents given evidence that emerging mental health challenges are often characterized by non-specific or transdiagnostic symptomatic manifestations [38,39]. Further, mounting criticism has called into question the cross-cultural relevance, reliability, and validity of Western-constructed psychiatric classification systems [40\u0026ndash;42]. Findings from the current study give additional weight to these arguments by emphasizing that categorical diagnoses may not be reflective of the way adolescents themselves understand and discuss their own mental health. Adolescents around the world voiced a spectrum of mental health challenges with tangible impacts on their lives despite not necessarily rising to the level of psychopathology. As such, it is apparent that taking a purely diagnostic approach across both screening and treatment efforts may exclude many adolescents in need of support. Instead, as is increasingly recommended, it is clear that these efforts should take a more dimensional approach which recognizes variable stages in the progression of mental health challenges during this sensitive developmental period [36,37]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults from this study also underscore the necessity of targeting social and environmental determinants in order to influence adolescent mental health. It was clear that adolescents frequently perceive ongoing states of distress as being inseparable from underlying contextual factors: for example, feeling \u0026ldquo;psychologically totally defeated\u0026rdquo; as a result of gender norms which severely restrict girls\u0026rsquo; self-realization. Advocates for mental health prevention and promotion approaches have long argued that treatment alone is insufficient, and that upstream strategies are absolutely essential in order to reduce the global burden of mental health challenges [36]. These arguments have particular salience when applied to adolescents, given the potential to mitigate acute and chronic mental health challenges throughout the life course through focused prevention and early intervention efforts during this sensitive developmental period [4,38,43]. There is concrete evidence regarding the impact of such strategies. For example, a large body of research suggests that family-focused prevention approaches targeting parents\u0026rsquo; or caregivers\u0026rsquo; capacities can significantly improve mental health among adolescents [44\u0026ndash;46]. Likewise, there is a growing emphasis on whole school approaches that collectively target classroom settings, school environments, and family and community partnerships in order to promote health and well-being among students [47,48], and recent guidelines released by the World Health Organization (WHO) and United Nations Educational, Scientific and Cultural Organization outline global standards for supporting mental health through health promoting schools [49,50]. Beyond families and schools, the current study suggests the necessity of integrating a mental health prevention focus into efforts targeting a wider range of structural factors: for example, violence, poverty, and gender inequity. Notably, this broad range of suggestions aligns with the WHO\u0026rsquo;s \u003cem\u003eGlobal Accelerated Action for the Health of Adolescents\u003c/em\u003e agenda, which emphasizes the importance of structural interventions (e.g., policies focused on socioeconomic determinants), organizational interventions (e.g., strengthening health promoting schools), and interpersonal interventions (e.g., increasing parenting skills) in order to address common mental health challenges in adolescence [51]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, it was evident that adolescents around the world need better formal and informal supports to adequately address their mental health needs. A cross-cutting refrain was the deep isolation that can result from distress, with adolescents often masking their struggles from the outside world and instead coping entirely on their own. This aligns with existing evidence regarding acute mental health treatment gaps among adolescents worldwide which suggests that the majority of adolescents are reluctant to seek help for their mental health challenges [52]. According to one systematic review focused on barriers and facilitators of help-seeking, common barriers reported by adolescents included their shame and embarrassment due to perceived mental health stigma as well as their desire to cope with problems by themselves [53]. Further, even when adolescents are willing to seek help, there are many settings around the world in which appropriate services are simply not available [16]. This evidence, alongside findings from the current study, emphasizes the need for multi-level stigma reduction and mental health literacy strategies that