A Social Determinants Perspective on Adolescent Mental Health during the COVID-19 Pandemic

Abstract

As a framework for understanding the structural factors that affect health, the social determinants of health (SDoH) have particular significance during the developmental stage of adolescence. When the global coronavirus pandemic (COVID-19) began, public health measures (PHMs) implemented to curb its spread shifted adolescents’ daily lives and routines, initiating changes to their mental health. The purpose of this study was to apply the SDoH to investigating the impacts of the pandemic-related PHMs on the mental health of adolescents in Canada. Using a youth engagement approach, interviews were conducted with 33 adolescents aged 14–19 years from two sites in Alberta, Canada. Participants shared their experiences of adjusting to the PHMs and how these shaped their mental health. Findings indicate that PHMs particularly affected the social determinants of education, access to health services, employment and income security, and social support amongst adolescents as online schooling, loss of connection with peers, income instability, and limited health services affected their mental health. Most commonly, adolescents expressed feeling greater anxiety, depression, or loneliness as the SDoH shifted with the PHMs. As we continue to understand the mental health impacts of the pandemic, the SDoH framework can be used to identify salient social determinants and evaluate these determinants post-pandemic. This study draws attention to the need for policies and programs that protect access to key SDoH at such a critical life stage as adolescence and promote their mental health resilience in shifting SDoH contexts.

1. Introduction

The broader contexts and conditions we live in shape our chances to achieve wellness and health. A social determinants of health (SDoH) framework emphasizes the structural factors that affect health outcomes, as well as the pathways where these contexts translate into health effects for adolescents [1], including both physical and mental health impacts. There is a known relationship between SDoH and mental health [1,2,3], whereby the social determinants together influence mental health and well-being for each individual across their lifespan [4]. For example, low income, lack of social support, low levels of education, and unemployment have consistently been linked to poor mental health amongst adults [2].

The SDoH have particular significance during the important developmental stage of adolescence when crucial psychological growth occurs, and behaviors and patterns are often established that can extend into adulthood [1,4]. At such a crucial developmental juncture, adolescents may be especially vulnerable to mental health challenges. For instance, 75 percent of mental health disorders, including anxiety and major depressive disorders, have been found to develop by the age of 24 [5]. Evidence also shows that adolescents are more likely to report a mood disorder (depression or bipolar disorder) than any other age cohort [6].

The COVID-19 pandemic, which began in March 2020, initiated significant shifts to the SDoH, significantly increasing adolescent stress levels [7]. Stress-induced hormones such as cortisol have been linked to declining mental health outcomes during lockdowns [8]. During such a key developmental phase, adolescents may be especially affected by increased cortisol levels [8]. As an additional environmental factor for adolescents to navigate, the pandemic compounded their vulnerability to poor mental health [9]. It is crucial, then, to explore the impacts of PHMs on mental health for adolescents using the SDoH framework to understand current and future mental health impacts.

This article reports findings from a qualitative study of adolescent perspectives on mental health during the COVID-19 pandemic. Although there is a growing body of literature on COVID-19 and adolescent mental health, studies to date have yet to apply the social determinants of health framework to studies with adolescents. By applying the social determinants of health framework we identified in our analysis those determinants that were most salient during the critical developmental phase of adolescence from the perspectives of adolescents themselves.

1.1. Background

When the global coronavirus (COVID-19) pandemic began in 2020, governments implemented public health measures (PHMs) to curb its spread. In Canada, these measures included physical distancing from others, mandating remaining at home; online, remote schooling; closing of public spaces and non-essential services; and canceling events and activities [10]. For the next two years (2020–2022), PHMs were in place to greater or lesser degrees, imposing substantial restrictions on the activities that formed adolescents’ daily lives and routines. For instance, physical distancing measures prohibited socializing indoors with friends, peers, or family members from other households; online schooling altered the daily routine of preparing for school and interacting with peers and teachers in person; and the cancellation of events and activities meant that sports teams, clubs, and other extracurricular activities were suspended [10]. There is a known relationship between physical health and mental health [11], as well as social connections and mental health, particularly for adolescents [12,13]. Consequently, as these aspects of adolescents’ daily lives and others shifted dramatically with the introduction of PHMs, so too did the social conditions that shaped their mental wellness.

