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An exploration of emotion regulation and mental health among older South African adolescents from low-income settings
Introduction: Adolescence is a unique and challenging phase, marked by physical, emotional, mental, and interpersonal changes. Within this context, adolescents—especially in Africa— bear the burden of mental health conditions (MHCs)1, particularly depression and anxiety. Most adolescents live in low...
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Department of Psychiatry and Mental Health
2026
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| access_status_str | Open Access |
| author | Ward-Smith, Chesney |
| author2 | Sorsdahl, Katherine |
| author_browse | Sorsdahl, Katherine Ward-Smith, Chesney |
| author_facet | Sorsdahl, Katherine Ward-Smith, Chesney |
| author_sort | Ward-Smith, Chesney |
| collection | Thesis |
| description | Introduction: Adolescence is a unique and challenging phase, marked by physical, emotional, mental, and interpersonal changes. Within this context, adolescents—especially in Africa— bear the burden of mental health conditions (MHCs)1, particularly depression and anxiety. Most adolescents live in low- and middle-income countries (LMICs), where psychological support is often inaccessible. Available South African adolescent mental health (MH) research shows that older adolescents (15–18-year-olds) also bear the burden of MHCs, and that few indicated psycho-social interventions for anxiety and depression symptoms are available for this vulnerable population in LMIC settings. Transdiagnostic approaches that strengthen adaptive skills in emotion regulation (ER) in combination with physical activity elements may hold promise for addressing depression and/or anxiety symptoms among older adolescents. Adaptive ER skills appear to play an important role in protecting against MHC development among adolescents. Using a mixed-methods design, this study achieved the following four objectives by 1) identifying associations between depression and/or anxiety symptoms and ER among older adolescents from low-income settings, 2) determining the psychometric properties of an ER measure (Difficulties in ER Scale-16 (DERS-16)) among older adolescents from low-income settings, 3) quantitatively assessing the acceptability and feasibility of a co-adapted, task-shared, group-based ER intervention with physical activity elements for older adolescents from low-income settings who were experiencing depression and/or anxiety symptoms, and 4) qualitatively eliciting participants' perceptions of the feasibility, acceptability and impact of the ER intervention. Methods: For objectives 1 and 2 of the study, 12 schools were selected in collaboration with two non-governmental organisations. Students aged 15–18-years were recruited to complete a tablet-based survey. ER, depression, anxiety, and other psycho-social measures were included. For objective 1, frequency distributions and descriptive statistics for categorical and continuous variables were compared by gender using chi-square or t-tests. Pearson's correlations examined ER, anxiety, and depression scores. Unadjusted and adjusted linear regressions assessed associations between socio-demographic, psycho-social factors, and ER. For objective 2, the psychometric properties of the English-language DERS-16 were determined using internal consistency, test-retest reliability, convergent validity, and exploratory and confirmatory factor analyses. For objectives 3 and 4, eight groups of adolescents (n = 85) from four Western Cape schools participated in a pre-post, non-randomised, single-arm feasibility study. The school-based intervention, locally named the #FeelThinkMove (#FTM) programme took place weekly, after school, over seven weeks. Participants completed MH surveys at baseline, one week, and three months post-intervention. These surveys included measures on depression and anxiety symptoms, self-esteem, and physical-activity levels. Feasibility outcomes were assessed via identified indicators such as recruitment and retention figures. Facilitator competency and content fidelity were assessed descriptively via the Therapeutic Attributes and Competencies for Teen Groups—South Africa (TACT-Groups-SA) and session fidelity checklists respectively. Acceptability was quantified using the Child Evaluation Inventory (CEI), rated on a 5-point scale (1= not at all acceptable; 5=very acceptable) and the proportion of participants scoring > 4 was reported. For objective 4, a subsample of adolescent intervention participants (n = 20), facilitators (n = 4) and stakeholders (n = 7) completed 4060-minute semi-structured interviews at the final follow-up to qualitatively explore perceptions of the feasibility, acceptability, and impact of the intervention. Results: For