encourage adolescents to openly discuss their mental health concerns while equipping peers, caregivers, and other trusted individuals with the skills to help. In addition, where more intensive support is needed, it is critical to ensure that adolescents have access to appropriate mental health and psychosocial support services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral limitations to this study should be noted. The inclusion of 13 countries with different geographic, economic, and cultural environments\u0026nbsp;was intended to reflect the viewpoints of a diverse group of adolescents. It is important to emphasize, however, that these results cannot be considered transferable either within or across countries. For example, as most adolescents were drawn from urban environments, findings may not adequately capture the perspectives of those living in rural areas. Further research should endeavor to replicate these efforts with adolescents living in additional contexts. Data analysis relied on English translations of original language transcripts and was primarily conducted by two English-speaking analysts based at an academic institution in the United States. While efforts were made to reduce translation issues through review by bilingual researchers in each country, the large number of included countries increases the likelihood that pertinent information was lost in translation. Further, while local stakeholders were involved in preliminary analysis efforts in order to triangulate findings, the positioning of the data analysts may have influenced the interpretation of results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYoung people around the world are reshaping the conversation around mental health and driving positive changes related to how society views and addresses mental health challenges. Through listening to their voices, we can better understand a spectrum of mental health challenges which extend beyond existing diagnostic categories, the complex social and environmental conditions which give rise to these challenges, and the difficulties many young people face in receiving adequate assistance. It is clear that active listening and engagement with young people is essential for guiding mental health prevention and promotion efforts, and for making mental health and psychosocial supports more relevant, accessible, destigmatized, and inclusive across sectors.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLMICs low- and middle-income countries\u003c/p\u003e\n\u003cp\u003eUNICEF United Nations Children\u0026rsquo;s Fund\u003c/p\u003e\n\u003cp\u003eJHU Johns Hopkins University\u003c/p\u003e\n\u003cp\u003eGEAS Global Early Adolescent Study\u003c/p\u003e\n\u003cp\u003eFGD focus group discussion\u003c/p\u003e\n\u003cp\u003eDRC Democratic Republic of the Congo\u003c/p\u003e\n\u003cp\u003eWHO World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Information:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Wellcome Trust through a contract with UNICEF Headquarters for the preparation of the State of the World\u0026rsquo;s Children 2021 report, \u003cem\u003eOn My Mind: Promoting, protecting and caring for children\u0026rsquo;s mental health.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was developed in conjunction with UNICEF\u0026rsquo;s \u003cem\u003eState of the World\u0026rsquo;s Children 2021\u0026nbsp;\u003c/em\u003ereport, \u003cem\u003eOn My Mind: Promoting, protecting and caring for children\u0026rsquo;s mental health\u003c/em\u003e. The study was initiated by UNICEF Headquarters in collaboration with the Johns Hopkins University Global Early Adolescent Study, and was made possible through partnerships with organizations across 13 countries. In particular, we would like to acknowledge the following individuals: in Belgium, Eveline Couck and Maud Dominicy from UNICEF Belgium, Léa Tilkens and Alexis Vanderlinden from Centre de R\u0026eacute;f\u0026eacute;rence en Sant\u0026eacute; Mentale, and Stefaan Plysier from Steunpunt Geestelijke Gezondheid; in Chile, Francisca Dávalos, Pablo Villalobos, Jorge Puga, and Matilde Maddaleno from Universidad de Santiago de Chile; in China, Xiayun Zuo, Chaohua Lou, Chunyan Yu, and Qiguo Lian from the Shanghai Institute for Biomedical and Pharmaceutical Technologies; in the Democratic Republic of the Congo, Aimée Lulebo, Benito Kazenza, and Eric Mafuta from the Kinshasa School of Public Health; in Egypt, Omaima El Gibaly and Doaa Mohammed Mohammed from Assiut University; in Indonesia, Siswanto Wilopo and Amira Wahdi from Universitas Gadjah Mada; in Jamaica, Abigail Harrison, Caryl James, Donna Kamicka, Georgia Satchwell, and Christina Silvera from the University of the West Indies; in Jordan, Marta Alberici, Sana Alhyari, Maria Bray, and Meilaa Khateeb from Terre des Hommes; in Kenya, Caroline Kabiru