There is increasing knowledge about the effects of the pandemic and subsequent PHMs on mental health. Cross-sectional survey studies have found that adolescents and young adults were more likely to experience poor mental health outcomes during the pandemic compared to other age groups [9,14]. Studies have also found that mental health problems increased significantly amongst adolescents during the pandemic (i.e., [15,16,17]), including trauma [18] and depression [19]. A systematic review of adolescent mental health during COVID-19 and previous pandemics found that a pandemic context commonly increases depression and anxiety, as well as stress and feelings of helplessness [20]. Public health measures also played a role in impacting mental health. A systematic review by Ludwig-Walz and colleagues [19] associated physical distancing and full or partial school closures with increased depression symptoms amongst adolescents. Several other studies have noted that when online school or physical distancing mandates were in place, mental health outcomes were worse (i.e., [21,22]).

Research has shown that changes in mental health during the pandemic were mediated by key risk and protective factors such as income security, family and peer relationships, and school experiences [9,17,21,22,23,24]. For example, in Canada, a cohort study found that experiencing poverty increased the likelihood of poor mental health for Canadian adolescents while also limiting their access to mental health services during the pandemic [9]. Beyond Canada, family environment and family life satisfaction have been found to be associated with adolescent mental health in Switzerland [23] and in Hong Kong [17]. In Australia, students who reported a greater quantity or quality of friendships were less likely to experience distress during the pandemic, and those who felt less connected to their school reported higher distress levels [24].

These correlates or predictors of mental health during COVID-19 can be examined using the social determinants of health framework. For example, research has shown that the social determinants of mental health mediated and moderated the impacts of the COVID-19 pandemic, especially for vulnerable populations [25]. In a cohort study of children in the United States during the pandemic, increased trajectories of perceived stress and sadness were associated with SDoH, particularly food insecurity, parental unemployment, and disrupted mental health treatment [26].

To our knowledge, studies on adolescent mental health during the COVID-19 pandemic have yet to directly apply the SDoH as a framework. Moreover, there has been very limited qualitative exploration of mental health from the perspectives of adolescents. Although contributing valuable insights such as prevalence rates (i.e., [14,20]) and correlations between risk factors and mental health outcomes (i.e., [9,17,27,28]), adolescents’ lived experiences and perceptions of their mental health during the pandemic remain less well understood. Applying the SDoH framework may help to further interpret findings, contextualize extant and emerging knowledge about adolescent mental health during pandemics, and facilitate the mobilization of research findings into practice and policy changes. The present study aims to address these gaps by applying the SDoH framework to explore adolescents’ perspectives on their experiences during the COVID-19 pandemic and how these shaped their mental health.

1.2. Purpose and Research Questions

The purpose of this study was to investigate the impacts of COVID-19 pandemic-related public health measures on the mental health of adolescents in Canada. The study explored the following research questions: (1) How did the pandemic-related public health measures shape the everyday lives of adolescents? (2) What are the perspectives of adolescents on how the pandemic has affected their mental health?

2. Materials and Methods

2.1. Study Design and Setting

This study used interpretive description [29] and drew on a youth engagement approach [30]. This approach focuses on engaging adolescents in the research process by creating meaningful opportunities for adolescents to actively participate, and authentically valuing their contributions [30]. Four youth research collaborators (YRCs) were recruited through a community partner organization at the beginning of the study to inform and guide the research activities based on their lived experiences as adolescents. The community partner organization shared the opportunity to join the study as a YRC with adolescents connected to their programs, and interested adolescents contacted the research team directly. The YRCs were 15–16 years old when the study began and lived in the same region of Alberta as the research participants. A diagnosed mental health condition or other specific experiences or qualifications were not required to become a YRC in this study. YRCs met with the research team regularly throughout the course of the study to learn about the research process while also informing the implementation of corresponding study activities, including recruitment, data collection, and analysis.

Data were collected in 2022 after the PHMs had been lifted to explore if and how adolescents’ daily lives and mental health were affected across the full span of the PHMs’ implementation. Data were analyzed using constant comparative analysis techniques [31] and by applying the SDoH framework to interpreting the findings. The research team’s university research ethics boards provided ethics approval for this study.

This study was conducted in two sites in the province of Alberta in western Canada: a metropolitan site of about 1.5 million people (Edmonton), and a second site including a small-sized city and a town of fewer than 20,000 people, referred to as ‘Grove County’ in this article. Since PHMs, including online schooling and social distancing, were provincially mandated, restrictions were the same for both sites. These measures were fully implemented in Alberta from March until May 2020. Thereafter until March 2022, PHMs in Alberta fluctuated in length and severity as states of emergency came into effect or were lifted according to provincial infection rates, although some degree of social distancing remained in place throughout the extent of this period.

