"Girls get stressed due to the situation we are facing": Multi-level mental health stressors and resilience enablers among adolescent girls and young women in South Africa.

Poor mental health, including high levels of stress, is associated with increased risk behaviours and subsequent negative sexual and reproductive health (SRH) outcomes amongst adolescent girls and young women (AGYW). Multilevel mental health stressors reflect various levels of AGYW's social ecology. We use the social-ecological model as a framework to analyse qualitative data collected through interviews with 51 AGYW in two South African communities characterised by high rates of HIV, early pregnancy and school drop-out. We explore AGYW's narratives of stressors, coping strategies, and impacts of participating in an intervention on mental well-being. Individual level stressors included low self-esteem, non-heteronormative sexuality, academic stress, and early child-bearing. Interpersonal level stressors included perceived lack of psychosocial support, emotional isolation, communication barriers, peer pressure and bullying. Microlevel stressors at the family or household level included violence, conflict and substance use. Structural level stressors included household food insecurity, economic hardship and gendered inequalities. Coping strategies and resilience enablers at the individual level included maintaining a positive outlook, engaging in self-care activities and spending time with family. Resilience strategies at the interpersonal level included seeking psychosocial and emotional support and talking about feelings, whilst resilience enablers at the macrosystem level included faith communities and access to social workers. Respondents who had participated in the intervention reported improved mental health and well-being due to increased access to psychosocial support. Intersecting factors across individual, interpersonal and structural levels are salient mental health stressors experienced by AGYW. However, some AGYW manage to draw on internal individual resources and external interpersonal and contextual resources to increase resilience and promote coping. Strengthening and bolstering resilience enabling resources available to AGYW, through enhancing AGYW's competence and self-efficacy in accessing psychosocial support, alongside ensuring that support is available, may be important components to include in future interventions to support AGYW mental wellbeing.