and Beatrice Maina from the African Population and Health Research Center; in Malawi, Effie Chipeta, William Stones, Princess Kayira, and Razak Mussa from the Kamuzu University of Health Sciences; in Sweden, Anna Mia Ekström, Carl Fredrik Sjöland, Leo Ziegel, and Maria St\u0026aring;lgren from Karolinska Institutet; in Switzerland, Yara Barrense-Dias, Lorraine Chok, Joan Carles Suris Granell, and Sophie Stadelmann from Unisant\u0026eacute;; in the United States, Denese Shervington, Lisa Richardson, Jakevia Green, Gabrielle Roude, Jennifer Latimer, and Tylar Williams from the Institute of Women and Ethnic Studies. We are immensely grateful to these researchers and program specialists who helped to shape the research questions and then organized, facilitated, recorded, transcribed, and translated focus group discussions with adolescents. We would also like to gratefully acknowledge the support from the Wellcome Trust and from UNICEF country offices. Above all, we are thankful for the young people around the world who gave their candid insights during 71 focus groups discussions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. The Lancet 2012;379:1630\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003ePatton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet commission on adolescent health and wellbeing. The Lancet 2016;387:2423\u0026ndash;78.\u003c/li\u003e\n\u003cli\u003eInstitute for Health Metrics and Evaluation. GBD Results. Available at: https://vizhub.healthdata.org/gbd-results/.\u003c/li\u003e\n\u003cli\u003ePatel V, Flisher AJ, Hetrick S, et al. Mental health of young people: a global public-health challenge. The Lancet 2007;369:1302\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eMcGrath JJ, Al-Hamzawi A, Alonso J, et al. Age of onset and cumulative risk of mental disorders: a cross-national analysis of population surveys from 29 countries. Lancet Psychiatry 2023.\u003c/li\u003e\n\u003cli\u003eSolmi M, Radua J, Olivola M, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 2022;27:281\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eHarrison L, Carducci B, Klein JD, et al. Indirect effects of COVID-19 on child and adolescent mental health: an overview of systematic reviews. BMJ Glob Health 2022;7:e010713.\u003c/li\u003e\n\u003cli\u003eDeng J, Zhou F, Hou W, et al. Prevalence of mental health symptoms in children and adolescents during the COVID-19 pandemic: A meta-analysis. Ann N Y Acad Sci 2023;1520:53\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003evan Nieuwenhuizen A, Hudson K, Chen X, et al. The Effects of Climate Change on Child and Adolescent Mental Health: Clinical Considerations. Curr Psychiatry Rep 2021;23:88.\u003c/li\u003e\n\u003cli\u003eUnited Nations High Commissioner for Refugees. Global Trends: Forced Displacement in 2022. Copenhagen: United Nations High Commissioner for Refugees; 2023.\u003c/li\u003e\n\u003cli\u003eSave the Children. Stop the War on Children: The Forgotten Ones. Save the Children; 2022.\u003c/li\u003e\n\u003cli\u003eSantos RMS, Mendes CG, Sen Bressani GY, et al. The associations between screen time and mental health in adolescents: a systematic review. BMC Psychol 2023;11:127.\u003c/li\u003e\n\u003cli\u003eValkenburg PM, Meier A, Beyens I. Social media use and its impact on adolescent mental health: An umbrella review of the evidence. Curr Opin Psychol 2022;44:58\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eKieling C, Baker-Henningham H, Belfer M, et al. Child and adolescent mental health worldwide: evidence for action. The Lancet 2011;378:1515\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eErskine HE, Baxter AJ, Patton G, et al. The global coverage of prevalence data for mental disorders in children and adolescents. Epidemiol Psychiatr Sci 2017;26:395\u0026ndash;402.\u003c/li\u003e\n\u003cli\u003eMorris J, Belfer M, Daniels A, et al. Treated prevalence of and mental health services received by children and adolescents in 42 low-and-middle-income countries. J Child Psychol Psychiatry 2011;52:1239\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eJuengsiragulwit D. Opportunities and obstacles in child and adolescent mental health services in low- and middle-income countries: a review of the literature. WHO South-East Asia J Public Health 2015;4:110\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eMcCabe E, Amarbayan MM, Rabi S, et al. Youth engagement in mental health research: A systematic review. Health Expect Int J Public Particip Health Care Health Policy 2023;26:30\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eYamaguchi S, Bentayeb N, Holtom A, et al. Participation of Children and Youth in Mental Health Policymaking: A Scoping Review [Part I]. Adm Policy Ment Health Ment Health Serv Res 2023;50:58\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eAli AZ, Wright B, Curran JA, et al. Review: Patient engagement in child, adolescent, and youth mental health care research \u0026ndash; a scoping review. Child Adolesc Ment Health n.d.;n/a.