Adolescents in Malawi face a range of psycho-social challenges that affect their well-being and academic performance. This study aimed to identify an effective approach for managing common psycho-social problems among adolescent learners in Zomba, Malawi. A quasi-experimental, non-equivalent groups design was employed, utilizing a quantitative approach. The study targeted 317 adolescent learners from two secondary schools. Findings revealed a high prevalence of psycho-social challenges among adolescent learners, including depression (87%), suicidal thoughts (26.4%), substance use (31.3%), while few participants had positive attitudes towards mental health problems (26.4%), and knowledge of mental health problems (23.3%). The combined psycho-education and group counselling intervention contributed to a reduction in psycho-social problems. However, its impact was not statistically significant in some tested variables. The study highlights the need for targeted interventions to address adolescent psycho-social challenges. While the combined psycho-education and group counselling approach demonstrated some effectiveness, further research is needed to explore its impact in different educational settings, including community day secondary schools, primary schools, and higher education institutions. Findings from this study will inform stakeholders on effective strategies for supporting adolescent mental health.

This section describes psychosocial problems among adolescents identified in the literature. These include but are not limited to: a) depression, b) psychoactive substance use, c) suicidal thoughts, d) attitudes towards mental health problems, and d) knowledge of mental health problems. Studies have assessed patterns of depression among adolescent learners, and most of the available studies were conducted in High-Income Countries (HICs) and Low and Middle-Income Countries (LMICs) and reveal that adolescents experience depression.  (Balogun, Koyanagi, Stickley, Gilmour, & Shibuya, 2014; Johannessen, Andersson, Bjørngaard, & Pape, 2017; Torikka, Kaltiala-Heino, Rimpelä, Rimpelä, & Rantanen, 2001; Unger et al., 2001). The WHO has identified depression as the fourth most significant risk factor for disease burden and leading causes of disability in the world  (WHO, 2016; Witkiewitz & Stauffer, 2014). Therefore, depression is a big problem in different parts of the world, including Malawi. Previous studies have revealed that the prevalence of depression among adolescent learners varies from 6% to 70% (Kutcher et al., 2017; Magklara et al., 2015; Wichaidit, Pruphetkaew, & Assanangkornchai, 2019; Young, Miller, & Khan, 2010). The following risk factors have been associated with depression in adolescence: family history of depression, substance use, being female, negative cognitions, physical or emotional abuse by the family, academic workload, interpersonal conflict, low social support, and stressful life events. (Balogun et al., 2014; Johannessen et al., 2017; D. T. Nguyen, Dedding, Pham, Wright, & Bunders, 2013; Unger et al., 2001; Young et al., 2010). Based on the reviewed literature, depression is a big problem among adolescents in both HIC and LMC. It was worth developing necessary interventions that would help to manage the psychosocial problems. However, little has been investigated on the associated factors of depression, prevalence, and management of depression among Malawian adolescent learners in Zomba district.

To develop appropriate strategies for substance use prevention amongst adolescent learners, an understanding of the associated risk and protective factors is essential. Research suggests that there are several risk factors associated with substance use among adolescents (Gillman, Yeater, Feldstein Ewing, Kong, & Bryan, 2018; Heron et al., 2012; Maserumule, Skaal, & Sithole, 2019). Further, substance use among adolescents can have harmful effects on those who use it, commonly resulting in many health problems  (WHO-ASSIST-Working-Group, 2002; WHO, 2010). Psychoactive substance use, like alcohol use, has been reported to be the third largest risk factor for disease burden and the leading cause of disability (WHO, 2016; Witkiewitz & Stauffer, 2014). Several studies have reported on the prevalence of substance use among adolescents, which varies from 5% to 80 % (Beck & Legleye, 2009; Ogel et al., 2004; Patrick et al., 2013; Shimane & Wada, 2007; Wichaidit et al., 2019; Zarrouq et al., 2016). The use of psychoactive substances has so many effects on adolescents’ life, which include poor academic performance, distorted brain development, poor relationship with friends at school, reduced decision-making ability, and being rebellious to parents(Beaton, Shubkin, & Chapman, 2016; Whitesell, Bachand, Peel, & Brown, 2013).  A systematic review of commonly used psychoactive substances in Sub-Saharan Africa found that the following substances; alcohol, cannabis, tobacco, khat, cocaine, stimulants, and heroin are widely used among adolescents (Acuda, Othieno, Obondo, & Crome, 2011; Zarrouq et al., 2016). Furthermore, a national study among adolescent learners in Zambia shows that more adolescent males use psychoactive substances than females  (Siziya et al., 2013) and similar studies have further reported that the use of psychoactive substances among adolescent learners is associated with the history of having engaged in sexual intercourse, having been bullied and poor parental support  (Siziya et al., 2013; Zarrouq et al., 2016). The reviewed literature shows that adolescents use substances. Therefore, there is a need to provide interventions that would help to reduce the prevalence of substance use among adolescents. However, little has been investigated on the associated factors of psychoactive use, prevalence, and management of psychoactive substance use among Malawian adolescent learners. 

