Project HASHTAG: testing a school-based intervention to improve adolescent mental health in Nepal and South Africa

INTERVENTION: In each country (South Africa and Nepal), a random‐number generator will be used to randomize two schools to intervention condition, and two to control condition, after evaluating equivalency across a number of domains. Intervention arm recipients will receive a school climate and mental health intervention, HASHTAG, comprised of two parts: Thriving Environment in Schools (TES) and Thriving Together (TT). In South Africa, trained community‐based facilitators will implement the intervention; in Nepal, trained school counsellors will fulfill this role. TES will include 1) School Action Groups, 2) teacher‐focused workshops, and 3) mental health awareness raising activities. School Action Groups will involve students from across multiple grade levels, as well as teachers and administrators; they will meet regularly and act as a steering committee at the school level to facilitate implementation of HASHTAG, as well as overseeing the implementation of the mental health awareness activities. Three teacher workshops totaling 7 hours and will aim to improve psychosocial wellbeing and classroom management skills. Mental health awareness raising activities will include text messaging to parents/caregivers, students, and teachers, a school‐wide campaign, and parent meeting components. TT will be delivered to students in Grade 8 in South Africa and Grade 7‐9 in Nepal. It will include six 90‐minute weekly sessions focused on emotional regulation, stress management, problem‐solving, interpersonal skills and relationships, and assertiveness training. Control arm schools will receive a shortened version of the student sessions after follow‐up interviews are complete (i.e. “enhanced treatment as usual” [eTAU]). CONDITION: Positive mental health, depression, anxiety in adolescents in Nepal and South Africa ; Mental and Behavioural Disorders PRIMARY OUTCOME: ; Measured at baseline and immediately post‐intervention ( 5 months):; 1. Positive mental health, measured using the Stirling Children’s Wellbeing Scale (15 items); a culturally‐suitable adaptation of Resilience Scale (8 items); and the Multidimensional Student Life Satisfaction Scale (family subscale, 7 items, South Africa only).; 2. Depression will be assessed using the 9‐item Patient Health Questionnaire – Adolescent version (PHQ‐A). Incidence of depression will be measured at or above a threshold of 10. In addition, we will measure change in depressive symptomatology.; 3. Anxiety symptomatology will be assessed using the 7‐item Generalized Anxiety Disorder‐7 (GAD‐7; 7 items). Incidence of anxiety will be measured at or above a threshold of 10. In addition, we will measure change in anxiety symptomatology.; SECONDARY OUTCOME: ; Measured at baseline and immediately post‐intervention ( INCLUSION CRITERIA: School going adolescents in South Africa (Grade 8) and Nepal (Grade 7‐9) 5 months):; 1. Psychosocial functioning is measured using the Strengths and Difficulties Prosocial Scale (5 items), and the World Health Organization Disability Assessment; 2. Schedule (WHODAS) 2.0 (life activities items, 9 items).; 3. Substance use will be measured using the Alcohol Use Disorders Identification Test (10 items) and one self‐report question on tobacco and illicit drug use.; 4. Aggression will be measured using the Aggression Scale (11 items).; 5. Self‐harm and suicidality will be measured using 9 self‐report questions on self‐harm intentions and behaviours.; 6. Social support will be measured by the Social Connectedness Scale (8 items) and the Oslo Social Support Scale (3 items).; 7. School environment will be measured using the Beyond Blue School Climate Questionnaire (28 items).; 8. Bullying experiences will be measured using the Gatehouse Bullying Scale (4 items with 2 follow‐ups each; potential total of 12 items).;