The Effect of Group Social Work Intervention with an Empowerment Approach on Self-Care of Afghan Adolescent Students

Introduction

Self-care is a conscious practice in which each individual uses their acquired abilities and skills in a way that allows them to take care of themselves personally and independently (1). Self-care is a function performed voluntarily and without coercion by individuals in society to create, maintain, and improve their health (2). Self-care leads to individuals' adaptation to life's stresses and crises and increased independence in performing daily activities (3). Adolescence is one of the most important and at the same time most stressful and damaging stages of life, in which rapid biological, neurological, and psychological changes are evident (4,5). Adolescents experience many pressures, stresses, and crises due to the conflict between their inner needs and the demands and expectations of the society (6). Immigrant adolescents and refugees are more exposed to social and psychological risks due to the lack of family and friends, customs, economic issues, and the need to adapt to a new cultural environment (7,8); as a result, lack of awareness of self-care skills can lead to the exacerbation of numerous problems (9-11). Adolescents have needs such as love, security, a sense of belonging, respect, purpose, and growth and development. Unfortunately, from the perspective of Afghan adolescents, fulfilling these needs seems impossible. Inside Afghanistan, ongoing war and unstable political conditions hinder meeting these needs. Outside Afghanistan, due to unfamiliarity with the host society, low levels of family awareness, and sometimes prejudice and bias from the host community, adolescents become discouraged and stop striving. They face socio-cultural challenges such as social isolation, discrimination, homesickness, dietary adjustments, climate challenges, and financial constraints (12).

According to the World Health Organization (2024) (13), migration is one of the factors affecting self-care, and there are 35 million (17%) young migrants worldwide. Of these, 9 million (25%) are in the age group of 10-14 years and 11 million (32%) are in the middle to late adolescence (14-19). Young people are forced to migrate without parents or guardians to escape war, persecution, gang violence and extreme poverty in their own country (14). Iran is one of the countries where many Afghan migrants have taken refuge, most of whom are adolescents. In addition, Afghan adolescents often have lower physical and mental health due to their migration and refugee status and are deprived of national programs for health promotion, disease prevention, treatment and care (13). Afghan students consist of more than 93% of non-Iranian students in Iranian schools, about 51% of whom are boys and 49% girls (15). They are deprived of learning many skills due to dysfunctional family environments, numerous immigration problems, and differences in culture and social values of the host country (16).

The experience of migration can lead to increased psychological and social stress (17), which increases the need for training and improving self-care skills, because failure to observe self-care can lead to serious consequences such as mental disorders, reduced self-confidence, and inability to manage life challenges (18). As a result, if this phenomenon is not managed, it poses a threat to the countries of origin and destination (19). Afghan migrant adolescents, under conditions of asylum and migration, are exposed to compounded pressures such as discrimination, social isolation, identity crisis, and limited access to healthcare and education. These challenges have widespread negative impacts on their physical and mental health and increase the need for targeted and specialized support (20-23).

One of the target groups of social workers is immigrants that help them to improve their quality of life, especially during adolescence. Currently, the issue of self-care has changed from focusing on treatment to encouraging  to learn essential health skills based on self-care activities, and pay more attention to prevention than treatment; because the problems of not observing self-care, in addition to creating numerous costs, cause adolescents to spend more time on treatment and are deprived of necessary training (24). One of the benefits of self-care for adolescents is the enhancement of self-confidence and self-esteem (25). During migration, individuals encounter cultural, social, linguistic, and economic changes that may lead to negative emotions such as anxiety, depression, loneliness, and a sense of alienation. Therefore, maintaining mental and emotional health after migration is of paramount importance. Therefore, the empowerment approach in social work, by focusing on strengthening individual strengths and capacities, emphasizing the identification and strengthening of individual capacities, encourages adolescents to acquire the necessary skills to manage life challenges. These interventions, especially in group settings, can lead to create a sense of solidarity and social support, which are the key factors for promoting mental health among adolescents (26).