The knowledge of psycho-social problems is important among adolescent learners as it can help them easily seek help from experts if they need the services  (Yakushi et al., 2017). For example, a study done by Ruble, Leon, Gilley-Hensley, Hess, and Swartz (2013) shows that knowledge of depression through psycho-education can reduce symptoms of depression. Similarly, a study done by Wahl, Susin, Lax, Kaplan, and Zatina (2012) on knowledge and attitudes about mental illness among middle school students found that students' knowledge about mental illness was inconsistent. Important gaps of knowledge were evident, particularly with respect to the symptoms of specific mental health problems   (Wahl et al., 2012). Furthermore, a study conducted by  Ojio et al. (2015)  on the effects of school-based mental health literacy education for secondary school students delivered by school teachers in Australia found that knowledge of mental health and desirable behavior for help-seeking were significantly improved immediately after the psycho-education (Ojio et al., 2015). The reviewed literature shows that there is a knowledge gap among young people, which may affect how they think about mental health problems and healthcare-seeking behaviors, and if adolescents have the knowledge of mental health problems, they can easily seek healthcare from mental healthcare providers. However, little has been investigated on the knowledge gap towards mental health problems and effective management of mental health problems among Malawian adolescent learners.

Generally, adolescents have negative attitudes towards mental health problems and adolescents’ attitudes towards mental health problems can affect how they seek psychological help from experts in different parts of the world (Dat Tan Nguyen, Dedding, Pham, & Bunders, 2013; Wahl et al., 2012).  For example,  Watson, Miller, and Lyons (2005) .The study found that adolescents have negative attitudes and proposed strategies that are aimed at reducing negative attitudes among adolescents by specifically targeting categorical thinking about mental health problems and perceptions that people with mental health problems are violent and out of control. Further, a similar study suggests that adolescent learners’ attitudes toward depression can improve if the attitudes of their parents and teachers change toward them  (Dat Tan Nguyen et al., 2013). Similarly, another study reports that attitudes toward individuals with a mental illness were generally positive among adolescent learners, but substantial numbers of students had less favorable attitudes  (Wahl et al., 2012). In addition, a study by Taylor-Rodgers and Batterham (2014) in Australia found that young people have stigma attitudes towards mental health problems like anxiety and depression, this makes young people have poor mental health-seeking behaviours  (Taylor-Rodgers & Batterham, 2014). 

In Malawi, a study done by Crabb et al. (2012) on attitudes towards mental illness among patients and carers attending mental health and non-mental health-related clinics in a general hospital in Blantyre, found that most of the participants had attributed mental illness to alcohol and illicit drug abuse(95.7%). This was closely followed by brain disease (92.8%), spirit possession (82.8%), and psychological trauma (76.1%). The reviewed literature indicates that young people have negative attitudes towards mental health problems. This has a negative impact when deciding to seek mental health care. Therefore, there was a need to conduct a study to learn more about the attitudes of adolescents toward mental health problems in order to provide necessary interventions that would improve the lives of adolescents. 

Suicide remains a challenge across the world, and it is difficult to predict and prevent because people consider killing themselves. Suicide often are unwilling or unable to disclose their intentions. Also, suicidal thoughts remain a main challenge in general population including adolescent learners ranging from 3.1% - 31.3% in both HICs and LMICs, this was reported in countries like USA, Uganda, Zambia, Kenya, Botswana, Ghana, and Ethiopia (Amare et., 2018; Kinyanda., 2011; Rudatsikira,.2007; Nalugya-Sserunjogi., 2016; Swahn., 2012).   Further, the prevalence of suicidal thoughts among adolescents tends to increase with age (Voss et al., 2019). The reviewed literature shows that suicidal thoughts remain high among adolescents. Therefore, there was a need to create ways how to manage these psychosocial problems among adolescents. However, in Malawi, the knowledge of the prevalence and management of suicidal thoughts among adolescent learners remains scanty. Hence, this study aimed to address this knowledge gap. 

Studies reveal that psycho-social challenges among adolescent learners can be well managed by doing psychotherapies like psycho-education and group counselling (Adegbolagun, Ani, Adejumo, James, & Omigbodun, 2020; Bass et al., 2006; Bella-Awusah, Ani, Ajuwon, & Omigbodun, 2016; Bolton et al., 2003; Thimm & Antonsen, 2014). 

