Sports-based mental health promotion for adolescents in rural Nepal: A pilot cluster-randomised controlled trial

Adolescent mental health disorders are a leading contributor to the global burden of disease, particularly in low- and middle-income countries where access to care is limited. Sport offers a promising platform for mental health promotion, but evidence from rigorous evaluations in these settings is lacking. In Nepal we tested the feasibility of a mental health promotion intervention comprising football, dance and martial arts coaching and community engagement through melas (community celebrations), home visits and consultation with community advisory groups. We conducted a parallel-group, two-arm superiority pilot cluster-randomised controlled trial with 1:1 allocation ratio. The study area was four community clusters (~1000 population per cluster). We conducted pre-intervention (n = 440) and post-intervention (n = 403) cross-sectional surveys of all adolescents aged 12–19 living in the clusters. The intervention was implemented for 10 months and open to all aged 12–19. Control was sport as usual. We collected data according to pre-specified progression criteria and compared trial arms post-intervention for wellbeing, depression, anxiety, self-esteem, self-efficacy, emotion regulation, social support and functional impairment. Among adolescents in intervention clusters 110/224 (49.11%) attended ≥5 sessions. Younger age and belonging to the least privileged caste group was associated with attendance. In 146/191 (76.44%) sessions, coaches demonstrated ≥75% of activities at satisfactory/superior level according to a fidelity checklist. We found only a small and uncertain difference in wellbeing between arms (effect size 0.05, 95% confidence interval -0.45 to 0.64) but moderate evidence towards improved depression (-0.32, -0.67 to 0.02), anxiety (-0.27, -0.61 to 0.06) and social support from a significant other (0.41, 0.05 to 0.77) in the intervention arm. The average implementation cost per session was $67.63 ($0.07 per adolescent in the community per session). Findings suggest the intervention is feasible and might help to reduce mental health inequities. Progression to a phase III trial is warranted.