Abstract
Importance:
Substance abuse among female youth in
post-conflict, resource-limited settings is a critical public health concern,
yet evidence for culturally appropriate interventions is scarce.
Objective:
To describe changes in hope levels (agency and
pathways thinking) associated with a hope-based intervention and to explore the
lived experiences, sources, mechanisms and contextual factors influencing
recovery.
Design,
setting and participants: This
quasi-experimental mixed-methods study was conducted at the Peace Mission
Training Centre (PMTC) and the Psychiatric Teaching Hospital in Freetown,
Sierra Leone. Twenty female youth (aged 18-45 years) in substance abuse
treatment were enrolled: 10 in a hope-based intervention group and 10 in a
standard-care comparison group. Qualitative interviews were conducted with 8
intervention participants and 5 staff members.
Main
outcomes and measures: Quantitative outcomes
were changes in Agency and Pathways thinking, measured using Snyder's Adult
Hope Scale (AHS). Qualitative outcomes included participant narratives on the
role, sources and outcomes of hope, as well as contextual facilitators and
barriers.
Results:
The intervention group demonstrated
statistically significant within-group improvements in agency (mean
increase=9.1 points, p=.001, Cohen's d=1.54) and pathways thinking (mean
increase=12.7 points, p<.001, Cohen's d=3.45). Significant baseline demographic
differences between groups precluded causal attribution. Qualitative analysis
revealed five sources of hope: spiritual/religious faith, family/parental
responsibility, community/peer connection, intellectual understanding of
addiction and altruism. Four mechanisms of change were identified: identity
redefinition, regained self-efficacy, trauma reframing and goal-directed
behaviour. Key facilitators included structured routines and peer support,
while barriers included post-discharge systemic failures and societal stigma.
Conclusions
and relevance: Hope-based interventions show
descriptive promise for female youth in substance abuse recovery in Sierra
Leone. Effective implementation requires trauma-informed, gender-responsive and
culturally adapted approaches that address structural barriers such as poverty,
inadequate aftercare and stigma.
Keywords: Hope-based
interventions, Substance abuse recovery, Female youth, post-conflict settings,
Sierra Leone, Mixed-methods research
1.
Introduction
Substance abuse among youth, particularly
female youth, has emerged as a critical public health concern with far-reaching
consequences1,2. Research
indicates that young women face unique challenges in recovery, including higher
rates of trauma exposure, stigma and systemic barriers to treatment access3. In post-conflict settings like Sierra
Leone, these challenges are compounded by a history of civil war (1991-2002),
the Ebola epidemic (2014-2016) and pervasive poverty4.
Hope-based interventions, grounded in Snyder’s
cognitive-motivational model of hope (agency and pathways thinking), offer a
promising strengths-based approach5,6.
Agency refers to the belief in one's ability to initiate and sustain action
toward goals, while pathways thinking is the capacity to generate strategies to
achieve those goals. Studies in high-income settings have shown that hope-based
interventions can improve self-efficacy and reduce substance use7-9. However, their applicability in
low-resource, post-conflict African contexts has not been empirically examined10.
To address this gap, this study aimed to (1)
describe changes in hope levels (agency and pathways thinking) among female
youth participating in a hope-based intervention compared to a non-equivalent
control group; (2) explore the lived experiences of female youth regarding the
role, sources and outcomes of hope in recovery; and (3) identify contextual
facilitators and barriers that interact with hope to influence sustainable
recovery outcomes.
2.
Methods
2.1.
Study design and setting
This study employed a quasi-experimental
mixed-methods design with a pre-test/post-test comparison group. The research
was conducted in Freetown, Sierra Leone, at two sites: the Peace Mission
Training Centre (PMTC) Rehabilitation Centre, which delivered a structured
hope-based intervention and the Psychiatric Teaching Hospital, which provided
standard care.
2.2.
Participants and sampling
A purposive sample of 20 female youth (aged
18-45 years) undergoing substance abuse treatment was enrolled. The
intervention group (n=10) was recruited from the PMTC and the comparison group
(n=10) from the Psychiatric Teaching Hospital. Inclusion criteria were:
self-identifying as female, age 18-45, active participation in a recovery
program and willingness to provide informed consent. For the qualitative
component, 8 participants from the intervention group and 5 staff members
(e.g., counsellors, nurses, the centre coordinator) were purposively selected
for semi-structured interviews.
2.3.
The hope-based intervention
The intervention at the PMTC was a 55- to
60-day residential program grounded in hope theory. It integrated several
culturally adapted components: bi-weekly hope-centred group therapy
(goal-setting, overcoming obstacles), weekly narrative hope workshops (reframing
personal stories), a mentorship program connecting participants with recovered
peers and bi-weekly family hope sessions. A strict daily routine provided
structure and stability.
2.4.
Data collection
Quantitative data were collected using a
structured survey that included demographic questions and Snyder’s Adult Hope
Scale (AHS), an 8-item Likert scale measuring agency and pathways thinking.
Surveys were administered pre- and post-intervention. Qualitative data were
gathered through in-depth, semi-structured interviews (25-30 minutes each)
conducted in the Krio dialect. Interviews explored participants’ experiences of
hope, recovery goals, support systems and challenges.
2.5.
Data analysis
Quantitative data were analyzed using
descriptive and inferential statistics (paired t-tests, independent t-tests,
Cohen’s d effect sizes) with SPSS. Qualitative data were transcribed verbatim
and analysed using thematic analysis, following the phases of coding, theme
development and interpretation.
2.6.
Ethical considerations
Ethical approval was obtained from the Ministry
of Social Welfare and the management of the participating institutions. All
participants provided written informed consent. Confidentiality was maintained
through the use of unique code names.