In HICs, studies show that psycho-education and depression can reduce psycho-social challenges like symptoms of depression, use of psychoactive substances, attitudes towards mental health problems, and knowledge of mental health problems.   For example, a study done by Thimm and Antonsen (2014) on the effectiveness of cognitive behavioral group therapy for depression in Norway found that group counseling can reduce depression feelings among study participants by 17.5%. Thus, scores decreased from 28.5% pre-intervention to 18.5% post-intervention at 3-months follow-up period  (Thimm & Antonsen, 2014). However, a meta-analysis of the effects of psycho-education on  depression, anxiety, and psychological distress by Donker, Griffiths, Cuijpers, and Christensen (2009) found that only 0.20% of the study participants had decreased symptoms of depression secondary to psycho-education  (Donker et al., 2009). Similarly, a systematic review examined by Werner-Seidler, Perry, Calear, Newby, and Christensen (2017) found that interventions like psycho-education and group counseling, if delivered by school staff, were effective in managing depression and prevention of depression among adolescent learners. 

Swartz et al. (2017) study on the effectiveness of a universal school-based depression education program among US Secondary School Students found that 46% of adolescent participants had increased knowledge of depression and started approaching the teachers about depression concerns. In addition, a study conducted by Straub et al. (2014) found that group counseling was effective in the management of depressive symptoms, improved quality of life, and reduced suicidal ideation. Also, a study in Indonesia found that psycho-education can improve knowledge and reduce smoking attitudes among adolescent learners   (Tahlil, Woodman, Coveney, & Ward, 2015). Similarly, a study done by Merry, McDowell, Hetrick, Bir, and Muller (2004) on psycho-education interventions for the prevention of depression in children and adolescents found that psychological interventions were effective in managing depression. Also, a quasi-experimental study by Wong et al. (2012) on the effectiveness of a universal school-based program for preventing depression in Chinese adolescents found that students who completed the program generally showed positive development in help-seeking attitudes and self-esteem. Similarly, a study done by Ruble et al. (2013) on depression, knowledge among adolescent learners in the USA found that there was a significant positive change in knowledge for students who received an intervention but not in the control group. Further, an intervention group also demonstrated a significant difference in willingness to share with someone their experiences concerning depression who is a peer, which was not present in the control group (Ruble et al., 2013). Additionally, a study in Australia by Taylor-Rodgers and Batterham (2014) among young people found that psycho-education can increase mental health knowledge, increase help-seeking behaviors, and decrease depression and anxiety symptoms. Also, Sharp, Hargrove, Johnson, and Deal (2006) found that psycho-educational intervention can help in improving attitudes toward seeking professional psychological help, as well as in some of their opinions about mental illness among young people in the classroom  (Sharp et al., 2006). 

In LMICs, similar findings were observed; for example, a study in Nigeria by Adegbolagun et al. (2020)   on the effectiveness of group therapy on depression among adolescents found  a significant reduction in depressive symptoms. Thus, pre-intervention, they found a mean of 4.50 (SD = 2.81), while post-intervention, they found 2.83 (SD = 1.92), p < 0.02. Furthermore, a similar study on depression in Nigeria among adolescent learners found that group counseling can reduce the prevalence of depression by 3.05%  (Bella-Awusah et al., 2016). Similarly, a study on effects of psycho-education on depression among adolescents by Isa, Ani, Bella-Awusah, and Omigbodun (2018) found that one-week post-intervention, the mean depression score was significantly reduced compared with baseline of 24.4 (SD, 2.10) while 3.94 (SD 11.18) post-intervention, p = 0.001)  (Isa et al., 2018). In addition, a study conducted by Bass et al. (2006) on the effects of group counseling on depression in Uganda communities found a 43.2% decrease in depressive symptoms among study participants. The treatment arm had 11.7%, while the control arm had 54.9% (Bass et al., 2006). Similarly, a study done by Bolton et al. (2003) on the impact of group psychotherapy on depression among rural Uganda communities found a decrease of 48.2% in the prevalence of depression among study participants after the intervention. Thus, a treatment arm had 6.5% while a control group had 54.7% (Bolton et al., 2003). 