objective 1, of the 733 adolescent participants from 12 Western Cape schools, 417 (56.90%) were experiencing clinically significant anxiety symptoms, 423 (57.70%) depression symptoms, 229 (31.40%) PTSD symptoms, and 263 (35.90%) risky alcohol use. Anxiety and depression symptoms showed strong correlations with ER difficulties. Further, correlations were strongest between high depression and anxiety symptom scores and high ER strategy scores. The adjusted linear regression model demonstrated that female gender; clinically significant depression, anxiety, and post-traumatic-stress symptoms; and risky alcohol use were all significantly associated with poorer ER scores, while high self-esteem was significantly associated with better ER scores. For objective 2, the English-language DERS-16 displayed excellent internal consistency (α= 0.93), average test-retest reliability (r= 0.64), and strong convergent validity with both the Center for Epidemiologic Studies Depression Scale (CES-D-10; r= 0.72) and the Generalized Anxiety Disorder Scale (GAD-7; r= 0.69). A weaker but significant negative correlation was found with the ER Skills Questionnaire (ERSQ; r=0.26). Exploratory factor analysis proposed a novel two-factor model with loadings ranging from 0.39 to 0.86. Confirmatory factor analysis provided additional support for the two-factor structure, with acceptable fit indices (CFI=0.91, TLI=0.89, RMSEA=0.089). For objective 3, all adolescents (n = 85) completed the baseline survey, 99% the eight-week follow-up, and 95% the three-month follow-up. Of the sample, 84% completed the programme. On the CEI, participants found the programme highly acceptable overall, with 93.80% (n = 76) scoring ≥ 4. Facilitators achieved a 96% therapeutic competency rating and an 86% content fidelity rating overall. Adolescent participants' depression, anxiety, PTSD and emotional-dysregulation scores were significantly lower at all follow-up points. Self-esteem and physical-activity scores were significantly increased at the eight-week follow-up, with self-esteem remaining significantly higher at the three-month follow-up. For objective 4, several key findings emerged from the qualitative data. Participants found the programme acceptable, enjoyable, and necessary for addressing adolescent MH needs. They reported improved mood, behaviour, adaptive anger management, and reductions in stress, anxiety, and depression symptoms. Adolescents found the core ER skills and strategies as well as physical activity beneficial post-programme. Facilitators perceived the task-sharing model, supported by competency-based training and supervision, as acceptable and useful. Conclusions: Objective 1 findings contribute to the South African adolescent MH literature and to the research gap on the links between emotion dysregulation and clinically significant depression and/or anxiety symptoms in this vulnerable population in an LMIC setting. Objective 2 findings confirm the DERS-16 as a sound tool for assessing ER in older adolescents, filling a critical gap and supporting its use by clinicians and researchers. Given that ER is vital for adolescent MH, these findings highlight the need to further develop and adapt tools for South African adolescents. Objectives 3 and 4's findings highlight the need for school-based, task-shared ER interventions with physical-activity elements for at-risk older South African adolescents from low-income settings. The findings support the intervention's feasibility, acceptability, and perceived positive impact. While it shows therapeutic potential, a randomised control trial is needed to confirm efficacy and cost-effectiveness for scaling. This study contributes to adolescent MH and ER research, emphasizing the need for contextually relevant, evidence-based tools and interventions in low-resource settings. It highlights adapting ER measures, advancing ER intervention research, and guiding investment in adolescent MH resilience. This feasibility study is registered with the Pan African Clinical Trial Registry (#PACTR202412659160564) (Appendix 1). This study can be accessed at: https://pactr.samrc.ac.za/Search.aspx. |
| format | Thesis |
| id | oai:open.uct.ac.za:11427/43409 |
| institution | University of Cape Town (South Africa) |
| language | English eng |
| last_indexed | 2026-07-01T04:02:48.391Z |
| license_str | Not specified — see source repository |
| provenance_str_mv | Harvested via OAI-PMH from UCTD — University of Cape Town Open Access Repository |
| publishDate | 2026 |
| publishDateRange | 2026 |
| publishDateSort | 2026 |
| publisher | Department of Psychiatry and Mental Health |
| publisherStr | Department of Psychiatry and Mental Health |
| record_format | dspace |
| source_str | UCTD — University of Cape Town Open Access Repository |