2.2. SDoH Framework

A social determinants of health (SDoH) framework was used to guide the design and implementation of this study. The SDoH are based on work conducted to examine health gradients according to social factors [32], and the term was widely introduced in a book titled Social Determinants of Health [33]. Since its introduction, the World Health Organization (WHO) has developed a conceptual framework for action highlighting the interplay of the various social determinants, with upstream and downstream effects. The current understanding of SDoH is anchored in the WHO definition where social determinants make up “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life” [34] (p. 1). While the determinants of health refer to the broad range of factors that determine individual and population health, the social determinants of health refer to social and economic factors that relate to a person’s place in society, such as income, employment, and education [35].

The social determinants of mental health include access to and quality of education; employment conditions, income, and job security; access to and quality of health services; and social inclusion/exclusion, social connections, and networks of support [3,36]. According to Viner et al. [1], the strongest determinants of adolescent health are structural factors, including income inequality and access to education. Safe and supportive families, schools, and peers have also been found to be critical in supporting adolescents to attain the best health outcomes, particularly in the transition to adulthood. Through this framework, our study focused on how structural factors, including education and income, as well as proximal conditions such as family and peer relationships, can shape adolescent health outcomes.

2.3. Sampling and Recruitment

Adolescents aged 14 to 19 who had been living in either research site during the COVID-19 pandemic were invited to join the study. This age range was selected to capture the unique experiences of a particular cohort during a critical developmental stage when psychological growth occurs; that is, adolescents in the secondary school age group. These adolescents would likely have experienced fairly similar conditions, and changes to these conditions, during the pandemic. Since data were collected in 2022, participants would have been aged 12 to 17 at the time of the pandemic and were reflecting on their experiences from 2020 onwards. In order to include diverse mental health experiences in the dataset, a diagnosed mental illness was not required to take part in the study. The inclusion criteria were intentionally kept broad so that adolescents of all identities and backgrounds could participate and thereby generate as diverse a sample as possible.

Participants were recruited using convenience and snowball sampling [37], supported by the project’s community partner organization, YRCs, and other youth-serving organizations. Both the community partner organization and YRCs provided experiential insight that guided the recruitment strategy, including where and how to recruit. For example, YRCs suggested recruiting in their schools, community centers, and other locations that adolescents frequent, and shared study posters in these settings. In this way, recruitment efforts were kept broad to reach adolescents of all backgrounds and identities. Those interested in the study could contact the research team and were subsequently emailed a link to access the study information and provide informed consent via REDCap, a secure web application [38]. Participants younger than 15 years old gave consent together with their parents or legal guardians. Adolescents were offered a CAD 25 e-gift card honorarium to acknowledge their expertise, time, and contributions to the study. In total, 33 adolescents aged 14–19 years old participated in the study.

2.4. Data Collection

In alignment with interpretive description, individual semi-structured interviews were conducted with adolescents to foreground their experiences. Between May and October 2022, 33 interviews were conducted by the lead author. Interviews were conducted remotely to ensure health safety even though PHMs mandating physical distancing had been formally lifted. Interviews followed a semi-structured interview guide, which was initially developed by the research team and then collaboratively refined by the YRCs to enhance its understanding, relevance, and resonance for the study participants. These revisions included changes to phrasing and question order, and identifying additional research questions to include. Interview questions focused on the PHMs that impacted participants’ daily lives and routines, and how participants perceived their mental health when the PHMs were in place. Questions were kept broad so that participants could speak about any PHM or change to their daily lives and routines; subsequently, all SDoH factors could be considered in the analysis stage. The interview guide was piloted with three participants and refined with YRC input, which was integral in enhancing clarity and eliciting meaningful responses from participants. Interviews ranged from 40 to 90 min, where we asked participants about changes to their daily lives and routines due to the public health measures, and any mental health changes they experienced. Participants reflected on their mental health at different periods, including prior to and during the pandemic, and following the formal end of public health measures in Alberta. Data collection concluded once no new experiences or perspectives were surfacing in participant interviews, indicating that saturation had been achieved [39].

2.5. Participant Characteristics

Of the 33 total participants, 16 lived in the Grove County site and 17 were from the urban metropolitan site. The majority of participants identified as young women, and nearly two-thirds were aged 18 or 19. Participants’ racial and ethnic demographic information was not collected for this study. Participant characteristics are described in

Table 1. Participant characteristics.

Demographic Categories	N (33)	Percentage (100%)
Residence during pandemic
Grove County	16	48.5
Edmonton	17	51.5
Gender identity at time of interview
Identify as a young woman	18	54.5
Identify as a young man	12	36.4
Identify as other	2	6.1
Undisclosed	1	3.0
Age at time of interview
14	1	3.0
15	2	6.1
16	5	15.15
17	5	15.15
18	12	36.4
19	8	24.2

.