In Malawi, a study done by Kutcher et al. (2015)  on improving Malawian teachers’ and young people's mental health knowledge and attitudes found that educating teachers and young people had significantly improved the knowledge (p < 0.0001, d = 1.16) and attitudes (p < 0.0001, d = 0.79) towards mental health  (Kutcher et al., 2015).  Similarly, a study done by Mwale and Muula (2019) on the efficacy of peer education in sexual behavioral change among adolescent learners in Northern Malawi found that there were significant improvements in the intervention arm as 96% of study participants were less likely to have sex than the control  (Mwale & Muula, 2019). Further, a similar study found effect size of 0.28 of psycho-education was able to reduce prevalence of negative attitudes towards psycho-social challenges among adolescents (Gaiha et al., 2021). Therefore, studies both in HICs and LMICs show that group counseling and psycho-education can result in increased knowledge about mental illness, change attitudes towards mental health problems, reduce prevalence of depression, suicidal thoughts and substance use. Also, there was need to test if a combined approach of group counselling and psycho-education intervention could be an effective way of managing psychosocial problems among adolescents in Malawi especially in school context. 

This section outlines the methods and materials employed in a study investigating the efficacy of group counselling and psychoeducation in reducing psycho-social challenges among adolescent learners in Malawi. The research adopted a mixed-methods approach, integrating constructivist (Appleton & King, 1997; Chen, Shek, & Bu, 2011; Fourie, 2015), phenomenological (Creswell, 2013; Eddles-Hirsch, 2015), and positivist philosophical paradigms (Creswell, 2009; Johnson & Onwuegbuzie, 2004). Positivism, chosen for its alignment with the study's quantitative nature, assumes an objective reality measurable through numeric data and statistical analysis.

The study utilized a non-equivalent group quasi-experimental design (Behi & Nolan, 1996; Krishnan, 2019), targeting 317 adolescents aged 10–19 from two urban boarding secondary schools in southern Malawi. These schools were selected for their similarity in structure, student demographics, and educational practices, ensuring generalizability. Participants were randomly sampled from Forms 1–4, with 163 participants in the study group and 154 in the control group. Data were collected via self-administered structured questionnaires. The study group received a two-month intervention comprising 16 sessions on topics such as depression, stress management, and coping skills, while the control group received no intervention. Data collection tools included validated instruments like the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST-Y) (WHO, 2016), Patient Health Questionnaire for Depression (PHQ-9) (Radloff, 1977), 20-Item Mental Health Knowledge questionnaire and Attitudes Toward Serious Mental Illness Scale-Adolescent Version (ATSMI-AV) (Borghero et al., 2018; Pinto-Foltz, Logsdon, & Myers, 2011). In order to establish the extent of the common psycho-social problems among adolescent learners.  

Research assistants and trained mental health nursing graduates administered the questionnaires and intervention in order to minimize bias, ensuring privacy and confidentiality. Baseline and post-intervention data were analyzed using SPSS version 26, with descriptive statistics summarizing demographic and psychosocial variables. Ethical considerations included obtaining consent from the University of Malawi, Education Division, School management, parental consent, adolescent assent, and maintaining data confidentiality. The study aimed to address gaps in understanding the prevalence and management of psycho-social challenges among adolescents in southern Malawi (Kutcher et al., 2017; Kuyokwa, Chiziwa, & Semphere, 2019), while testing the effectiveness of a combined psychoeducation and group counselling intervention (Gates et al., 2016; Klimas et al., 2014).

The study aimed at evaluating the effectiveness of the combined psychoeducation and group counselling approach in supporting adolescents with psychosocial challenges, whether it was successful or not. The following research question guided the study: How does the combined psychoeducation and group counseling approach support adolescents with psychosocial challenges?

Prevalence of Psycho-social Challenges Among Adolescent Learners

A total of 317 participants were sampled to participate during the baseline study. One hundred sixty-three participants were at the study site, while 154 were at the control site. During the evaluation study, a total of 261 participants were sampled, 158 of whom were at the study site, and 103 were at the control site. It was observed that some targeted participants dropped out of school because of different reasons. That is why the number of participants decreased during the evaluation study. Furthermore, to put ourselves in the context of the study, it is worthy of looking at the prevalence of the targeted psycho-social challenges (depression, substance use, attitudes towards mental health problems, and knowledge of mental health problems) that were established by this study and test the efficacy of the intervention in managing the psycho-social problems among the adolescents.

Prevalence of Positive Attitudes Towards Mental Health Problems

The study found that the prevalence of positive attitudes towards mental health problems among adolescents was 26% at the study site and 31% at the control site. Table 1 below shows the details. 

Table 1: Prevalence of positive attitudes towards mental health problems

Table 1 above shows that adolescents' attitudes toward mental health problems improved and ranged from 26% to 55% at the study site. At the control site, the prevalence of positive attitudes toward mental health problems ranged from 31% to 27% during the pre-and post-intervention period. This could be due to the lack of specific psycho-social support services for managing mental health problems.

