Pathways to resilience: a qualitative study and intervention framework among adolescents and young adults who use substances in Southern Africa

Background Substance use contributes substantially to morbidity among adolescents and young adults (AYAs) in Southern Africa, with lifelong consequences. This study aimed to characterize the substance use risk and resilience cycle among this population and identify participant-informed intervention leverage points. Methods We conducted 12 focus group discussions with 97 AYAs (16–24 years) in Zambia, Zimbabwe, and South Africa. Participants had moderate to severe substance use risk and a history of school non-completion or unemployment. We used thematic analysis informed by grounded theory to develop a model of risk and resilience. Findings Participants described a reinforcing cycle in which substance use was influenced by structural, interpersonal, and individual factors, particularly unemployment, school non-completion, poverty/financial stress, peer pressure, family conflict, mental distress, and gangsterism/crime. AYAs also described resilience pathways to reduce exposure to high-risk settings and sustain attempts to reduce or stop use. Building on these accounts, we mapped seven participant-informed resilience strategies to disrupt the cycle, including return-to-school and exam support, prosocial supports, and sports and rehabilitation. Interpretation Entry points to interrupt the cycle of substance use risk at the structural, interpersonal, and individual levels offer a practical framework to inform substance use intervention efforts for AYAs within low-resource African settings. Consistent with multisystem resilience theory, these pathways may operate through changes in resources and exposure, producing positive developmental cascades that reduce escalation and support recovery. Funding Swiss National Science Foundation (SNSF)/Swiss Agency for Development and Cooperation (SOR4D 400440_213259); SNSF (Ambizione PZ00P1_201690).