2.6. Data Analysis

Interview recordings were transcribed using the Zoom Audio Transcript feature [40] and all transcripts were accuracy-checked and de-identified by a research assistant. Guided by interpretive description [29] and using constant comparative analysis [31], the transcripts were inductively coded by the lead author to compare and contrast patterns of similarity and difference in adolescents’ perspectives. Initial coding was completed concurrently with data collection so that emerging insights from the analysis could iteratively inform the interviews [39]. Initial codes were inductively generated using NVivo 12 software. Next, codes were discussed and finalized with the PI (second author), with input from the YRCs and other research team members, and collated into a codebook. The social determinants of health theoretical framework was then deductively applied to grouping the codes together according to determinants that were affected by PHMs. For example, codes describing participants’ perspectives of changes to their peer relationships were grouped under the determinant of ‘social connectedness or inclusion’ [41]. The final themes represent the social determinants that were most impacted by the PHMs according to participants’ experiences and the subsequent effects on their mental health.

Preliminary findings, including the inductively developed codebook and de-identified excerpts of data, were shared and discussed with the YRCs and the research team, including the study investigators and the research assistant. A memos log was kept to track ideas and observations when organizing and interpreting the data and to record decisions and steps in the analysis process. Trustworthiness of the data was further increased through data saturation, iterative data collection, and analysis, using the team approach to data analysis described above. Finally, pseudonyms were assigned to all participants prior to disseminating the findings.

3. Findings

Participants shared their experiences during the COVID-19 pandemic when the PHMs were in place, and how these shaped their mental health. By drawing on the SDoH framework, we were able to identify the social determinants that were foregrounded in the study data. Based on our analysis, the findings indicate that the following PHMs were especially affected: education; access to health services; employment and income security; and social support, as shown in Figure 1 and described in the respective themes below. In this section, we outline the findings based on each of these social determinants, and in relation to mental health implications, from the perspectives of the adolescent participants.

3.1. Education: “The One That Hit the Hardest”

Participants described how the public health measures resulted in changes to educational instruction as classes transitioned to remote, online delivery, to comply with physical distancing guidelines. The experience was positive for those who found it a conducive learning environment with less stress and lower academic expectations. For participants such as Lisa (age 15), who had previously been homeschooled, the transition to online learning was familiar and, consequently, easier. As a result, Lisa expressed, “I loved [online schooling] at that time” (age 15, Edmonton).

For other adolescents, the transition to online schooling during the pandemic introduced barriers to learning. It was more difficult to learn at home compared to learning in the classroom because “my concentration when staring at the screen [was] just not so good like when I’m attending a physical class” (Reggie, age 18, Edmonton), or because it was more difficult to understand concepts when attending online school. Remote learning challenged comprehension for some adolescents; as Steven said, “I’m not a visual kind of person. I don’t like online stuff, I like being talked to face-to-face so that I can understand what you are trying to say” (age 19, Edmonton). For Amanda, the transition to online learning had significant implications: “My study habits went down drastically and they never came back up … I definitely think COVID-19 ruined my study habits” (age 18, Grove County). Changes to teaching approach and delivery, coupled with participants’ responses to these changes, affected their learning and academic progress: “My grades slipped really, really bad … Online school was probably the hardest thing for me to adjust to” (Ava, age 16, Grove County).

Furthermore, online schooling limited the range of learning support available, primarily by curbing peer-learning opportunities: “When the class was dismissed … it was very difficult to get a friend to take me through what I didn’t understand during class, because … [it’s] not something that I could move from my desk to their desk” (Reggie, age 18, Edmonton). Participants also missed the social bonding moments that occurred in physical classes with their peers, particularly classmates and friends. Consequently, participants expressed feeling lonely and isolated: “I was learning from my laptop at home, I felt like I’m alone because I was used to being with my fellow students” (Carlos, age 18, Edmonton). In general, participants spoke about the transition to remote learning in terms of diminished mental health.

3.2. Access to Health Services: “Everything Was Shut Down”

As non-essential services closed entirely or transitioned to remote delivery, accessing formal support such as mental and physical health services became more difficult. During the pandemic, one participant was unable to receive treatment for a physical injury he had previously sustained:

I couldn’t get the normal medical routine I used to … I was trying to get treatment, [but] everywhere was shut down. So I couldn’t get the treatment I was supposed to get. The injury started getting serious because everywhere was locked down.

(Steven, age 19, Edmonton)

Such experiences of inability to access needed health services were upsetting for some participants, calling into question perceptions of basic rights to care. Reflecting on his experience, Steven (age 19, Edmonton) added, “it was terrible, [everything] was shut down … I was thinking that this is not the Canada that I would choose or that I’d want to choose. So it really affected me in a very big way”.