Prevalence of Knowledge of Mental Health Problems

The study found that the prevalence of positive attitudes towards mental health problems among adolescents was 23% at the study site and 25% at the control site. Table 2 below shows the details. 

Table 2: Prevalence of knowledge of mental health problems

Table 2 above shows that adolescents had reduced knowledge about mental health problems. However, the knowledge about mental health problems improved with the intervention, and it ranged from 23% to 70% at the study site, while at the control site, there was a reduced level of knowledge of mental health problems, and it ranged from 25% to 23% during the pre and post-intervention period. A similar study also revealed that adolescents have some form of knowledge about mental health problems, and this has also been observed in different countries, including Malawi and Tanzania (Kutcher et al., 2019). 

Prevalence of Substance Use

The study found that the prevalence of substance use among adolescents was 31% at the study site and 22% at the control site. Table 3 below shows the details. 

Table 3: Prevalence of substance use

Table 3 above shows that substance use is prevalent among adolescents and that at the study site, it ranged from 31% to 26%. This shows that the intervention had a positive impact on substance use because it was able to reduce the prevalence of depression, while at the control site, it ranged from 22% to 10%; the decrease could be due to available psycho-social support services in school during the pre and post-intervention period.  However, a similar study in South Africa found a higher prevalence of substance use, 56.5% among adolescents. (Tshitangano & Tosin, 2016).

Prevalence of Suicidal Thoughts

The study found that the prevalence of suicidal thoughts among adolescents was 26% at the study site and 8% at the control site. Table 4 below shows the details.

Table 4: Prevalence of suicidal thoughts

Table 4 above shows that the prevalence of suicidal thoughts was relatively high at the study site. Notably, it decreased with the intervention from 26% to 25%. However, at the control site, the prevalence of suicidal thoughts increased from 8% to 14%. This could be due to a lack of psycho-social support services in schools. However, the prevalence of suicidal thoughts among adolescents was slightly higher in this study as compared with other studies, as observed by other researchers who reported a prevalence of 17% of suicidal thoughts among adolescents in different countries  (Uddin, Burton, Maple, Khan, & Khan, 2019). The difference could be due to social contexts and the effects of Covid-19.

Prevalence of Depression

The study found that the prevalence of depression among adolescents was 87% at the study site and 86% at the control site. Table 5 below shows the details.

Table 5: Prevalence of depression

Table 5 above shows that the prevalence of depression among adolescents remained high despite intervention at the study site, which ranged from 87% to 88.0% during the pre and post-intervention period. This shows that the intervention failed to reduce the prevalence of depression among adolescent learners. A similar study observed this in Malawi. It found that there was a 70% prevalence of depression among adolescents attending schools in Lilongwe  (Kutcher et al., 2017). However, the results of the previous study are lower than those of the current study. At the control site, the prevalence of depression was also high, as it ranged from 86% to 80% during the pre and post-intervention periods. This shows that the intervention had no impact on depression. What is noteworthy here is that there was a slight decrease in the prevalence of depression at the control site. Also, the decrease could be due to some form of psycho-social interventions that were available in schools. Further, the high prevalence of depression could also be secondary to challenges that were associated with COVID-19 and the teachers’ national strike.

The study found that psychosocial problems are prevalent among adolescent learners in schools. The study results show that generally, the combined psycho-education and group counseling approach intervention had a positive impact on behavior change in terms of substance use, reducing negative attitudes/stigma towards mental health problems and knowledge gap about mental health problems. However, the prevalence of depression remained high despite the intervention at the study site. The depression results could be due to various reasons and are not limited to the following: the time when the evaluation study was conducted. It was conducted a week before the end of the term test, and the researcher’s suspicion is that either adolescents were anxious about the impending examinations or there was no continued psycho-social support among adolescents by relevant stakeholders. The study was conducted when Covid-19 prevalence was very high in the country and most people were hopeless about the future because it was not clear when the pandemic would end. This could also have affected the adolescents. Further, this study was conducted during a nationwide secondary teachers strike when adolescents were kept in school. This could also have affected the results of the study. In addition, the psycho-social intervention was only two months long. Therefore, the intervention period might not be sufficient, and hence, future studies should focus on increasing the duration of the psycho-social intervention among adolescent learners. Furthermore, the intervention was more effective in managing stigma/negative attitudes towards psycho-social problems and the knowledge gap about mental health problems than substance use, suicidal thoughts, and depression among adolescents. This was observed in proportions after comparing the baseline and evaluation study findings. In addition, some form of psycho-social interventions that the study participants received at the control site during the study period could have helped to reduce the prevalence of depression and substance use at the control site.