Exploring Access,Utilisation,and Barriers to School Health Systems for Managing Mental Health Challenges: A Case Study of Mapanzure High School,Masvingo District,Zimbabwe

Abstract

Introduction:

Globally, between the ages of 10 and 19, 15% of teenagers have mental health issues, according to the World Health Organization (WHO). Mental health issues in schools lead to dropouts, poor academic performance, social isolation, and increased substance misuse. Various strategies, including universal screening and raising mental health literacy, have been implemented. However, constraints like limited resources and inadequate training hinder effective management. Therefore, this paper aimed to explore student access to and utilisation of the school health system for mental health challenges, and to identify key barriers to its effectiveness from the perspective of students and staff in Mapanzure Masvingo District.

Methods:

A mixed-method survey was used with interviews and questionnaires to gather information from key informants and 62 randomly selected students. The key informants were purposively sampled, including two nurses, two teachers, three health masters, and two administrators. Quantitative data was analysed in Excel and SPSS and presented as tables and graphs, while the qualitative data was recorded, transcribed verbatim, coded, and thematically analysed.

Results:

The study found a high prevalence of self-reported mental health symptoms among students, including attention deficit (62.9%) and low self-esteem (72.6%). This high burden of need contrasted sharply with utilisation of the school health system was low (40.3%), primarily due to a lack of student awareness. This indicates a significant gap between system provision and student access. Key informants identified health clubs and guidance counselling as core components of the system, but their effectiveness was hampered by major barriers like poverty and substance abuse.

Conclusion:

It can be concluded that students are experiencing mental health issues, and key informants generally view school health systems as helpful. However, there are certain obstacles, such as poverty and substance use and abuse hindering implementation and optimal functioning of school health systems. These results may help create a supportive and inclusive environment that values student health and emotional wellbeing that can lead to improved academic outcomes and positive life for students.

Keywords

school health services mental health school based mental health student health clubs

Introduction

The global prevalence of mental health challenges among children and adolescents has become a significant concern, with the World Health Organization (WHO) estimating that up to 20% of this population is affected.¹ Recent studies have highlighted the increasing role of schools as crucial locations for early intervention in addressing these mental health issues.² The implementation of comprehensive school health programs to support students’ physical, mental, and social welfare is considered essential in managing mental health challenges in this demographic.

Globally, the most prevalent mental health issues among students include eating disorders, anxiety, depression, and substance abuse.³ These challenges have far-reaching consequences, including academic difficulties, increased risk of substance addiction, social isolation, and physical health problems.⁴ In response, various prevention and management strategies have been developed, such as implementing school health systems, universal screening for mental health issues, and promoting mental health literacy among students, teachers, and parents.⁵

Several countries have implemented successful intervention programs. For instance, Canada’s Resilience Project aims to prevent mental health problems in adolescents, while the Friends for Life program, based on cognitive-behavioural therapy, has been implemented in Canada, China, South Africa, and the United Kingdom.⁶ Finland’s well-being program, addressing children’s social, emotional, and physical needs, and New Zealand’s positive behaviour for learning program, provide further examples of effective school-based interventions.^7,8

In Africa, adolescents face several mental health challenges, primarily depression, anxiety, and trauma.⁹ These issues can lead to school dropout, lower academic performance, social isolation, and increased risk of substance abuse.¹⁰ Poverty, violence, and poor access to mental health services are identified as primary contributing factors.¹¹ Various strategies have been employed to address these challenges in Africa. Telehealth interventions have shown promise in enhancing mental health outcomes.¹² School-based programs such as the U-Rise program in South Africa and the Friends for Life program in Mozambique focus on improving the emotional well-being and life skills of adolescents.¹³ In Malawi, the introduction of a policy on mental health and psychosocial support in schools has led to increased teacher training and improved mental health support for students.¹⁴

In Zimbabwe, the 2019 Multiple Indicator Survey revealed that one in five adolescents reported experiencing symptoms of anxiety, while one in ten reported signs of depression.¹⁵ A subsequent report by UNICEF indicated that among adolescents aged 15 to 17 years, 2% suffered from depression and 3% from anxiety.¹⁶ These mental health challenges have significant consequences, including poor academic performance, social isolation, and increased risk of substance abuse and suicide.^17,18