Some participants expressed that accessing mental health services was more difficult during the pandemic as the public health measures simultaneously increased demand and limited access, especially during the initial lockdown:

At that time there wasn’t always the resources to help you … because everything was shut down. Even if you did [access mental health services], it’d be so long to wait to talk to someone. And things were always virtual which I didn’t, I don’t necessarily love. At the time I hated it.

(Amanda, age 18, Grove County)

For Amanda, long wait times to receive mental health support during the pandemic, coupled with the transition to online or virtual delivery of mental health services, made it even more difficult to access mental health services.

Another participant felt that the transition to online delivery of mental health services posed barriers: “I was terrified of online, talking online, there was this barrier for me … So [mental health services] were there, but I don’t think I had the tools I needed in my brain to properly utilize them” (Ava, age 16, Grove County). Although mental health services were available, the mode of delivery rendered them inaccessible for Ava. These added barriers to accessing mental health resources hindered adolescents’ ability to address and support their mental wellness during the pandemic.

3.3. Employment and Income: “How Am I Going to Cope with My Basic Needs?”

The closing of workplaces, primarily during the initial lockdown, left some participants and/or their parents without employment and in precarious financial situations. As income security became more tenuous, adolescents experienced significant mental health consequences. When both her parents lost their jobs due to workplace closures, one participant recalled experiencing significant distress: “I was actually depressed because I was wondering, how are we going to survive with no source of income?” (Christine, age 18, Grove County). Another participant described the educational and social repercussions of no longer being able to afford internet access when her mother’s workplace closed:

Now that my mom is at home [unemployed], we don’t have really enough [financial] resources to stay online all the time. So sometimes when I’ll miss my classes, that will make me feel so sad because when I’m trying to read it on my own, I don’t really understand. Just feeling like this is now the end of me, like I don’t have any friends to ask the questions.

(Mary, age 18, Edmonton)

Loss of employment was a significant challenge for adolescents who relied on their own income. For Melissa (age 18, Edmonton), a part-time employee and part-time student, the financial implications of her workplace closing caused stress and anxiety:

When I heard that my work was canceled and I wasn’t going to work, I was like, “How am I going to cope with my basic needs or providing for myself?” … I was just shattered. How am I going to do financially? Because this was the main source of my income. How am I going to compensate?

(Melissa, age 18, Edmonton)

Melissa (age 18, Edmonton) primarily attributed income insecurity during the pandemic to her diminished mental wellness: “My main difficulty was my financial help. How will I be financially capable of taking care of my needs? That really had a negative impact on me and I wasn’t stable for the early few months of the pandemic”. The lack of financial security that accompanied PHMs for Melissa introduced additional worry, with mental health impacts.

For some, however, the shift to online schooling and cancellation of events and activities created more schedule flexibility for working and earning money. In these cases, participants felt that the public health measures boosted job stability and income security. According to Kyle (age 18, Grove County):

I felt really blessed to be able to go from a 15-h workweek to like 30 h a week, so I was able to make more money than what I was before … Not only was I available to work more, I could manage school and work at the same time.

(Kyle, age 18, Grove County)

Although most adolescents experienced stress and worry as workplaces closed and income insecurity increased, the PHMs also contributed to greater financial stability for others as their schedules became more flexible. Changes to employment and income, including for adolescents and their families, subsequently affected some participants’ educational experiences and social support as well, with mental health consequences.

3.4. Social Support: “I Almost Lost My Mind”

All adolescents discussed changes to their social support during the pandemic, primarily discussing relationships with their peers and family members. The majority of participants felt that they became less connected to their friends and classmates due to physical distancing measures, online schooling, and the canceling of extracurricular activities. For example, Christine (age 18, Grove County) shared that “not being able to see people was really difficult. It was like an isolation. You isolate yourself from people and that was the most difficult part of the whole thing”. Connecting with friends online or via text instead of in person, and diminished frequency of those connections, affected the strength of friendship bonds: “Before Covid, with my friends we were close, very close. But now it will be the distance—the friendship, it became weak” (Carlos, age 18, Edmonton).

Many adolescents felt that their mental health became poorer as a consequence of limited peer interactions and social disconnection. Most commonly, participants felt an increased sense of loneliness and sadness as they spent more time alone and communicated with others less frequently. The experience of being alone was described as a difficult adjustment. For Peter, “human beings are social animals. So when we are alone, you don’t enjoy life … People were not together and [this] was not physically affecting me, but mentally.” (age 18, Edmonton). Other adolescents noticed changes in their behavior due to limited social interactions and the subsequent mental health repercussions:

I started [to] not enjoy talking to people. Before Covid hit, I really loved talking to people … But once I got that separation, it just became hard to even consider planning socially distanced meetups. I just didn’t want to go through the trouble of it, it just wasn’t worth going out there. I just lost my social connection, and not having that really hurt my mental health.

