Being there: A scoping review on psychosocial challenges faced by adolescents during bereavement in the Southern African Development Community

Background information: Bereavement enhances adolescent’s chances of suffering from psychosocial problems globally and adolescents in the Southern African Development Community (SADC) are not an exception. Due to the mourning condition, some of the adolescents become susceptible to multiple mental disorders, stigmatization and social rejection leading to maladaptive coping mechanisms such as substance abuse. Purpose: This study aimed to synthesize the existing literature on the psychological challenges faced by adolescents during bereavement in SADC. Methods: We opted for a scoping review due to its ability to rapidly map the existing literature sourced from international databases (JSTOR, and PubMed), local databases (Sabinet African Journal) and performed hand-search using Google Scholar. We made use of operators and techniques such as Boolean operators, truncations and MeSH terms. The inclusion of the study was limited to adolescents aged 10–26 years within SADC, primary studies (qualitative, quantitative and mixed methods) and a 10-year projection of studies conducted from 2013 to 2023 in SADC. Results: The findings of the study revealed that adolescents in SADC experience feelings of hopelessness, low self-esteem, anger, grief overload, suicidal thoughts, shock and confusion as a result of bereavement. They are also battling with poor academic performance and abuse due to being socially stigmatized and rejected. To cope with this ordeal, some of the adolescents’ resort to dropping out of school, social isolation and substance abuse. Conclusions and recommendations: Our research has revealed that bereavement in adolescents is closely linked with psychological challenges. In addition to psychological distress, our research has unveiled profound social challenges faced by bereaved adolescents. Adolescents frequently encounter the risk of abuse within their families and experience financial hardships following the loss of loved ones. Thus, recommends a constructive active plan for offering support services to bereaved adolescents and, the adoption and promotion of bereavement programs within families, communities and social welfare centres to address risk factors of maladaptive coping.


Introduction
Bereavement, also known as the mourning or grief period, is a time of intense emotional distress and sadness experienced after the death of a loved one.The terms grief, mourning, and bereavement are frequently used interchangeably, but their meanings vary [1][2][3][4] .Bereavement can be regarded as an umbrella term that encompasses both grief and mourning.In this paper, we define bereavement as a process one endures after experiencing the loss of a loved one [5,6] .We have observed that during this period, individuals who have lost a loved one require support, especially adolescents as they will be experiencing emotional and psychological distress.It is during this period, that they need support and as authors, we have observed that in South Africa, Namibia and Zambia, family and community members come together to comfort the bereaved family, adolescents included.According to Mildred, the support that community and family members provide to the bereaved family represents the ubuntu, resilience and strengths of African communities during difficult periods.Again, African communities also provide insight and valuable advice to the bereaved family [7,8] and valuable insight on how the bereaved family should stick to their cultural and/or traditional practice to provide a descent sent off to the loved one [9,10] .
That goes to show that in African communities, "being there" represents the emotional, physical and spiritual support [11] that is provided during the bereavement period.This is largely due to the fact that those offering support, also assume the role of counselling and providing a safe space for the bereaved family to express their grief and also share some memories of the late one (a process noted as debriefing) [12,13] .Thus, we say African communities understand the transformative power of collective mourning, recognizing that by coming together, individuals can find solace, share memories, and collectively honour the life of the deceased [8,14,15] .The Southern African Development Community abbreviated as SADC is regarded as a Regional Economic Community which has about 16 countries which make up the community.Those communities which are the member states of SADC are Angola, Botswana, Comoros, Democratic Republic of Congo, Eswatini (previously known as Swaziland), Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, United Republic Tanzania, Zambia and Zimbabwe.These countries joined forces with each other to "promote sustainable and equitable economic growth and socio-economic development through efficient, productive systems, deeper cooperation and integration, good governance and durable peace and security; so that the region emerges as a competitive and effective player in international relations and the world economy" [16] .Given the nature of this study, we wanted to synthesize how these 16 countries work together in order to promote social development during difficult periods in the lives of adolescents.

