Adolescents’ experiences of participating in a school-based preventive mental health intervention in Nepal: a nested qualitative study

Abstract

Adolescence is a critical period for mental health, with poverty and adversity increasing vulnerability to depression and anxiety. Understanding how adolescents experience preventive interventions, including their perceived benefits, challenges, and factors influencing engagement, is important, particularly in low- and middle-income countries (LMICs) where evidence remains limited. This qualitative study explored how adolescents, caregivers, and head teachers experienced three modalities of a school-based intervention in Nepal: self-regulation, economic, and combined (self-regulation and economic) interventions delivered within a pilot prevention programme. This qualitative study was nested within a pilot cluster-randomized controlled trial in Nepal. Post-intervention semi-structured interviews were conducted with 18 adolescents, 18 caregivers, and 3 head teachers between September and October 2024 across 6 participating intervention schools. Participants were purposively sampled to capture a range of engagement levels across intervention arms. Interviews explored experiences, perceived benefits and challenges, and observations of changes. Audio-recorded interviews were transcribed verbatim and analyzed using framework analysis, combining deductive and inductive coding. Perspectives across participant groups were compared to support triangulation. Analysis generated six overarching themes covering adolescents’ perceived changes, motivations for participation, acceptability, challenges, and caregivers’ and head teachers’ observations. Adolescents described perceived changes in emotional regulation, interpersonal relationships, financial behaviors, discipline, and future orientation across intervention arms. Self-regulation participants described learning breathing and stress-management strategies that they perceived as supporting emotion regulation and communication. Economic intervention participants described developing financial skills, including saving, expense tracking, and distinguishing needs from wants. Combined-arm participants described experiences spanning emotional and financial domains. Facilitator support, peer interaction, and interactive activities were important to engagement and acceptability. Caregivers and head teachers also described perceived changes in communication, responsibility, and engagement at home and school. Adolescents reported challenges related to academic pressures, competing responsibilities, and sustaining new practices, while accounts of the interventions were predominantly positive. Adolescents and adults described the interventions as acceptable and perceived them as supporting emotional, behavioral, and practical skills. However, these findings reflect perceptions shortly after intervention completion and do not establish sustained behavioral change or intervention effectiveness. Supportive facilitation, peer and family engagement, and attention to school and social contexts may be important when implementing and adapting school-based preventive interventions for adolescents.