The Zimbabwean government has introduced the National School Health Policy to provide a framework for integrated health services within the education system, recognising it as a strategic investment to enhance both health and educational outcomes.¹⁹ This policy mandates the implementation of a coordinated school health program, which includes core components such as: (1) health education integrated into the curriculum; (2) guidance and counselling services; (3) physical education and co-curricular activities; (4) establishing health clubs; and (5) creating partnerships with local health facilities for support and referral.¹⁹

However, the implementation and effectiveness of this policy in real-world, resource-constrained settings like rural Zimbabwe remain poorly understood. Available literature suggests significant challenges. For instance, studies indicate that even teachers designated as guidance and counselling officers often lack adequate training, leading to a poor understanding of mental health issues and difficulty in identifying and referring students in need.²⁰ Furthermore, systemic barriers such as inadequate funding, overcrowded classrooms, and competing academic priorities often sideline health programs, reducing them to peripheral activities rather than core functions.²¹ There is a critical gap in understanding the on-the-ground operation, student engagement with, and constraints facing school health systems in managing mental health disorders, particularly in the Zimbabwean context. Therefore, this paper aimed to explore (1) the mental health challenges and help-seeking needs of students, (2) the utilisation of and access to the existing school health system, and (3) the perceived barriers and potential strategies for improving the system at Mapanzure High School in Masvingo District.

Methodology

Study Area

The study was conducted in Mapanzure, a rural secondary school located 56 km from Masvingo town in the Masvingo district of Zimbabwe. The area comprises of a single rural health clinic. According to 2023 enrolment statistics, the school had a total population of 642 students. A map of the study area is shown in Figure 1.

Figure 1.

Study area map.

Study Design

This study employed a mixed-methods approach to generate both quantitative and qualitative data, allowing for a comprehensive examination of mental health challenges and school health systems in Mapanzure, Zimbabwe. The research design was carefully structured to address the multifaceted nature of the research questions and to provide a nuanced understanding of the subject matter.

Target Population and Sampling

The primary target population for the quantitative component consisted of all 642 students enrolled at Mapanzure High School. This population was selected due to their direct experience with potential mental health challenges and their engagement with school health systems. For the qualitative component, the target population included key stakeholders in the school health system: three teachers, two nurses, two school health masters, and two school administrators. These participants were all staff members of Mapanzure High School. These participants were chosen based on their professional expertise and close interaction with students, providing valuable insights into the functioning of school health systems and the mental health challenges faced by students.

For the quantitative component, a stratified random sampling technique was employed to ensure representation across different grade levels. Students from Forms 1 to 3 (equivalent to grades 8-10) were sampled separately from those in Forms 4 to 6 (equivalent to grades 11-13) to achieve equal representation. The sampling process involved a color-coded system, with separate selection pools for male and female students to ensure gender balance. The final sample size was 62 students, determined using a margin of error of 10%, a confidence level of 90%, and a response distribution of 50%, given the total population of 642 students. Furthermore, purposive sampling was utilised to select participants for interviews based on their potential to provide rich, relevant data. This non-probability sampling method was chosen to ensure that the most knowledgeable and experienced individuals were included in the study, thus maximising the quality and depth of the qualitative data collected.

Inclusion and Exclusion Criteria

The study applied specific inclusion and exclusion criteria to ensure the selection of appropriate participants. For the quantitative component, students were included if they were currently enrolled at Mapanzure High School, aged 12 to 20 years, and willing to provide assent (with parental consent for minors). Students with severe cognitive impairments or language barriers preventing comprehension of the questionnaire were excluded. For the qualitative component, key stakeholders (teachers, nurses, school health masters, and administrators) were included based on their direct involvement in student welfare and school health systems, while those with less than 1 year of experience in their roles were excluded to ensure informed perspectives. These criteria helped maintain the relevance and reliability of the collected data.