A study by Randeree et al. (2025) showed that a structured group program for self-care, mindfulness, and interpersonal effectiveness enhances emotional regulation and improves mental health in adolescents (27). Self-care behaviors also mediate the relationship between mindfulness and psychological distress, and relaxation training or mindfulness meditation reduces tension, pain, and psychological distress in people with dialysis disease (28). Self-care behavior increases the quality of life in patients (29) and plays an important role in the prevention and control of diseases. A study by Sarabian et al. (2023) on young people showed that belief in performing health behaviors affects their self-care, and the more obstacles’ people perceive, the less self-care they perform. It seems that appropriate educational interventions can promote self-care in order to increase self-care in young people (30). A study on sexual self-care education for female students showed that a structured educational program promotes awareness and increases sexual self-care in these students (31). Self-care education also allows the individual to renew their energy and create a new perspective and positive feelings towards life. A person who has learned self-care experiences a sense of happiness, calmness and peace. Self-care increases self-confidence and self-esteem, and also increases the individual's enthusiasm for life and motivation for success; therefore, it can reduce symptoms of depression in adolescents (32). In another study, the impact of Orem’s self-care intervention on sleep quality and academic self-efficacy among nursing students was positively evaluated (33). Additionally, the self-care management program had a positive effect on the awareness of adolescents with systemic lupus erythematosus (34). The findings of a review study also demonstrated that self-care behaviors in adolescents are influenced by biological, psychological, economic, and social factors. Since this is a multifactorial process, individuals working with adolescents must possess adequate knowledge about adolescents' health status and learn how to understand the role of culture in adolescents’ self-care behaviors (35)

Studies have been conducted to identify the concept and dimensions of empowerment, the factors affecting it, and the impact of various factors on empowerment. Despite the important and undeniable role of social workers in the field of empowerment, no group-based intervention with a development approach has been conducted to evaluate self-care in Afghan adolescents. Therefore, the present study was conducted with aim to determine the effect of a group social work intervention with an empowerment approach on self-care in Afghan adolescents, which not only responds to the specific needs of this group but can also help policymakers and social workers to design effective and sustainable programs to support this vulnerable group.

Methods

This semi-experimental study with pre-test-post-test designs including experimental and control groups was conducted on Afghan adolescents in Yazd city from September 2023 to February 2024. According to the Department of Education, approximately 17,000 Afghan students were enrolled in Yazd Province in 2022-2023, of whom about 5,500 studied in schools designated for Afghan nationals in Yazd city (15). Given the specific characteristics of the target group, purposive and convenience sampling was carried out based on the inclusion criteria that were Afghan nationality, students studying in the seventh, eighth, and ninth grades, willingness to cooperate, and living in Yazd city. Exclusion criteria included absence from more than two sessions or withdrawal of consent. The researcher obtained permission from the Ministry of Education and the researcher administered 100 self-care questionnaires to students aged 13 to 15 years. Following the initial analysis, the sample size was estimated using G*Power software, assuming a medium effect size (f= 0.25) according to Cohen’s guidelines, with α = 0.05 and power = 0.80. The calculation indicated 26 participants were required; to account for attrition, 30 participants were selected and randomly assigned to experimental (n=15) and control (n=15) groups (Figure 1). All participants signed the informed consent form and expressed their satisfaction with the group placement method. The group social work intervention sessions, based on Orem’s self-care techniques (36), were conducted by the researcher over eight 90-minute in-person sessions. These sessions were held with the coordination of the principals of Taghi Rasoulian Girls’ School and Shaheed Andarzgoo Boys’ School, as well as the participation of the experimental group members (Table 1). The design of the social work intervention protocol in this study was based on the Orem self-care model. It was further developed through interviews and consultations with three social work specialists familiar with the Afghan adolescent community, and the session content was adapted to align with the specific cultural, social, and economic conditions of Afghan adolescents. The sessions included topics such as healthy nutrition, personal hygiene, exercise, stress management, strengthening social skills and emotional self-care techniques. The control group was placed on a waiting list to receive the necessary training, and after data extraction, the necessary training was also provided to this group.