\u003c/li\u003e\n\u003cli\u003eFaithfull S, Brophy L, Pennell K, et al. Barriers and enablers to meaningful youth participation in mental health research: qualitative interviews with youth mental health researchers. J Ment Health Abingdon Engl 2019;28:56\u0026ndash;63.\u003c/li\u003e\n\u003cli\u003eSheikhan NY, Kuluski K, McKee S, et al. Exploring the impact of engagement in mental health and substance use research: A scoping review and thematic analysis. Health Expect n.d.;n/a.\u003c/li\u003e\n\u003cli\u003eUnited Nations Children\u0026rsquo;s Fund. The State of the World\u0026rsquo;s Children 2021: On My Mind \u0026ndash; Promoting, protecting and caring for children\u0026rsquo;s mental health. New York: UNICEF; 2021.\u003c/li\u003e\n\u003cli\u003eJohns Hopkins Bloomberg School of Public Health, United Nations Children\u0026rsquo;s Fund. On My Mind: How adolescents experience and perceive mental health around the world. Baltimore and New York: JHU and UNICEF; 2022.\u003c/li\u003e\n\u003cli\u003eSandelowski M. Sample size in qualitative research. Res Nurs Health 1995;18:179\u0026ndash;83.\u003c/li\u003e\n\u003cli\u003eCharmaz K. Constructing grounded theory: A practical guide through qualitative analysis. London: Sage Publications; 2006.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eLincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park: Sage Publications; 1985.\u003c/li\u003e\n\u003cli\u003eATLAS.ti Version 9.1. ATLAS.ti Scientific Software Development GmbH 2013.\u003c/li\u003e\n\u003cli\u003eVERBI Software. MAXQDA 2020 2019.\u003c/li\u003e\n\u003cli\u003eRamaiya A, Wheeler J, Stones W, et al. Understanding adolescents\u0026rsquo; perceptions and experiences of violence victimization and its perceived impact on mental health: a qualitative study across 13 countries. Under review.\u003c/li\u003e\n\u003cli\u003eFine SL, Harrison A, Rykiel NA, et al. Adolescents\u0026rsquo; perceptions of gendered influences on mental health: Results from a 13-country qualitative study. Under review.\u003c/li\u003e\n\u003cli\u003eMaina BW, Athero S, Ziegel L, et al. Poverty as a social determinant of mental health among young people: Qualitative findings across 13 countries. Under review.\u003c/li\u003e\n\u003cli\u003eZiegel L, Sj\u0026ouml;land CF, Xiayun Z, et al. \u0026quot;It depends (on what you do with it)\u0026rdquo;: Adolescent perspectives on digital communication and mental health in 11 countries. Under review.\u003c/li\u003e\n\u003cli\u003eWahdi AE, James C, Nadhira DA, et al. Barriers and facilitators of seeking help for mental health challenges among adolescents across 13 countries: A qualitative investigation Under review.\u003c/li\u003e\n\u003cli\u003ePatel V, Saxena S, Lund C, et al. Transforming mental health systems globally: principles and policy recommendations. Lancet Lond Engl 2023;402:656\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003ePatel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development. The Lancet 2018;392:1553\u0026ndash;98.\u003c/li\u003e\n\u003cli\u003eUhlhaas PJ, Davey CG, Mehta UM, et al. Towards a youth mental health paradigm: a perspective and roadmap. Mol Psychiatry 2023:1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eMcElroy E, Belsky J, Carragher N, et al. Developmental stability of general and specific factors of psychopathology from early childhood to adolescence: dynamic mutualism or p-differentiation? J Child Psychol Psychiatry 2018;59:667\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eMalott KM, Barraclough S, Yee T. Towards Decolonizing Diagnosis: a Critical Review and Suggested Alternatives. Int J Adv Couns 2023;45:1\u0026ndash;17.\u003c/li\u003e\n\u003cli\u003eBemme D, Kirmayer LJ. Global Mental Health: Interdisciplinary challenges for a field in motion. Transcult Psychiatry 2020;57:3\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eSummerfield D. How scientifically valid is the knowledge base of global mental health? BMJ 2008;336:992\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Guidelines on mental health promotive and preventive interventions for adolescents: Helping adolescents thrive. Geneva: World Health Organization; 2020.\u003c/li\u003e\n\u003cli\u003eYap MBH, Morgan AJ, Cairns K, et al. Parents in prevention: A meta-analysis of randomized controlled trials of parenting interventions to prevent internalizing problems in children from birth to age 18. Clin Psychol Rev 2016;50:138\u0026ndash;58.