(Ava, age 16, Grove County)

For Ava, social isolation began to breed more social isolation, compounding the mental health difficulties they encountered during the pandemic.

Public health measures also prevented participants from adequately receiving support from peer networks as they attempted to adapt to the measures. For Reggie (age 18, Edmonton):

Before Covid, if I had [something] eating me up, I could just talk it over with someone. I used to rather talk [about] it with someone one on one. During [the pandemic] and all those restrictions that came with it, people that I interacted with [were] just my family members, and those things I can’t talk [about] with my family.

(Reggie, age 18, Edmonton)

When Cory (age 16, Grove County) experienced the death of a close friend during the pandemic, separation from his peers only magnified the negative effect on his mental health. In becoming disconnected from their friends and peers, participants expressed that they had lost a significant aspect of their social support networks.

Participants discussed their perceptions of changes to social support from family members as well. The shift to extended periods of time at home with family members introduced new relational patterns that precipitated tensions for some adolescents. Amongst those who felt that connections with their siblings and parents grew weaker, “too much time” was frequently mentioned as the cause: “When you spend a lot of time with your parents, you start getting too much … You have some feelings, or here and there conflicts” (Ashley, age 19, Grove County). Another participant commented, “I was sick of them after a week” (Ava, age 16, Grove County). One participant, however, shared that her relationship with her parents changed due to spending less time together. Since they were frontline healthcare workers, she saw her parents less frequently during the pandemic “because they had to spend a lot of time at work” (Stephanie, age 18, Grove County), and their relationship grew more distant.

Most commonly, participants found that as the pandemic mandated the closure of places of work and schools, family bonds grew stronger. As Reggie (age 18, Edmonton) shared, “I feel like maybe I understand my family better now than before. I spent time with them, [so] I do think I understand my family a little better than I did”. When Emily’s mother became ill with COVID-19, providing care for her at home created a closer bond: “The fact that I was having my mother sick, we just needed to be strong for each other. So we became closer” (age 17, Edmonton). Reflecting on their closer relationship, Emily said, “It was the best moment of my life” (age 17, Edmonton). Closer family bonds provided a positive counterbalance to the stress and anxiety that accompanied the pandemic and PHMs for some adolescents. According to Melissa (age 18, Edmonton), “During the pandemic since everyone was home and everyone was in this, we got to have very close relationships and found time together as a family. So that was the part of me that was impacted positively”. Family relationships experienced strain in some cases, yet, for the majority of participants, bonds with their parents and siblings improved or became stronger, with positive impacts for participants.

4. Discussion

This study aimed to explore adolescents’ perspectives of how public health measures (PHMs) during the COVID-19 pandemic affected their daily lives and routines, and the potential impacts on their mental health. We applied the SDoH framework to interpret participants’ experiences and situate study findings within a health lens. While other studies have similarly found that changes to mode of education, social support, and income and job security affected adolescents’ mental health during the pandemic (i.e., [17,21,23,24]), they lack a broader framework to contextualize and interpret findings. To our knowledge, this is the first study to date to explicitly apply the SDoH framework to exploring the mental health of adolescents during the COVID-19 pandemic. Applying the SDoH lens elevates our understanding of how changes to key social determinants, at the critical developmental stage of adolescence, may intersect with mental health and affect overall wellness amongst adolescents. The following discussion draws on findings from the present study, as well as those from other studies of adolescent mental health during the COVID-19 pandemic, to explore some of these intersections in more detail.

The findings from our study indicate that the social determinants of education, social support, access to health services, and employment and income shifted due to pandemic-related PHMs, affecting adolescent mental health. For instance, nearly all participants felt that online schooling, loss of connection with peers, income instability, and limited health services affected their mental health, either positively or negatively. This is consistent with the findings of previous studies, which found that the stress and anxiety accompanying school closures contributed to diminished mental health [20,24,42], while mandated physical separation from friends and peer groups increased loneliness, sadness, and depression during the pandemic [15,19,28,43]. In terms of income, quantitative studies have identified a relationship between income insecurity due to the closing of workplaces and increased anxiety, feelings of desperation, and stress [9,27,44]. Participants’ experiences in the present study, supported by findings from previous studies, indicate that the sudden, simultaneous implementation of public health measures shifted several SDoH all at once, significantly destabilizing adolescents’ foundation for mental wellness. During adolescence, health is strongly affected by social factors [1]. It should not be surprising, then, that mental health has consistently been found to have worsened for adolescents during the pandemic compared to other age groups [9,14]. As such, efforts to restore and maintain adolescent mental wellness, both in pandemic and non-pandemic contexts, may be strengthened by ensuring stability of SDoH.