Significance of the study
This study may assist the community members in understanding that during bereavement adolescent experiences significant and unique cultural, social and economic challenges that require attention and support from the family.Synthesizing the existing literature from 16 member states of SADC may show community members measures that they can use to sensitively approach distressed adolescents during the bereavement period and also assist in developing community-based interventions for grieving adolescents.
Moreover, these findings may assist policymakers as policymakers rely on comprehensive research for guidance in formulating effective policies that can assist the community in addressing mental health issues.Given that this is the scoping review, the synthesized information is drawn from comprehensive research which then provides the policymakers with a summary of which articles to consider when making policy on the mental health of adolescents during bereavement.Lastly, the findings may assist other scholars in the field of Social Sciences to identify gaps in terms of methodologies which are mainly used by researchers when addressing psychosocial challenges faced by adolescents during bereavement.

Problem statement
Bereavement is the most distressing experience that one could experience [17,18] and young people are at the core of the adverse pain of losing a parent(s).The United Nations Children's Fund [UNICEF] reported that there were about 151 million young people who were bereaved by the death of their parents [19] .It has been reported by Pynoos and colleagues that bereavement is prevalent among young people and often leads them to experience mental illness and seek mental health services to cope with the death of a loved one [20] .The researchers opted to conduct a scoping review on younger people because Layne et al. reported that young people between the ages of 10-24 were more prone to dying under traumatic events.Layne and colleagues' view upheld earlier findings by United States Centers for Disease Control and Prevention which established that people aged 10-24 years died due to external factors.Evidently, about 30.2% of young people experienced trauma after the death of their loved one [21,22] .Layne and colleagues established that the vulnerability of young people in experiencing trauma after the loss of their loved one is due to the large social network that adolescents establish [23] .
It is undeniable that there is a close correlation between bereavement and mental health problems.Several authors have conducted studies in that field and they have discovered that during bereavement adolescents experience depression, PTSD and substance abuse [24,25] .Moreover, some authors have noted that some adolescents develop feelings of guilt and anger [24,26] .Instead of receiving support from the community, it has been established that adolescents are rather stigmatised and rejected in their communities [25,26] .While other adolescents use substances to cope with the feeling of rejection, some authors have noticed that some adolescents cannot stand the stigmatisation and they then attempt suicide [24,27] .Moreover, other adolescents indulge in different risky behaviours including taking marijuana, binge drinking and engaging in violent activities [24,26,[28][29][30][31] .

Methods
This study adopted a scoping review research method to broadly map and explore the existing literature on the phenomenon of bereavement in adolescents.We opted for a scoping review as we were aiming to rapidly map the existing literature on the study phenomenon [32] using various databases.We opted for scoping reviews due to their ability to rapidly synthesise a range of studies published using various research designs including grey literature [32,33] .In conducting the scoping review, we followed five stages of scoping review as proposed by Arksey and O'Malley [32] and advanced by Levac and colleagues [33] .Our research question was "what are the psychosocial challenges experienced by adolescents during the bereavement period in SADC?".In order to address the research question, we searched the literature from international databases (JSTOR, PubMed and Google Scholar) and local databases (Sabinet African Journal).We used the following keywords: (Adolescent OR Youth OR Teenager OR "young person") AND (Africa OR SADC OR "Southern African Development Community") AND (Bereavement) AND ("Psychological challenges" OR "psychological impact") AND ("social challenges" OR "social impact") AND ("psychosocial challenges" OR "psychosocial impact").We included articles that focused on adolescents in SADC between the ages of 16-25.We opted for the age 10-25 as Sawyer and colleagues define adolescents as individuals between the ages of 10-25 [34] .Moreover, we included qualitative, quantitative, and mixed-method studies, studies published in SADC and published in English between 2013-2023.
Data extraction was guided by PRISMA-ScR [35] (see Figure 1) and placed on Zotero reference manager.Two reviewers (FM and NC) independently screened the title and abstract with KR serving as an individual to resolve conflict.After the title and Abstract, KR and MW were involved in retrieving full text for full-text screening and FM was available to resolve conflicts.In reviewing the full text, the two reviewers (KR and MW) were looking for two options: 1) does the study meet the inclusion criteria?2) from the findings, what are the psychosocial challenges faced by adolescents during bereavement?Whenever the two reviews (KR and MW) found discrepancies in terms of the content of the article if it met the inclusion criteria, they contacted the third review (FM) to address the discrepancies.The involvement of the third reviewer promoted transparency and also addressed the issue of possible bias on the path of reviewers of articles.Again, to ensure that there was transparency, we summarised the whole process of screening articles reported using PRIMSA-ScR [35] .
Figure 1.Flow chart of study selection.Source: Moher et al. [35] After extracting data (see Table 1), we moved to presenting the main findings using descriptive analysis.Levac and colleagues recommend that researchers make use of content analysis in order to analyse the data [33] .However, in our study, we decided to use descriptive analysis to analyse the methodology section and content analysis to provide a synthesised analysis of the study's main findings.Descriptive analysis involves summarizing the data extracted guided by the theory used for the study [32] .In this study, we relied on the ecosystems theory when analysing data.The ecosystems theory is one of the used theories in the field of social sciences as it is able to provide a clear conceptual lens on the interdependence of human behaviour and social structures [36] .Ecosystems theory assisted the researchers in considering the interpersonal relationship that an individual has with different systems and how that might contribute to or affect an adolescent's capabilities to build sustainable relations [37] .As we were busy analysing data, we were mindful of how the adolescent microsystem (family) contributes to his or her inability to interact with the mezzo system (groups or peers) and macro system (community members) when experiencing or after bereavement about his or her challenges.We presented the findings with basic statistics to indicate how many articles were found that said the same thing regarding the phenomenon.