Figure 1. Flowchart of the effect of group social work on self-care of Afghan adolescents

The data collection tool was Adolescent Self-Care Questionnaire (AS-CLQ). The students in both groups simultaneously completed the AS-CLQ before and after the intervention. The questionnaire consists of 48 questions in three sections: physical, psychosocial, and emotional self-care that is scored on a Likert scale (0 to 4) (4= always, 3= often, 2= sometimes, 1= rarely, and 0= never). This questionnaire yields a total score and three sub-scores. The range of the total self-care score is from 0 to 192. A high score on both the total scale and subscales indicates high self-care, and a low score indicates low self-care. The physical self-care score ranges from 0 to 68, the psychosocial self-care score from 0 to 72; and the emotional self-care score from 0 to 52. The questionnaire's content validity was confirmed using construct validity and experts’ opinion. Cronbach's alpha for the questionnaire was 0.92 overall, and 0.91, 0.84, and 0.87 for its subscales, respectively, indicating good reliability (37). The data were analyzed using descriptive statistics (such as mean and standard deviation) for the initial analysis of data distribution. Then, the analysis of covariance (ANCOVA) test was used to compare the pre-test and post-test scores in the experimental and control groups. The test assumptions, including normality of data distribution and equality of variances, were examined using the Kolmogorov-Smirnov and Levene’s Test.

Table 1: Content of self-care skill training sessions

Ethical Consideration

The study was derived from the Master’s thesis in social work, fulfilled at Yazd University, Yazd, Iran and also was approved by the Ethics Committee of Yazd University (ethical code: IR.YAZD.REC.1404.002). Informed consent was obtained from the participants after explaining the purpose of the study. The participants were aware of the stages and methods of conducting the study. Also, the privacy and confidentiality of the subjects were guaranteed. Also, after the intervention, the control group was provided with similar training. All information was reported with observing the principles of confidentiality and honesty, and any possible harm to participants was prevented.

Results

The three self-care indicators (physical, psychosocial, and emotional) across the two test phases, based on Kolmogorov–Smirnov test in the control and experimental groups indicated no significant distributional differences between the two groups. In addition, Levene’s test for equality of variances between the two groups for all indicators showed p>0.05, supporting the assumption of homogeneity of variances. Box’s M test confirmed that the assumption of homogeneity of variance–covariance matrices between the groups was met (p=0.902). The significance levels associated with the interaction effect of pre-test and group for all three indicators were greater than 0.05; therefore, the assumption of homogeneity of regression slopes in the analyzed models was supported, and no significant differences were observed in regression slopes between the two groups.

Table 2. Demographic information of Afghan students in experimental and control groups

A total of 15 Afghan adolescents in the seventh grade, 5 in the eighth grade, and 10 in the ninth grade participated in this study. The subjects were equally divided into control and experimental groups, so that 15 participants in the experiment group and 15 in the control group answered the research questionnaires in both the pre-test and post-test stages. Moreover, 17 adolescents were female and 13 were male (Table 2).

Before the intervention, there was no significant difference between the control and experimental groups in the overall self-care score after adjusting for the pretest (i.e., controlling for baseline scores). The initial (pretest) difference is acknowledged as a potential source of non-homogeneity; hence, ANCOVA with the pretest as a covariate was employed to estimate the intervention effect on posttest self-care scores. After controlling for baseline, the posttest analysis revealed a significant effect of the intervention on total self-care: F (1, 56)= 118.239, p<0.001, partial η²= 0.825. For the sub dimensions, the results were: Physical Self-Care: F (1, 56)= 77.923, p<0.001, partial η²= 0.736; Psychosocial Self-Care: F (1, 56)= 51.370, p<0.001, partial η²= 0.670; Emotional Self-Care: F (1, 56)= 0.906, p=0.350, partial η²= 0.035, indicating significant improvements in physical and psychosocial self-care but not in emotional self-care. These findings confirm the effectiveness of the intervention on most self-care dimensions after accounting for initial differences (Table 3).

Table 3: Self-care components in the experimental and control groups

Table 4 indicate that the significance level of the independent variable (pre-test) (p=0.001) has a significant relationship with the dependent variable (post-test), so the above analysis was valid. The significance level corresponding to the control and experimental groups is (p=0.001). Considering the average adjustment of the self-care variable in the control and experimental groups in the post-test scores (105.65 and 110.15, respectively), and significancy of the null hypothesis in the analysis of covariance, the main hypothesis of the study "group social work intervention with an empowerment approach is effective on the self-care of Afghan adolescents" was accepted with a confidence level of 0.95. The significance level for the control and experimental groups in both stages of the test and for the variables of physical, psychosocial, and emotional self-care is more than 0.05, so the null hypothesis of the test is not rejected (p>0.05).

