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.