By applying the SDoH framework, we were able to identify salient social determinants and the ways in which they intersected during the pandemic. Participants of this study shared experiences suggesting that one public health measure affected more than one social determinant of health. For example, participants perceived that a major challenge of online schooling was the loss of peer connections, disturbing learning for some and social support for others. This suggests that the transition to online learning not only affected the social determinant of education but also that of social support networks and connections. For another participant, when public health measures resulted in the closure of their parent’s workplace, their family was no longer able to afford internet access, and so she was unable to attend remote classes or connect with peers online. In her experience, the PHM mandating the closure of workplaces affected income security, and, in turn, her education and social connections, with ensuing mental health consequences. As social determinants overlapped and shaped adolescents’ daily lives in complex ways, the impacts of the PHMs on SDoH may have been compounded. Further, the findings from the present study suggest that the PHMs may have served to strengthen and reinforce the relationship between SDoH and mental health for adolescents.

Although the public health measures were instituted to protect physical health, participants expressed that they were detrimental to their mental health and overall wellness. Consistent with results from previous studies [45,46], participant experiences in the present study indicate that adolescents encountered barriers to accessing mental health services during the pandemic as services closed or transitioned to alternative modes of delivery. In this way, the PHMs both contributed to the need for mental health support while simultaneously restricting access to a fundamental social determinant of health, potentially magnifying and compounding the PHMs’ impact. As adolescents, participants were already in a critical stage of psychological development and vulnerable to mental health challenges [5,6]. When coupled with the pandemic and PHMs, the intersection of these factors had the potential to create a perfect storm for adolescent mental health, with potential long-term consequences. In the post-PHMs era, studies indicate that mental health has not entirely been restored for Canadian adolescents [47,48]. As with many other countries, in the wake of the COVID-19 pandemic, Canada is experiencing a growing need for mental health care services [49], adding strain to already limited systems of support. As such, although mental health issues remain a key concern for adolescents following the pandemic, this social determinant of health may be increasingly difficult to access.

In the face of systemic limitations to medically addressing mental health concerns, adolescents can turn to internal strengths to mitigate these effects. Resilience is an important protective factor moderating mental health impacts of life events [50]; during the COVID-19 pandemic, resilience contributed to reducing mental health challenges amongst Chinese adolescents [51]. This suggests a need to increase support for adolescents to build their resilience to shifting SDoH. Specifically, supporting adolescents to develop adaptability and problem-solving skills, especially in ever-changing socio-political contexts, is paramount. Knowing the impact of significant shifts to SDoH for adolescents specifically, policies should be implemented to protect adolescents’ access to key SDoH in future pandemic contexts, as well as in everyday, non-pandemic life, and promote positive mental health outcomes. Further, when significant shifts to SDoH cannot be avoided, providing mental health resources and support should be prioritized.

Our study indicates that the most salient social determinant of health for adolescents during the pandemic was social support. As participants reflected on the ways in which their daily lives and routines were impacted by the PHMs, they most commonly highlighted changes that occurred in their social connections, primarily with friends, classmates, and family members. All participants shared that they became disconnected from their peer social circles as in-person interactions were prohibited, extracurricular activities were canceled, and online schooling prevented regular interactions with classmates and friends. Nearly all participants perceived changes to this social determinant as most significantly diminishing their mental health, as it became more difficult to maintain friendships and receive support from peers in navigating the pandemic. Several other studies of adolescent mental health during the pandemic have also noted the impact of social isolation on mental health, including moderate to severe increases in depression [19,43], sadness [21], anxiety [21,43], and psychological distress [52]. For example, a longitudinal study found that social isolation was the greatest concern for adolescents during the pandemic, even exceeding worries about contracting the virus and becoming ill, and was correlated with increased anxiety and depression [28]. This is not surprising, given that peer relationships are an especially important SDoH during the developmental stage of adolescence [1], and that the connection between strong peer relationships and positive mental health is well known [53,54,55]. Efforts to promote adolescent mental wellness, in pandemic contexts as well as in everyday life, should support adolescents to maintain strong connections to their peer networks. In future pandemics or other contexts where physical distancing or separation from peers is necessary, the availability of creative adaptations to peer engagement, such as health apps or video-chat platforms, should also be a priority [43,52].

While peer relationships were strained, family bonds improved for several participants. Ballonoff and colleagues [56] also found that more time at home with parents and siblings contributed to increased connection and intimacy, which continued to positively impact adolescents past the end of lockdown measures. Although family relationships are distinct from peer relationships and not entirely interchangeable, strong family connections can be a protective factor to buffer adolescent mental health [57], especially when engaging in peer relationships is more difficult [58]. As a key SDoH for adolescents, supporting them to have sustained social support, from peers or family in particular, is critical to their mental wellbeing.