Author(s) and year Title Design Population Location Main findings
Agere and Tanga [38] A critical examination of the nexus between psychosocial challenges and resilience of child headed households: A case of Zola, Soweto.
Qualitative approach, case study design 60 child headed households Zola and North Soweto (South Africa) 1. Due to loss, children in child-headed families consistently got worried due to food security.2. Children experienced feelings of hopelessness, inadequacy, insecurity and low self-esteem which lead to poor academic performance.
3. Children had to assume parental responsibilities to their younger siblings because their parent was no longer there to look after them.This decreased their ability to socialize and engage in social activities such as hanging out with friends.4. Children experienced confusion and anger and started to withdraw from social interactions.5. Lack of counselling after the death of parents debilitated their ability to deal with loss and grief.6.Most of the children were stigmatized and discriminated for receiving welfare assistance and they detached themselves from these services.This disengagement worsened their ability to cope with their loss.
Woollett et al. [39] Reticence in disclosure of HIV infection and reasons for bereavement: impact on perinatally infected adolescents' mental health and understanding of HIV treatment and prevention in Johannesburg, South Africa.
N/A (Approach qualitative)

adolescents
Johannesburg, South Africa 1. Adolescents receive little support from their family and friends during bereavement period.
2. Sometimes the loss of the caregiver leaves children without physiological needs.
3. Some of the adolescent get separated with their siblings to live in other paths of the country.4. Children are sometimes not indulged or informed about the cause of the death of their caregivers.5. Children are not given opportunity in a group form to remember their caregivers who passed away.6. Children experience mental health challenges as they were not allowed to go to graveside nor be involved in the arrangements and rituals to bury their caregiver as they were seen as children.
7. Death brought shock and confusion in the life of the participants.8. Counselling was imposed on the participants and grief made the participants to also not take medication for their wellbeing.

Table 1. (Continued).
Author(s) and year Title Design Population Location Main findings Mohale [40] The burden of grandparenting: Caring for aidsorphaned grandchildren in Lephalale, South Africa.
Qualitative study (Phenomenological design) randomly selected through purposive sampling

Grandmothers of AIDS orphaned children
Wellness Clinic in Lephalale District, Limpopo 1. Children were constantly asking the whereabouts of their deceased parents.
2. The children were associated with behavioural problems such as not taking medication, disciplinary issues including emotional and behavioural problems.
3. Adolescents engaged with wrong peers who introduced them to substance abuse.4. Children were reported to be uncooperative, impulsive and hyperactive and demanding.5. Children school work deteriorated because they are unable to cope with the loss of their parent.6. Grandchildren refuse to play with other children as they feel like outcasts when other children talk about their mothers.7. Children were also reluctant to receive psychological interventions.

