Adolescents as Co-Designers: How Youth Perspectives Can Shape the Foundation for Mental Health Interventions in Northern Ghana.

Background: Adolescents in low- and middle-income countries (LMICs) face significant mental health challenges, yet their voices are often underrepresented in intervention design. Co-design approaches, such as human-centered design, offer a promising approach to tailor interventions to specific needs and context; however, this requires careful adaption in LMICs where resources, design experience, and cultural factors impact engagement and efficacy. This study documents how human-centered design was adapted to engage adolescents in co-designing a school-based mental health intervention, highlighting the contextualization of co-design methods to the Ghanaian sociocultural context and the unique participation of youth. Methods: Guided by the first two phases of human-centered design, we conducted two workshops with 24 students from 12 public senior high schools in Tamale, Ghana. Workshop 1 (Inspiration) explored adolescent perspectives on mental health using structured case-based discussions guided by the Consolidated Framework for Implementation Research (CFIR). Workshop 2 (Ideation) focused on identifying preferred mental health prevention strategies using interactive, choice-based activities. To accommodate cognitive and sociocultural factors, workshops incorporated structured facilitation, visual analogies, peer-driven engagement, and scaffolded decision-making. Qualitative data from discussions, facilitator notes, and artifacts were analyzed thematically. Results: Workshop 1 (Inspiration) identified key adolescent mental health concerns, including stigma, confidentiality fears, and peer and family influences. Gender-segregated discussions provided insights into culturally-specific challenges, such as substance use norms among boys and gendered expectations limiting girls' access to support. Workshop 2 (Ideation) led to the prioritization of five school-based prevention strategies: teacher training, mental health curricular integration, mentorship programs, teaching positive thinking and mindfulness, and using entertainment-based methods for mental health education. Adolescents shifted from viewing mental health challenges as individual struggles to recognizing the role of schools and communities in prevention. An adolescent advisory board was formed to sustain youth engagement in intervention refinement. Conclusions: Contextualized co-design methods can meaningfully engage adolescents in LMICs, leading to culturally grounded and actionable mental health interventions. Structured facilitation enhances the feasibility and authenticity of youth-driven co-design, contributing methodological insights for implementation science in resource-limited settings. This study provides a replicable framework to apply to diverse LMIC contexts and health topics and elevates youth voices in shaping effective, sustainable interventions.