Table 4: The results of covariance analysis to evaluate the effect of group social work intervention with an empowerment approach on self-care of

Discussion

The purpose of the present study was to determine the effect of group social work intervention with an empowerment approach on self-care of Afghan adolescents with regard to self-care dimensions. In this study, the findings clearly showed that group social work intervention with an empowerment approach was effective on increasing self-care of Afghan adolescents. Other studies with findings consistent with the present study have shown that post-migration stressors—including discrimination, financial pressure, and concerns for family and home—lead to psychological distress, anxiety, and depressive disorders among Afghan migrants. These findings underscore the importance of designing empowerment-based and culturally sensitive interventions, as such programs can mitigate the negative effects of post-migration stressors on the mental health and resilience of Afghan Refugees (17,20-23). Acculturation stress has a significant relationship with identity crisis, and cultural, social, and family pressures can lead to cultural adaptation challenges and value differences for immigrants. These findings emphasize the importance of empowerment interventions, as they can mitigate the negative effects of such pressures on the identity crisis and mental health of Afghan adolescents (38).

 In addition, the self-care scores of adolescents before and after the intervention were significantly different, except for emotional self-care. In the post-test stage, the performance scores of adolescents in the experimental group were significantly higher than those in the control group. The results of the present study showed that group social work intervention with an empowerment approach improved self-care of adolescents in physical and psychosocial dimensions, which indicated a positive effect of the intervention on the experimental group. This result is consistent with the results of Akbari's study (2022), which showed that teaching assertiveness skills creates self-care and promotes health in adolescents aged 14 to 17 years (18). The study of Sarabian et al. (2023) similarly showed that young people's beliefs about performing health behaviors affect their self-care (30).

Chauhan in his study (2025) showed a significant difference between the control and experimental groups in teaching sexual self-care to female students, and a structured educational program was effective in sexual self-care of female students (31), which is in line with the results of the present study. Moreover, Zari Moghadam et al. (2021) also showed that self-care education allows a person to renew his energy, gives a new perspective and positive emotions to his life, and understands a feeling of happiness, calmness and peace, increases his self-confidence and self-esteem, and also increases his enthusiasm for life and motivation for success; therefore, it can reduce the symptoms of depression in adolescents (32).

In addition, Malak's study (2025) also showed that social support has an effect on self-care and is practically considered a kind of mediator for self-management (39). Badiepeyma et al.'s study (2024) also showed that self-care skill training can improve the physical condition of patients and it requires the use of non-pharmacological treatment alongside pharmacological treatment (40). Takeuchi et al. (2024) in their study also concluded that using a comprehensive self-care approach in optimizing self-care after liver transplantation is essential in the treatment of children and adolescents (41), which is in line with the present study. Randeree et al. (2025) also reported that a structured and group program for self-care, mindfulness, and interpersonal effectiveness strengthens emotional regulation and improves mental health in the experimental group (27), which is in line with the results of the present study. Shohani et al. (2024) also showed that there is a significant relationship between self-care behavior and the quality of life of patients, and self-care is of great importance in the prevention and control of diseases (29). Abdoli and Tamanaeifar (2024) also concluded in their study that self-care behaviors play a mediating role in the relationship between mindfulness and psychological distress, and relaxation training or mindfulness meditation reduces tension, pain, and psychological distress in patients with dialysis disease (28). Kortesoja (2022) showed in his study that self-care and life skills training require people to develop their self-awareness, recognize their strengths, and be aware of their thinking patterns and be able to change them. One of these management skills is self-awareness and time management, the observance of which leads to prioritization and stress reduction(42), which is in line with the present study.

