In short

• Adolescents in low- and middle-income countries face complex mental health stressors shaped by personal, societal and environmental pressures.
• Low mental health literacy limits recognition of problems and help-seeking.
• Stigma, inequality and limited services hinder access to care.
• Social media, climate change and food insecurity add emerging stress.
• Multi-layered responses are needed.

Adolescence is widely recognised as a high-pressure life stage, yet most evidence on what drives that stress comes from high-income countries. To help close this gap for low- and middle-income countries, HSRC researchers and partners convened a workshop in Nairobi in January 2024. Using a rapid consensus method, participants prioritised youth mental health stressors that warrant further research. 

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A large body of research suggests that adolescence can be a uniquely stressful life stage, as young people undergo rapid developmental shifts. These shifts include changes in self-concept and identity, and a growing reliance on peer relationships both within and beyond the family. Much of this research has been conducted in high-income countries in Europe and North America.  

However, research on adolescent stressors in low- to middle-income countries (LMICs) remains scarce. In 2022, the Being mental health initiative was conceived to build and fund research to understand the drivers that impact the mental health of young people (aged 10 to 24), particularly in LMICs. 

In 2024, to inform the Being initiative’s future research and funding, HSRC researchers collaborated with the University of KwaZulu-Natal, the Science for Africa Foundation and Walter Sisulu University to organise a workshop in Nairobi, Kenya. At this workshop, representatives from 11 LMICs gathered to produce a ranked list of priority adolescent mental health stressors. The process and results of the workshop were laid out in a peer-reviewed article. 

Representatives were individuals who lived or worked in an LMIC and held a stake in youth mental health. Expertise included research officers, research coordinators, university lecturers and directors of mental health. The countries represented were Senegal, Sierra Leone, Tanzania, Ghana, Ecuador, Colombia, India, Pakistan, Vietnam, Romania and Indonesia. 

Rapid consensus 

To produce the ranked list, the workshop utilised the nominal group technique, a rapid consensus-building method aiming to allow a small group to quickly agree on priorities. The session worked in five stages and ran for two hours. The stages included individual idea-generation, the sharing of ideas and classification of stressors, a group discussion, an online ranking of stressors, and then an anonymous vote on each stressor’s prevalence, value of addressing, impact and national priority. 

What are stressors? 

Stressors can be grouped into three main categories: psychological, physiological and behavioural. The workshop specifically focused on psychological stressors experienced during youth. Psychological stressors relate to cognitive and emotional experiences, such as worry, negative thoughts, social comparison and low self-esteem, which often manifest as anxiety or depression. Representatives at the workshop categorised psychological stressors into one of three categories – personal, societal or environmental – and ranked each stressor from most significant (1) to least significant (9), as seen in Table 1. 

Table 1. List of stressors according to rank

Personal stressors 

At the personal level, the ranking exercise revealed that representatives at the workshop prioritised poor mental health awareness and low mental health literacy as major stressors for young people across LMIC settings. Representatives discussed how low mental health literacy meant that many adolescents struggled to identify when they (or a friend) might be experiencing a mental health problem; to understand symptoms such as persistent worry, low mood, sleep problems, irritability or loss of interest; or to know where or how to seek help – for example, because they cannot differentiate the roles of psychiatrists, psychologists and social workers.  

Educational expectations were also prioritised as a personal stressor and included pressure to perform well academically; high parental or societal expectations around school success; burdens of exams and academic competition; bullying within school environments; and conflictual or unsupportive relationships with teachers. Other personal stressors included in the ranked list were substance abuse, poverty; childhood trauma, and food insecurity.  

Societal stressors 

Societal stressors were dominated by stigma, particularly within healthcare and social environments. Participants noted that negative attitudes towards patients with mental health problems among service providers and communities often resulted in inadequate care or delayed treatment because young people were at times discouraged from seeking help, owing to feelings of shame and exclusion.  

Educational expectations were also categorised as a societal pressure. Representatives discussed how adolescents may face pressure to do well at school alongside conflicts with teachers or peers, while growing social and economic responsibilities can push them towards employment, thus limiting higher-education prospects. Violence and conflict; bullying; policy environments; economic inequality; and limited access to mental healthcare systems were identified as significant societal pressures that shape young people’s mental wellbeing in LMICs. 

Environmental stressors 

Broader structural and contextual forces shaped environmental stressors. These factors operated beyond the individual or immediate social setting but had tangible psychological effects on young people’s daily lives. Media exposure, particularly social media, was ranked in the workshop as the most significant environmental stressor. Representatives highlighted social comparison, cyberbullying, and information overload as key pressures on young people. 

Climate change and technological change were also identified in the workshop as emerging environmental stressors. Workshop discussions linked these to uncertainty and shifting social expectations. Policy environments were also a stressor, as laws, systems and public priorities can fail to adequately protect or support young people’s mental health. 

Food insecurity as a cross-cutting stressor 

Although food insecurity was ranked lower than other stressors, the workshop showed how it cut across personal, societal and environmental domains. Representatives noted that in many low- and middle-income countries, young people live in households with limited or unstable access to food, which creates chronic stress, anxiety and uncertainty. Food insecurity is closely linked to poverty, economic inequality and climate-related pressures, and it can undermine both physical health and psychological wellbeing, making it an important underlying driver of mental health risk.  

What does this mean? 

The research suggests that because youth mental health stressors operate at multiple levels, responses must also be multi-layered. Strengthening mental health literacy, for example, can involve a range of community-based approaches, especially given the clear recognition of the big impact of societal stressors on youth. Interventions such as the Friendship Bench – a Zimbabwean community-based mental health intervention programme that combines brief psycho-education (information, advice and support) with structured problem-solving therapy delivered by trained lay health workers in primary care – can help people recognise and make sense of distress. The programme also uses symptom screening and clear referral/self-referral pathways, making it easier for people to seek help and be linked to appropriate care within resource-constrained environments. 

Addressing stigma and service gaps requires supportive school and community systems, as well as policies that expand youth-friendly mental health services. For social media and digital stressors, researchers noted both risks – such as social comparison, cyberbullying and information overload – and opportunities, such as the use of online platforms for mental health promotion and accessible digital interventions. Together, these approaches highlight the need for coordinated education, community support and policy action to improve prevention and foster early intervention. The list of stressors and their ranking is thus a useful tool and reference for framing policy action in relation to youth mental health in LMICs.  

Research contacts and acknowledgements 

This article was written by HSRC science writer Jessie-Lee Smith with inputs from Dr Zaynab Essack (senior researcher) from the HSRC’s Public Health, Societies and Belonging Division. It is based on the research article Applying the nominal group technique to determine emerging stressors related to youth mental health: findings from a multi-country stakeholder consensus-building exercise.  

The research team included Nazeema Isaacs (senior researcher) from the HSRC’s Research, Development, Science and Innovation and Dr Zaynab Essack (senior researcher) from the HSRC’s Public Health, Societies and Belonging Division, and Lilian Mutengu, Dr Salome Wawire, Susan Gichoga, Dr Uzma Alam, Constance Mabia, Dr Alphonsus Neba, and Dr Byron Bitanihirwe from the Science for Africa Foundation and Dr Palesa Rose Sekhejane from Walter Sisulu University. 

For more information about this work, please contact Dr Zaynab Essack at zessack@hsrc.ac.za.