Data Collection Procedures and Tools

Quantitative data was collected using a structured questionnaire administered through KoboCollect software. The questionnaire was designed to capture socio-demographic information (age, sex, education level, and religion) as well as specific mental health indicators, perceptions of school health program effectiveness, and suggestions for improvement.

The mental health screening section was adapted from standardised modules used in adolescent health surveys, drawing on items from the WHO’s Global School-Based Student Health Survey (GSHS) and the Shona Symptom Questionnaire (SSQ) to ensure cultural relevance and contextual appropriateness for Zimbabwean adolescents.¹⁵ This approach allowed for the assessment of symptom clusters associated with common mental health challenges without conducting clinical diagnoses. The questionnaire was pre-tested with a small group of students (n = 5) not included in the final sample to check for clarity, comprehension, and relevance. Internal consistency for the piloted mental health modules was calculated using Cronbach’s Alpha, yielding a score of .79, which indicates acceptable reliability for a screening tool. Adjustments were made to wording and question structure based on this pilot feedback. The questionnaire was designed to capture students’ self-reported experiences and perceptions; it was not used as a clinical diagnostic tool for mental health conditions. Symptom scores were calculated for depression, anxiety, attention deficit, mood disorders, and self-esteem, with predetermined cut-off scores established based on a review of similar screening approaches in the literature (Table 1).

Table 1.

Determining and Characterising Mental Health Challenges.

Mental challenge	Rating	Score
Depression	Not depressed	0-4
Depression	Depressed	5-9
Anxiety	No anxiety	0-3
Anxiety	Anxiety	4-7
Attention deficit	No attention deficit	0-3
Attention deficit	Attention deficit	4-6
Mood disorders	No mood disorders	0-3
Mood disorders	Mood disorders	4-8
Self esteem	No self esteem	0-1
Self esteem	Self esteem	2-4

Qualitative data was gathered through in-depth, semi-structured interviews with the selected stakeholders to gather data on their perspectives regarding the implementation of school health systems, observed mental health challenges among students, and barriers to effective service delivery. The interview guide was piloted and refined to ensure clarity and relevance of questions. Interviews were conducted face-to-face to allow for observation of non-verbal cues and to establish rapport with participants. Data saturation was achieved through the use of an appropriate sample size and the selection of information-rich participants. These interviews were audio-recorded with participant consent and later transcribed for analysis.

Data Management and Analysis

Quantitative data was analysed using descriptive and inferential statistical methods. Scores for various mental health indicators (depression, anxiety, attention deficit, mood disorders, and self-esteem) were calculated based on participants’ responses. The analysis of mental health indicators served to establish the prevalence and burden of need within the student population. The predetermined cut-off scores for each challenge (detailed in Table 1) were established based on a review of similar screening approaches in the literature.²² A challenge was considered “present” if a participant’s score met or exceeded this threshold. This method of using a symptom count threshold is a common screening approach to identify individuals at high risk who may require further assessment. The tool captured current self-reported experiences and did not account for students who might be on treatment, as the study aimed to assess the current burden of symptomatic experiences within the student population at the time of the survey Chi-square tests and cross-tabulations were performed to examine relationships between variables, such as self-esteem and attention deficit. Results were presented using tables, graphs, and pie charts to effectively communicate findings.

Additionally, qualitative data was analysed using a systematic thematic analysis approach. Thematic analysis followed the six-phase approach by Braun and Clarke (2006)²³ After transcription, two researchers independently familiarised themselves with the data and generated initial codes. Codes were then collated into potential themes, which were reviewed and refined iteratively to ensure they formed a coherent pattern. To enhance validity, emerging themes were discussed with the research team (peer debriefing) and a summary of findings was shared with two key informants for feedback (member checking), ensuring the analysis accurately reflected their experiences. The analysis process involved multiple iterations of coding and theme refinement to ensure the robustness of the findings.

Validity and Reliability

The research proposal was reviewed by the National University of Science and Technology Institutional Review Board (NUST IRB) to obtain approval (NUST/IRB/2024/016) for this study. Both the methodology and data collection instruments were adjusted according to the input received. A pre-test was conducted to sample the feasibility of data collection using the interview guide.