Nabunya and
Ssewamala [41] The 1. Participants reported feelings of sadness, loneliness, anger, frustration and hopelessness associated with the loss of parent.
2. Participants felt alone and isolated from their peers and extended family members.Participants feel they do not have time to socialize with their peers because of the household responsibilities.
3. Feelings of deep loss and inability to cope with adult responsibilities of caring for siblings with minimal resources.4. Some of the adolescents reported having suicidal thoughts and not having anybody there to care for them like a mother would. 5. Feelings of anger, frustration and blame towards the parents and family members.
6. Feelings of hopelessness, helplessness, powerlessness to improve their situations because they do not have much parental guidance.7. Some of the adolescents were exposed to physical and emotional abuse, and others were exposed to being homeless after being chased out of parents homes by relatives.8. Children who lost their parents lack of financial support and that leads to high school dropouts.
In the articles we sampled, we have found that adolescents in SADC experience psychological challenges in the form of experiencing feelings of hopelessness [38,41,42] , low self-esteem [38] anger [38,41] , and inability to deal with grief and suicidal thoughts [38,42] , shock and confusion [38,40] and they are imposed to counselling [39] , denial [40] , during the bereavement period.
In terms of the social challenges, the sampled articles indicated that adolescents are unable to engage in social activities [38,42] , are stigmatised in society [38] , have poor academic performance [38,40,42] , lack support from families and friends, unable to bury their loved ones due to their age [39] .It also emerged that after the loss of the breadwinner, some of the adolescents are abused by their relatives and lack financial support [42] .
Even though adolescents experience challenges, there are several coping mechanisms that adolescents use during the bereavement period.From the sampled articles it emerged that adolescents use substances [40] , bunk-of school [41] and isolate themselves from their peers [42] .

Discussion
The study reviewed that adolescents are faced with psychological and social challenges during their bereavement.However, they also employ some coping mechanisms.The following were the experiences:

Psychological challenges
Following the loss of a loved one, adolescents encountered a deep sense of bleakness.This could be because of the overwhelming feelings during the grieving process that seem to shatter the world [38,41,42] .This would entail that adolescents are struggling to find purpose for their lives which may have adverse effects on their overall mental well-being and quality of life.These intense feelings of hopelessness and anger may lead to feelings of despair and a dreary outlook for the future.Their anger is often directed inward in the process of blaming themselves for the loss of their loved one, hence feeling frustrated with their own emotions.This anger can also be exhibited towards others, or it can be outwardly directed towards the death circumstances [38,41] .Consequently, this becomes a way for adolescents to express their pain and frustrations as a coping mechanism.

Low self-esteem and inability to cope with grief
Losing a loved one can disrupt one's sense of identity and self-worth leading to a decline in an adolescent's self-esteem thereby portraying a negative self-image.Adolescents tend to blame themselves for the death of a loved one and inauspiciously compare themselves with others [38] .This inability to deal with grief questions their value system and may contribute to a lack of coping skills and may emanate from suicidal thoughts or self-harm.Such type of experience indicates the severity of emotional distress they found themselves in as grief can be a multifaceted and devastating emotion that adolescents may struggle to cope with effectively [38,42] .Therefore, adolescents' mental health support in order to curb challenging thoughts and ensure safety is very cardinal.

Shock, confusion and denial
Adolescents may experience feelings of disbelief and confusion following the death of a loved one especially if it is a sudden and unexpected death.Such experience may be difficult to comprehend resulting in the struggle to come to terms with the reality.Ultimately, making it difficult to navigate their emotions, and understand and accept the ordeal which can complicate their grieving process.This can be exacerbated by denial especially if they were subjected to counselling which they may not have received well (38-40).This kind of emotional turmoil can be very disruptive to their daily lives.

Social challenges
When adolescents are bereaved, they suffer from an emotional drain that make it difficult for them to relate with peers who don't have the same experience resulting in isolation and disconnection from their peer and social activities.The emotional distress that adolescents experience can be exacerbated by society's social stigma due to misconceptions regarding grief and loss [38,42] .This could be due to a lack of understanding of the magnitude that grief has on adolescents and their well-being.The judgments and insensitive comments from society may lead to further isolation and feelings of shame, difficulties in obtaining help or expressing how they feel.

