Brave Heart Intervention and Mental Health Outcomes Among Young People in Sierra Leone

Substance use disorders (SUDs) and poor mental health literacy are major contributors to disability among young people worldwide, with roughly half of adult mental disorders emerging before age 14 and three-quarters before age 24. Sierra Leone, a post-conflict, low-income country with a median age of 19, faces a particularly severe version of this burden. The national mental health workforce consists of only a small number of psychiatrists and no psychologists for a population exceeding 8 million, and mental health care is centralized in a single, chronically underfunded psychiatric hospital in Freetown. Over the past several years, the country has seen a sharp rise in use of "kush," a synthetic cannabinoid-like substance, among adolescents and young adults, with drug-related hospital admissions increasing dramatically since 2020. Existing national drug policy is oriented toward punitive enforcement rather than prevention, and no structured, evidence-based SUD prevention or mental health literacy programs currently operate at scale in Sierra Leonean schools or communities.

Given the shortage of specialist providers, this study tests a task-shifting model: delegating delivery of a structured prevention curriculum to trained non-specialists, secondary school teachers and community leaders, who are themselves supervised and equipped through a standardized training program. Task-shifting approaches have shown feasibility and effectiveness in other low-resource global health contexts, including for mental health service delivery, but have not been rigorously evaluated for SUD prevention and mental health literacy promotion in Sierra Leone specifically.

The Brave Heart Intervention integrates three components delivered jointly: (1) structured psychoeducation and cognitive-behavioral techniques aimed at helping young people recognize and manage risk factors for substance use and mental health difficulties; (2) life skills and digital skills training intended to strengthen coping capacity, resilience, and future economic opportunity, partly delivered through a mobile health application (SIMBIHealth); and (3) community and policy engagement activities intended to build local ownership and support sustained, systemic uptake of prevention practices beyond the trial period.

This is a cluster randomized controlled trial. Randomization occurs at the cluster level, schools and communities, rather than individuals, to reflect the way the intervention is naturally delivered (to intact groups of students within a school, or community members within a defined community) and to reduce contamination between intervention and control participants who share the same social environment. Twenty secondary schools and two communities are allocated to the intervention arm, and twenty schools and two communities to the control arm, drawn from Freetown's Western Urban and Western Rural areas to capture both urban and semi-urban/rural variation.

Within intervention schools, teachers are trained and then deliver the curriculum to groups of students; within intervention communities, trained community members (with preference given to individuals with lived experience of substance use disorder) deliver the curriculum to youth participants. Data are collected from young people (ages 10-24), as well as from the teachers and community leaders who deliver the intervention, using validated quantitative instruments administered electronically at baseline and endline, alongside qualitative focus group discussions and in-depth interviews conducted with a purposive subset of participants at both timepoints. Quantitative analysis will use mixed-effects multilevel regression models to account for clustering by school/community while comparing change scores between intervention and control arms; qualitative data will be analyzed using thematic content analysis with dual coding and inter-coder reliability checks. A parallel policy analysis will assess baseline adoption of SUD- and mental-health-relevant policies in participating schools and communities.

The study is grounded in the Government of Sierra Leone's Education Sector Plan, which identifies student mental health and well-being as a strategic priority, and is intended to generate evidence on whether a task-shifted, school- and community-based prevention model is a feasible, acceptable, and effective way to extend SUD prevention and mental health support to young people in settings where specialist care is largely inaccessible.