3.
Results
3.1.
Quantitative findings
Baseline demographic analysis revealed
significant differences between the intervention and control groups. The
intervention group was significantly younger (mean age 24.0 vs. 36.1 years,
p<.0001), more likely to be unmarried (60% vs. 0%, p=.0006) and less likely
to have children (40% vs. 100%, p=.003). These differences preclude causal
attribution.
Within the intervention group, participants
demonstrated statistically significant improvements in both hope components
from pre- to post-intervention. For the Pathways subscale, the mean increase
was 12.7 points (t(9) =10.95, p<.001, Cohen’s d=3.45), representing an
extremely large effect size. For the Agency subscale, the mean increase was 9.1
points (t (9) =4.87, p=.001, Cohen’s d=1.54), a very large effect size. The
comparison group also showed significant but smaller improvements (Pathways:
+6.9 points, p<.001, d=1.98; Agency: +3.9 points, p=.002, d=1.32).
3.2.
Qualitative findings
Five primary sources of hope were identified
from participant narratives:
·Spiritual and Religious Faith: Prayer
and belief in divine purpose provided daily strength. “It has not been easy... but with God... I
am learning to walk again” (P02, age 19).
·Family and Parental Responsibility: Children
served as a powerful motivational anchor. “My journey is about my children... My recovery is the path to getting
them back” (P10, age 29).
·Community and Peer Connection: Shared
experience reduced shame and created accountability. “We understand each other's shame and
fear... We console each other” (P10, age 29).
·Intellectual Understanding: Understanding
addiction as a disease externalised shame. “This knowledge is power. It externalises the enemy” (P09,
age 29).
·Altruism and Helping Others: Mentoring
peers gave recovery a transcendent purpose. “Being a peer supporter... reframed my entire identity” (P05,
age 24).
Participants described four mechanisms of
change: identity redefinition (from “addict” to “survivor”), regained
self-efficacy (“I am the author of my life”), trauma reframing (“turning trauma
into triumph”) and goal-directed behaviour (pursuing education, family
reunification).
Staff interviews identified key contextual
facilitators (structured program routines, spiritual encouragement, peer
support, family involvement, use of the Krio language) and significant
barriers, including post-discharge systemic failures (no follow-up, no
vocational training), societal stigma and negative peer influences.
4.
Discussion
This mixed-methods study provides a
comprehensive description of hope-based interventions for female youth
recovering from substance abuse in post-conflict Sierra Leone. The quantitative
findings demonstrate that participants in the hope-based intervention showed
significant within-group improvements in agency and pathways thinking. The
qualitative findings substantially enrich this picture by revealing the
specific sources, mechanisms and contextual factors that shape hope in this
unique setting.
The study’s findings support and extend
Snyder’s Hope Theory5,6.
Consistent with the theory, participants’ recovery was goal-directed and the
intervention enhanced both their motivation (agency) and their ability to plan
(pathways). However, the findings also suggest that the theory’s individualist
orientation may require modification for collectivist, post-conflict contexts.
Participants described agency not only as an individual capacity but as a
resource drawn from family, community and spiritual sources. This finding
aligns with research on collectivist approaches to healing in Africa11.
The role of spirituality and faith as a primary
source of hope is a key contribution. In a context where over 95% of the
population identifies as Muslim or Christian, hope-based interventions may be
more effective when explicitly integrated with spiritual frameworks12. This study demonstrates that faith is
not merely a coping mechanism but a foundational element of meaning-making and
resilience.
The identification of post-discharge systemic
failures as a critical barrier highlights a major limitation of time-limited
residential interventions. Hope cultivated within a structured environment may
rapidly erode when individuals return to environments of poverty, unemployment
and stigma13. This finding
underscores the urgent need for aftercare and continuity in substance abuse
treatment in Sierra Leone.
5.
Limitations
This study has several limitations. First, the
quasi-experimental design and significant baseline differences between groups
preclude any causal attribution of the intervention’s effectiveness. Second,
the small sample size (N=20) limits generalizability. Third, the absence of
long-term follow-up data means the durability of hope improvements is unknown.
Fourth, the Adult Hope Scale has not been formally validated in the Sierra
Leonean context. Finally, qualitative data were collected only from the intervention
group, preventing a full comparative analysis.
6.
Conclusion
This study provides descriptive evidence that
hope-based interventions are associated with significant improvements in agency
and pathways thinking among female youth in substance abuse recovery in Sierra
Leone. The findings reveal that hope operates through multiple culturally
specific sources—spiritual, relational, intellectual and altruistic-and is
shaped by complex contextual facilitators and barriers. Effective
implementation requires trauma-informed, gender-responsive and culturally
adapted approaches that address structural barriers, including poverty,
inadequate aftercare and stigma.
7.
Acknowledgments
The authors express profound gratitude to the
Ministry of Social Welfare and the management and staff of the Peace Mission
Training Centre and the Psychiatric Teaching Hospital in Freetown. We are
especially thankful to the female youth participants who shared their stories
with courage and honesty. The authors also acknowledge the faculty of China
Women's University for their academic guidance.
8.
Conflict of Interest
The authors declare no conflicts of interest.
9.
Funding
This study was supported by a scholarship from
the MOFCOM Administration of the People's Republic of China. The funder had no
role in the design, conduct or reporting of the research.
10.
Ethical Approval
This study was approved by the Ministry of
Social Welfare and the institutional review boards of the participating
treatment centres in Sierra Leone. All procedures followed the ethical
standards of the Helsinki Declaration.
11.
References