\u003c/li\u003e\n\u003cli\u003eKuhn ES, Laird RD. Family support programs and adolescent mental health: review of evidence. Adolesc Health Med Ther 2014;5:127\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eHealy EA, Kaiser BN, Puffer ES. Family-based youth mental health interventions delivered by nonspecialist providers in low- and middle-income countries: A systematic review. Fam Syst Health J Collab Fam Healthc 2018;36:182\u0026ndash;97.\u003c/li\u003e\n\u003cli\u003eGoldberg JM, Sklad M, Elfrink TR, et al. Effectiveness of interventions adopting a whole school approach to enhancing social and emotional development: a meta-analysis. Eur J Psychol Educ 2019;34:755\u0026ndash;82.\u003c/li\u003e\n\u003cli\u003eShackleton N, Jamal F, Viner RM, et al. School-Based Interventions Going Beyond Health Education to Promote Adolescent Health: Systematic Review of Reviews. J Adolesc Health 2016;58:382\u0026ndash;96.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, United Nations Children\u0026rsquo;s Fund, United Nations Educational, Scientific and Cultural. How school systems can improve health and well-being: topic brief: mental health. Geneva: World Health Organization; 2023.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, United Nations Educational, Scientific and Cultural. Making every school a health-promoting school: implementation guidance. Geneva: World Health Organization and United Nations Educational, Scientific and Cultural; 2021.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation, second edition. Geneva: 2023.\u003c/li\u003e\n\u003cli\u003eAguirre Velasco A, Cruz ISS, Billings J, et al. What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review. BMC Psychiatry 2020;20:293.\u003c/li\u003e\n\u003cli\u003eRadez J, Reardon T, Creswell C, et al. Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. Eur Child Adolesc Psychiatry 2020.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Wellcome Trust","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adolescents, Youth, Mental health, Risk and protective factors, Help-seeking, Low- and middle-income countries, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-6717469/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6717469/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eAdolescence is a sensitive developmental period for the emergence of mental health challenges, but few multi-country qualitative studies explore how adolescents themselves understand these challenges. Through focus group discussions (FGDs) with adolescents across 13 countries, this study aimed to understand adolescents’ perspectives on significant mental health challenges in their age group, key risk and protective factors, and principal coping strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA total of 71 FGDs were conducted between February and June of 2021. Countries were selected to ensure geographic, economic, and cultural diversity, and included: Belgium, Chile, China, the Democratic Republic of the Congo, Egypt, Indonesia, Jamaica, Jordan, Kenya, Malawi, Sweden, Switzerland, and the United States. Within each country, FGDs were stratified by sex and age. FGDs were recorded, transcribed verbatim, and translated into English for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAcross countries, adolescents generally described and understood mental health challenges in terms of \u003cem\u003edistress\u003c/em\u003e(e.g., sadness, loneliness, anger) rather than \u003cem\u003edisorder\u003c/em\u003e (e.g., depression, anxiety). They emphasized the many contexts that drive mental health challenges, including family adversity, peer and school environments, pervasive violence, endemic poverty, and restrictive gender norms. They also discussed significant barriers to help-seeking, which frequently resulted in adolescents coping without what they perceived as sufficient support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAdolescents around the world highlighted numerous social and environmental factors that contribute to mental health challenges, as well as a pressing need for greater formal and informal supports. The non-clinical terminology favored by adolescents suggests that taking a purely diagnostic approach may exclude many adolescents in need of assistance.\u003c/p\u003e","manuscriptTitle":"Adolescents’ reflections on mental health: Key findings from a 13-country qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-26 08:17:50","doi":"10.21203/rs.3.rs-6717469/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b2860a58-b366-4043-95dc-7e50cd66b29d","owner":[],"postedDate":"May 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":48862152,"name":"Psychology"},{"id":48862153,"name":"Epidemiology"}],"tags":[],"updatedAt":"2025-05-26T08:17:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-26 08:17:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6717469","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6717469","identity":"rs-6717469","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}