| spelling | oai:open.uct.ac.za:11427/43409 An exploration of emotion regulation and mental health among older South African adolescents from low-income settings Ward-Smith, Chesney Sorsdahl, Katherine Van Der Westhuizen, Marie-Claire adolescence mental health Introduction: Adolescence is a unique and challenging phase, marked by physical, emotional, mental, and interpersonal changes. Within this context, adolescents—especially in Africa— bear the burden of mental health conditions (MHCs)1, particularly depression and anxiety. Most adolescents live in low- and middle-income countries (LMICs), where psychological support is often inaccessible. Available South African adolescent mental health (MH) research shows that older adolescents (15–18-year-olds) also bear the burden of MHCs, and that few indicated psycho-social interventions for anxiety and depression symptoms are available for this vulnerable population in LMIC settings. Transdiagnostic approaches that strengthen adaptive skills in emotion regulation (ER) in combination with physical activity elements may hold promise for addressing depression and/or anxiety symptoms among older adolescents. Adaptive ER skills appear to play an important role in protecting against MHC development among adolescents. Using a mixed-methods design, this study achieved the following four objectives by 1) identifying associations between depression and/or anxiety symptoms and ER among older adolescents from low-income settings, 2) determining the psychometric properties of an ER measure (Difficulties in ER Scale-16 (DERS-16)) among older adolescents from low-income settings, 3) quantitatively assessing the acceptability and feasibility of a co-adapted, task-shared, group-based ER intervention with physical activity elements for older adolescents from low-income settings who were experiencing depression and/or anxiety symptoms, and 4) qualitatively eliciting participants' perceptions of the feasibility, acceptability and impact of the ER intervention. Methods: For objectives 1 and 2 of the study, 12 schools were selected in collaboration with two non-governmental organisations. Students aged 15–18-years were recruited to complete a tablet-based survey. ER, depression, anxiety, and other psycho-social measures were included. For objective 1, frequency distributions and descriptive statistics for categorical and continuous variables were compared by gender using chi-square or t-tests. Pearson's correlations examined ER, anxiety, and depression scores. Unadjusted and adjusted linear regressions assessed associations between socio-demographic, psycho-social factors, and ER. For objective 2, the psychometric properties of the English-language DERS-16 were determined using internal consistency, test-retest reliability, convergent validity, and exploratory and confirmatory factor analyses. For objectives 3 and 4, eight groups of adolescents (n = 85) from four Western Cape schools participated in a pre-post, non-randomised, single-arm feasibility study. The school-based intervention, locally named the #FeelThinkMove (#FTM) programme took place weekly, after school, over seven weeks. Participants completed MH surveys at baseline, one week, and three months post-intervention. These surveys included measures on depression and anxiety symptoms, self-esteem, and physical-activity levels. Feasibility outcomes were assessed via identified indicators such as recruitment and retention figures. Facilitator competency and content fidelity were assessed descriptively via the Therapeutic Attributes and Competencies for Teen Groups—South Africa (TACT-Groups-SA) and session fidelity checklists respectively. Acceptability was quantified using the Child Evaluation Inventory (CEI), rated on a 5-point scale (1= not at all acceptable; 5=very acceptable) and the proportion of participants scoring > 4 was reported. For objective 4, a subsample of adolescent intervention participants (n = 20), facilitators (n = 4) and stakeholders (n = 7) completed 4060-minute semi-structured interviews at the final follow-up to qualitatively explore perceptions of the feasibility, acceptability, and impact of the intervention. Results: For objective 1, of the 733 adolescent participants from 12 Western Cape schools, 417 (56.90%) were experiencing clinically significant anxiety symptoms, 423 (57.70%) depression symptoms, 229 (31.40%) PTSD symptoms, and 263 (35.90%) risky alcohol use. Anxiety and depression symptoms showed strong correlations with ER difficulties. Further, correlations were strongest between high depression and anxiety symptom scores and high ER strategy scores. The adjusted linear regression model demonstrated that female gender; clinically significant depression, anxiety, and post-traumatic-stress symptoms; and risky alcohol use were all significantly associated with poorer ER scores, while high self-esteem was significantly associated