Ethical Consideration

Ethical approval for this study was granted by the Institutional Review Board of the National University of Science and Technology (NUST IRB), Zimbabwe (Clearance Number: NUST/IRB/2024/016). Written informed consent was obtained from all participants aged 18 years and above, while for minors (below 18 years), written consent was provided by parents or legally authorised representatives (LARs), along with written assent from the students themselves. Stakeholders, including teachers, nurses, and administrators, also provided written consent prior to participation. The consent process ensured participants were fully informed of the study’s purpose, procedures, confidentiality measures, and their right to withdraw without consequence. All data were anonymised to protect participant identities, and no personally identifiable information was collected. Participation was entirely voluntary, with no penalties for withdrawal. The study adhered to strict confidentiality protocols, with data stored securely on password-protected systems. The NUST IRB reviewed and approved all consent procedures, and no waivers were required as full written consent was obtained in all applicable cases.

Findings

Mental Health Challenges Faced by Students

To establish the context and burden of mental health need that the school health system is tasked with addressing, students were screened for self-reported symptoms of common mental health challenges. A challenge was considered present if half or more of the associated symptoms were reported. The assessment covered depression, anxiety, mood disorders, self-esteem issues, and attention deficit. Figure 2 illustrates the self-reported burden of mental health symptoms among the sampled students. Anxiety (69.4%, n = 43), attention deficit (62.9%, n = 39), and self-esteem issues (72.6%, n = 45) emerged as the most prevalent challenges, with self-esteem issues and attention deficit affecting the largest number of students. Depression was found to be less common in comparison (33.9%, n = 21).

Figure 2.

Self-reported burden of mental health symptoms among students.

Attention Deficit

Out of 62 participants, females showed a higher prevalence of attention deficit (n = 23) compared to males. The age group 17 to 19 years had the highest number of students with attention deficit (n = 18), while the 13 to 14 years age group had the lowest (n = 8). There was an equal distribution between Form 1-2 and Form 3-4 students (n = 14 each). Chi-square analysis revealed a significant gender difference (P = .0123) but no significant differences across age groups or education levels (Table 2).

Table 2.

Cross Tabulation for Demographic and Attention Deficit.

Sociodemographic Characteristic	Attention deficit			Chi P value
Sociodemographic Characteristic		Yes (f)	No (f)	Chi P value
Gender	Female	23	7	.0123 Has significant difference
Gender	Male	16	16	.0123 Has significant difference
Age group	13-14	8	5	.2325 No significant difference
	15-16	13	5
	17-19	18	13
Level of education	Form 1-2	11	9	.5851 No significant difference
	Form 3-4	14	7
	Form 5-6	14	7

Abbreviation: f, frequency (count of students).

Self-Esteem Issues

Self-esteem issues were almost equally distributed between males (n = 23) and females (n = 22). The 17 to 19 age group showed the highest prevalence (n = 27), while the 13 to 14 age group had the lowest (n = 7). Form 5 to 6 students had the highest number of self-esteem issues (n = 18). Chi-square analysis showed no significant differences across gender, age groups, or education levels (Table 3).

Table 3.

Cross-Tabulation for Demographics and Self-Esteem.

Sociodemographic Characteristic	Self-esteem			Chi P value
Sociodemographic Characteristic		Yes (f)	No (f)	Chi P value
Gender	Female	22	8	.5847 No significant difference
Gender	Male	23	9	.5847 No significant difference
Age group	13-14	7	6	.6888 No significant difference
	15-16	11	7
	17-19	27	4
Level of education	Form 1-2	12	9	.3120 No significant difference
	Form 3-4	15	6
	Form 5-6	18	2

Abbreviation: f, frequency (count of students).

Utilisation of the School Health System

Despite the high self-reported symptom burden, utilisation of the existing school health system was low. Only 40.3% (n = 25) of the 62 students reported having ever used the system for mental health support. The primary reason cited by the majority of non-users (59.7%, n = 37) was a lack of awareness of the services available or how to access them.