4.1. Implications and Areas for Further Study

This study contributes to a growing awareness of how pandemic contexts may amplify the role of social determinants of health, especially amid the increased prevalence of mental health challenges during the COVID-19 pandemic for adolescents in particular. By building on what is known about the relationship between the SDoH and mental health [1,2], this study suggests that the pandemic-related measures shaped a range of social determinants, with mental health implications for adolescents in Canada. While this study contributed to understanding which social determinants of health were most impacted by the public health measures, future studies can explore specific SDoH in more detail to better understand the nuances of their impact on adolescent mental health. For example, further research can explore the relationship between adolescence as a key developmental stage and the mental health impacts of sudden and dramatic shifts to a specific SDoH, such as employment or access to services. A greater understanding of the intersection of these factors is needed to identify potential policies and programs that can support mental health resilience for adolescents despite changes to SDoH, and inform a national response to a growing concern and health priority.

As we continue to understand the mental health impacts of the pandemic, the SDoH framework can be used to identify salient social determinants before and after the COVID-19 pandemic, and to evaluate these determinants post-pandemic. The SDoH framework can be used as a tool for identifying priorities and evaluating interventions and resources. For example, our study found that social connections are an exceptional priority for adolescent mental health, suggesting that interventions and treatments, particularly in the post-COVID-19 recovery period, could support adolescents in maintaining and restoring these peer relationships through targeted programs in schools or communities. In this way, evidence from this study can be applied to future pandemics, states of emergency, and conditions that necessitate rapid and dramatic measures that can significantly shape the social determinants of mental health for adolescents in Canada and beyond.

This interpretive description study explored the nuanced experiences of adolescents by eliciting their perspectives directly. Its qualitative approach provided rich contextual data that complement the findings from the majority of studies on this topic that have used quantitative methods. As one of the very few studies to use a qualitative approach, the findings presented here help to elucidate and enrich the results of quantitative studies by making sense of adolescents’ perceptions and insights about mental health using the SDoH framework to interpret their experiences. Since data collection for this study was completed by the fall of 2022, only months after all PHMs were lifted in Alberta [59], it will be helpful for future studies to continue to examine adolescent perspectives and experiences regarding their mental health with the passing of more time since the COVID-19 pandemic.

4.2. Limitations

The majority of participants in each location were recruited through the project’s community partner organization, YRCs, and the research team’s networks, using convenience and snowball sampling. As such, the findings are limited to the experiences of the particular adolescents recruited through these channels. It is possible, then, that the findings are more reflective of some specific sub-groups of adolescents compared to others. While generalizability is not the aim of qualitative research [39,60], we have strived to ensure rigor in our analysis and interpretation of findings in relation to participant characteristics. For instance, nearly two-thirds of participants were older adolescents aged 18–19, indicating that the study findings may be more reflective of the experiences of older adolescents transitioning to young adulthood. Participation in online interviews was contingent on having access to the internet. For adolescents where this service was unavailable, they could not be included in the study. Furthermore, some adolescents may not have felt comfortable participating in an online interview because of various reasons, such as not having a private space in their home, and, thus, may not have been able to participate. Adolescents who chose to participate in this study may have been help-seeking adolescents whose experiences may have been different from adolescents who did not seek out this study or wish to participate. Participant racial and ethnic demographic information was not collected, and so it is not possible to interpret the results accordingly. However, other studies have indicated that race and ethnicity may have impacted adolescent mental health outcomes around the time of the pandemic [15,47], and so this social determinant could be explored further in future research.

5. Conclusions

This study highlights adolescents’ perceptions of how the pandemic-related public health measures shaped their mental health, applying the SDoH as an organizing framework to interpret and contextualize the findings. From the perspectives of adolescents, COVID-19-related PHMs affected education, social support, access to health services, and employment and income security, with most adolescents reporting diminished mental wellness as a result. Most participants felt that online schooling, disconnection from peers, the closure of non-essential health services, and job loss and income instability burdened their mental health. These findings emphasize the connection between the SDoH and adolescents’ mental health, and how this connection may have been shaped by the PHMs during the pandemic. While extending knowledge of the effects of the PHMs on adolescent mental health, this study can inform practice and policy considerations for educators, healthcare providers, administrators, and organizations working to enhance adolescent mental health in the wake of the COVID-19 pandemic. As adolescent mental health becomes an increasing priority, this study draws attention to the need for policies and programs that can support mental health resilience for adolescents in shifting SDoH contexts.