From Intervention to Everyday Life: Mental Health As Durable Capacity In Conflict-Affected Youth, Evidence from Sierra Leone

Background: In post-conflict Sierra Leone, conflict-affected youth contend with intersecting adversities, including economic precarity, psychosocial distress, and disrupted social bonds, in a context where the formal mental health workforce reaches fewer than 0.1 per 100,000 people. Youth FORWARD was designed to address this treatment gap through a structurally innovative approach: embedding the Youth Readiness Intervention (YRI), a transdiagnostic, group-based mental health program, within a youth entrepreneurship training sequence delivered entirely by trained non-specialist facilitators. Grounded in evidence-based therapeutic modalities, including cognitive-behavioral therapy, interpersonal therapy, and mindfulness-based techniques, the YRI equips participants with embodied, transferable coping competencies such as diaphragmatic breathing, cognitive reappraisal, systematic problem-solving, graduated goal-setting, and interpersonal communication skills. A Hybrid Type II effectiveness-implementation cluster-randomized trial demonstrated sustained reductions in depression and comorbid depression/anxiety symptomatology at the four-year follow-up. However, quantitative effect estimates cannot elucidate the mechanisms underlying sustained gains. This qualitative study addresses a critical gap in the implementation science literature by examining how participants retain, adapt, and mobilize psychosocial competencies across life domains years after program termination, and by identifying the contextual factors that shape, constrain, and enable that process.

Methods: Semi-structured in-depth interviews were conducted with purposively sampled former YRI participants across four districts in Sierra Leone, stratified by gender, geographic context, and livelihood trajectory. Data were analyzed using a codebook-based thematic analysis consistent with Braun and Clarke’s reflexive framework. A theoretically derived coding architecture comprising 37 subcodes organized within six analytic domains (knowledge retention mechanisms, application context, barriers and facilitators, behavioral and emotional outcomes, YRI-specific coping skill utilization, and livelihood outcomes) was applied at the sentence level to achieve fine-grained mapping of discrete skill activation across diverse, ecologically valid contexts.

Results: Participants reported durable, often spontaneous use of embodied emotion-regulation strategies, particularly diaphragmatic breathing and deliberate cognitive de-escalation, across household, intimate relationship, and commercial domains. Interpersonal competencies acquired through the YRI were consistently associated with reduced relational conflict and stronger social cohesion. Notably, youth identified customer interactions and market-based disputes as naturalistic rehearsal contexts where emotion regulation is continually practiced to preserve business relationships, revealing how the integrated YRI-entrepreneurship design generates reciprocal reinforcement across psychosocial and economic skill domains. Skill retention was supported by training materials, peer-to-peer transmission to non-participant family and community members, and internalized group rituals. Concurrently, structural constraints, persistent poverty and economic disruption attenuated functional and economic gains, even where psychosocial competencies remained robustly active.

Conclusions: These findings constitute rare, participant-generated evidence that a non-specialist-delivered transdiagnostic intervention can produce psychosocial competencies that remain functionally active four years after delivery, with significant implications for scalable, equity-oriented social work practice in conflict-affected settings. Results support integrating evidence-based mental health content into livelihood programming as a sustainable delivery architecture and identify organic peer diffusion as a viable mechanism for extending intervention reach. This study reframes mental health interventions not as time-bound services, but as durable, transferable capacities embedded in everyday life, offering a model for how scalable, community-delivered programs can generate lasting change in the absence of formal systems.