with better ER scores. For objective 2, the English-language DERS-16 displayed excellent internal consistency (α= 0.93), average test-retest reliability (r= 0.64), and strong convergent validity with both the Center for Epidemiologic Studies Depression Scale (CES-D-10; r= 0.72) and the Generalized Anxiety Disorder Scale (GAD-7; r= 0.69). A weaker but significant negative correlation was found with the ER Skills Questionnaire (ERSQ; r=0.26). Exploratory factor analysis proposed a novel two-factor model with loadings ranging from 0.39 to 0.86. Confirmatory factor analysis provided additional support for the two-factor structure, with acceptable fit indices (CFI=0.91, TLI=0.89, RMSEA=0.089). For objective 3, all adolescents (n = 85) completed the baseline survey, 99% the eight-week follow-up, and 95% the three-month follow-up. Of the sample, 84% completed the programme. On the CEI, participants found the programme highly acceptable overall, with 93.80% (n = 76) scoring ≥ 4. Facilitators achieved a 96% therapeutic competency rating and an 86% content fidelity rating overall. Adolescent participants' depression, anxiety, PTSD and emotional-dysregulation scores were significantly lower at all follow-up points. Self-esteem and physical-activity scores were significantly increased at the eight-week follow-up, with self-esteem remaining significantly higher at the three-month follow-up. For objective 4, several key findings emerged from the qualitative data. Participants found the programme acceptable, enjoyable, and necessary for addressing adolescent MH needs. They reported improved mood, behaviour, adaptive anger management, and reductions in stress, anxiety, and depression symptoms. Adolescents found the core ER skills and strategies as well as physical activity beneficial post-programme. Facilitators perceived the task-sharing model, supported by competency-based training and supervision, as acceptable and useful. Conclusions: Objective 1 findings contribute to the South African adolescent MH literature and to the research gap on the links between emotion dysregulation and clinically significant depression and/or anxiety symptoms in this vulnerable population in an LMIC setting. Objective 2 findings confirm the DERS-16 as a sound tool for assessing ER in older adolescents, filling a critical gap and supporting its use by clinicians and researchers. Given that ER is vital for adolescent MH, these findings highlight the need to further develop and adapt tools for South African adolescents. Objectives 3 and 4's findings highlight the need for school-based, task-shared ER interventions with physical-activity elements for at-risk older South African adolescents from low-income settings. The findings support the intervention's feasibility, acceptability, and perceived positive impact. While it shows therapeutic potential, a randomised control trial is needed to confirm efficacy and cost-effectiveness for scaling. This study contributes to adolescent MH and ER research, emphasizing the need for contextually relevant, evidence-based tools and interventions in low-resource settings. It highlights adapting ER measures, advancing ER intervention research, and guiding investment in adolescent MH resilience. This feasibility study is registered with the Pan African Clinical Trial Registry (#PACTR202412659160564) (Appendix 1). This study can be accessed at: https://pactr.samrc.ac.za/Search.aspx. 2026-06-29T09:50:03Z 2026-06-29T09:50:03Z 2026 2026-06-29T09:47:54Z Thesis / Dissertation Doctoral PhD http://hdl.handle.net/11427/43409 en eng application/pdf Department of Psychiatry and Mental Health Faculty of Health Sciences University of Cape Town |
| spellingShingle | adolescence mental health Ward-Smith, Chesney An exploration of emotion regulation and mental health among older South African adolescents from low-income settings |
| thesis_degree_str | Doctoral |
| title | An exploration of emotion regulation and mental health among older South African adolescents from low-income settings |
| title_full | An exploration of emotion regulation and mental health among older South African adolescents from low-income settings |
| title_fullStr | An exploration of emotion regulation and mental health among older South African adolescents from low-income settings |
| title_full_unstemmed | An exploration of emotion regulation and mental health among older South African adolescents from low-income settings |
| title_short | An exploration of emotion regulation and mental health among older South African adolescents from low-income settings |
| title_sort | exploration of emotion regulation and mental health among older south african adolescents from low income settings |
| topic | adolescence mental health |
| url | http://hdl.handle.net/11427/43409 |
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