Poor academic performance
The emotional turmoil of losing a loved one may lead to difficulties for adolescents to focus on their studies and realise their full potential thereby having significant effects on their academic performance [38,40,42] .This would entail a lack of concentration, motivation as well and affected memory which disrupts their everyday routine due to overwhelming emotions.Hence resorting to absconding from school or dropping out of school in order to deal with their grief.

Lack of support from families and friends
The absence of psychosocial support from loved ones amalgams the challenges faced by adolescents during their time of bereavement because of families and friends' struggles to provide the required emotional support [39] .Family members may also be focused on their grieving emotions which may pose a challenge to attend fully to the psychosocial needs of the bereaved adolescents.Friends on the other hand may be confused and may lack knowledge and skills of how to support and comfort their peers.This gesture results in feeling alone in the grieving process and a lack of understanding of the world around them.

Financial difficulties and potential abuse
This may lead to vulnerability and abuse especially after the loss of a breadwinner as some relatives can be abusers leading to financial hardship.Such circumstances create additional stress and emotional turmoil for the bereaved adolescents.Loss of income and financial resources may lead to mistreatment or abuse of adolescents by relatives who may perceive them as social burdens and take advantage of their vulnerability thereby exacerbating their challenges [42] .With such, adolescents may resort to substance abuse and other devious behaviours as a coping mechanism, which can have adverse effects on their mental and physical wellbeing.

Inability to participate in burial rituals
The other struggle faced by adolescents is the inability to take part in the burial procession and rituals.Most times, the elders would regard them as young and see no need for them to bid farewell to their loved ones, yet these rituals carry culturally significant meaning and can contribute to their grief challenges [39] .Allowing adolescents to participate in the funeral rituals may facilitate a healing process.
While the findings underline the crucial need for inclusive and culturally sensitive support programs in the SADC region for adolescents, helping them to navigate the grief and loss challenging journey is cardinal in addressing their psychosocial needs.This requires collaborative efforts in promoting healthier coping strategies that can nurture the resilience and recovery of these vulnerable people.

Conclusion
The findings of this study underscore the significance of recognizing and addressing the challenges confronted by bereaved adolescents in the SADC region.Our research has revealed that bereavement in adolescents is closely linked with psychological challenges.In addition to psychological distress, our research has unveiled profound social challenges faced by bereaved adolescents.Adolescents frequently encounter the risk of abuse within their families and experience financial hardships following the loss of loved ones.These findings underscore the pressing need for culturally sensitive and family-centred interventions to assist adolescents as they navigate grief and bereavement.One concerning discovery in our study is the prevalent use of substance abuse as a coping mechanism among adolescents and young adults dealing with grief and bereavement.This finding underscores the existence of negative coping strategies in response to the overwhelming emotions associated with loss.

Recommendations
While our study identified psychological challenges, mentioning a contrasting finding is noteworthy.Specifically, some adolescents in our research experienced imposed counselling services which implies that they may not have been fully prepared to receive such services during the bereavement process.This highlights the importance of tailoring support services to bereaved adolescents' unique needs and readiness.
Given the clear psychological challenges faced by bereaved adolescents, it is imperative to adopt nuanced approaches for promoting grief and bereavement programs within families, communities, and social welfare services.These programs should address the risk factors associated with negative coping strategies, such as substance abuse.The potential consequences of poor coping mechanisms, including risky decision-making, risky sexual behaviours, and academic setbacks, could have lasting impacts on the transition to adulthood for these young individuals.As such, proactive interventions are crucial to improve their long-term outcomes.

Limitations of the study
In each study, there are limitations that researchers have to accentuate.Equally, in this study, our limitations were that we only managed to search literature from three databases (two international and one African database) as authors could not access other databases due to no subscription in their institutions.Moreover, other databases such as MEDLINE and PubMed have a lot of duplicates as they share material (articles) whereas other databases such as Psych Articles researchers and librarian failed to export the material.As for Google Scholar, we used it for handpicking as it is not regarded as a database by other scholars.Lastly, there could have been more articles written in a language other than English, but we used our filter to accept only articles published in English due to researchers' ability to comprehend only English articles.