One of the most important outcomes of these interventions was an increase in adolescents' awareness of the importance of self-care and changes in behaviors related to self-care. Adolescents who participated in the present study showed that they had acquired better self-care skills than other adolescents in Afghan society who did not benefit from these interventions. This not only affected their physical health, but also helped improve mental and emotional status. Another effect of these interventions was to strengthen the adolescents' sense of self-efficacy and self-confidence, so that they were able to better cope with their daily challenges. Although there was no significant difference between the mean scores of emotional self-care in the experimental and control groups, the third hypothesis of the study, which was that "group social work intervention with an empowerment approach is effective in promoting emotional self-care in Afghan adolescents" was rejected, but this result could be because Afghan adolescents usually face emotional problems such as anxiety, depression, fear, and despair due to bitter experiences such as migration, war, and social pressures. In such circumstances, given that the empowerment approach can provide them with the necessary tools to manage these emotions, the immigrant adolescent is at risk for harm, but there is a need for more support and ongoing emotional self-care training.

Empowerment in these interventions is implemented by strengthening self-confidence and increasing emotional self-awareness of adolescents. They learn how to identify their feelings, express them correctly and use appropriate strategies to deal with negative emotions. Group interventions also allow adolescents to learn from the experiences of others and share their feelings in a safe and supportive environment; this type of intervention requires ongoing follow-up by social workers and policymakers.

The hypotheses of group social work intervention with an empowerment approach on promoting physical and psychosocial self-care of Afghan adolescents are confirmed and supported. Given the effectiveness of group social work intervention with an empowerment approach on promoting self-care, it is expected that the results of this study will be used in designing educational and support programs for refugee and immigrant adolescents. These programs can help strengthen social support structures and improve the overall health and well-being of adolescents and their families.

One of the limitations of the present study is that due to the large number of questions in the questionnaire, respondents may not have answered with sufficient accuracy; also, collecting data from individuals with different cultural and social conditions should be considered in generalizing the results. Therefore, it is suggested that after the end of the interventions, establishing continuous support groups for Afghan adolescents can help maintain and strengthen the effects of social work interventions. In addition, considering the rejection of the hypothesis of the effect of group social work intervention with an empowerment approach on promoting emotional self-care of Afghan adolescents, it is suggested that this hypothesis be implemented in the community with different sample size And a study titled “A Qualitative Analysis of Afghan Adolescents’ Experiences with Social Work Interventions” can be conducted. In addition, designing programs that involve families and teachers in the intervention process can significantly enhance the effectiveness of interventions, and broad collaboration among support organizations, social workers, schools, and healthcare centers can contribute to improving the quality of life for migrant individuals and help them better adapt to the host society. It is recommended that a prospective psychometric evaluation of a sample of Afghan adolescents be conducted and include: (a) assessing internal reliability and temporal consistency (ICC) with a sufficiently large sample, (b) conducting exploratory and confirmatory factor analyses to examine construct validity in this context, (c) measuring measurement heterogeneity in relevant groups (e.g., by gender and region), if possible, and (d) providing Afghan-specific validity and reliability evidence for the future.

Implications for practice

Group interventions with an empowerment approach can also be used as practical models for working with vulnerable populations, especially adolescents with specific characteristics and specific patients. These findings provide social workers with practical and effective tools for working with vulnerable individuals that can help them improve their physical, mental, and social health, so that they can function as more active and responsible members of society and use their abilities to care for and improve their own and their families' lives. The results of this study can also be used to design educational and support programs for refugee and immigrant adolescents as a vulnerable group. These programs can help strengthen social support structures and improve the overall health and well-being of vulnerable individuals and their families.

Acknowledgments

The authors hereby extend their sincere gratitude to the Vice Chancellor’s Office for Research at Yazd University and the Vice Chancellor’s Office for Education of the General Directorate of Education for their cooperation, as well as to all the staff, teachers and Afghan students of Shahid Andarzgo and Taghi Rasoulian schools in Yazd, who contributed to this research project.

Conflicts of interest

The authors declared no conflict of interest regarding the publication of this study.

Funding

This research receive financial resources from Yazd University.

Authors' Contributions

N.B. contributed to the conception, design, data collection, data analysis and drafting and revising the manuscript. R.Q. performed the conception, design, supervision of project, and revising the manuscript. S.R.J. conducted revising the manuscript. B.Z. contributed to data analysis and drafting the manuscript. M.B. performed statistical analysis and results. All authors contributed to the writing of the manuscript and discussed on the manuscript.