Curriculum and Content Service Package of School Health Systems

The qualitative data revealed that the school’s health system curriculum is primarily delivered through two main themes: Health Clubs and Guidance and Counselling. Additionally, five subthemes arose from these key themes. Interviews with staff outlined the various functions and modes of delivery for these components. Health clubs were described as a versatile platform for mental health education, operating through after-school and after-lunch programs. A teacher noted their importance for engagement: “After school programs like health clubs are very important as students engage and come together and do dammars that help in learning” (T1). Their role was seen as threefold: to educate, entertain, and foster interaction, thereby creating a less formal environment for learning. As one administrator explained, “They assist in giving education in a manner that gives entertainment and interaction with teachers, students and the nurses” (A2).

Regarding Guidance and Counselling (G&C), a key finding was the lack of specialised personnel. Instead, the responsibility is distributed among all teachers. A teacher highlighted this challenge: “Used to have a teacher specifically for guidance and counselling. . . currently all teachers are doing it” (T2). Despite this constraint, the school has formally integrated G&C into the weekly timetable “just like other subjects” (A1), signalling its institutional priority. The core purpose of this service was to equip students with knowledge to manage mental health challenges. A health master stated the goal was to “equip students with knowledge on mental health and give advice to all on how best to deal with the mental challenge before and after it has occurred” (HM3). These themes and supporting quotations are further detailed in Table 4.

Table 4.

Curriculum or Content Service Package of School Health Systems Aimed at Dealing with Different Mental Health Challenges.

Superordinate theme	Subordinate themes	Description of theme	Quotations
Health clubs	After school programmes for students	Participants cited that after receiving lectures they also have after school programmes that educate on mental health challenges.	“After school programs like health clubs are very important students engage and come together and do dammars that help in learning.” (T1)
	After lunch lessons cater for student health education	Participants cited after lunch programs are being done so that students receive lessons on mental health.	“We do after lunch programmes on mental health to cater for the students health education which are health clubs.” (HM2)
	Entertain, interaction and educate	Participants cited that health clubs help students to interact with each other and share views concerning mental health challenges.	“They assist in giving education in a manner that gives entertainment and interaction with teachers,students and the nurses that usually come for sessions.” (A2)
Guidance and counselling (GC)	All teachers are giving guidance and counselling	The participants cited that due to limited resources there is no specific teacher for guidance and counselling all teachers are participating in guidance and counselling so that service is provided to the students	“Used to have a teacher specifically for guidance and counselling who could identify those students and give necessary advice currently all teachers are doing it.” (T2).
	Guidance and counselling on time table	The participants cited that guidance and counselling has been included on the time table so that it is incorporated into the school curriculum.	“Guidance and counselling lessons included on the time table just like other subjects.” (A1).
	Equip with knowledge on mental health	The participants cited that guidance and counselling equip students with knowledge that will help them manage mental health challenges.	“Equip students with knowledge on mental health and give advice to all on how best to deal with the mental challenge before and after it has occurred.” (HM3)

Barriers to Implementation and Optimal Functioning of School Health Systems

Several barriers to effectively implementing school health systems were identified. Poverty was a predominant theme, directly hindering the system’s reach. Key informants explained that a lack of school fees and limited resources at home prevent students from attending school consistently, thereby excluding them from accessing any school-based services. As one administrator noted, “learners not going to school because of lack of school fees will not come to school for services” (A2). Beyond access, poverty also cripples the educational component of the system through a lack of resources. A teacher lamented the “lack of qualified resource personnel and reading material,” expressing a desire for basic materials “like pamphlets so that we can distribute to our learners and teachers” (T1). These findings are presented in Table 5.

Table 5.

Barriers to the Optimal Functioning of School Health Systems in Managing Mental Health Challenges.

Superordinate theme	Subordinate themes	Description of theme	Quotations
Poverty	Lack of school fees	Participants cited that if students have not paid school fees they will not have an opportunity to access services being provided at the schools.	“In most cases we see learners not going to school or not attending because of lack of school fees some learners are orphans and some are staying alone and because of lack of school fees they will not come to school for services.” (A2)
	Limited resources	Most homes have limited resources that will make it difficult for them to pay school fees and even provide food hence the school will not have access to students since they will not come to school due to lack of school fees.	“Some of these children would have lost parents and left under jurisdiction of guardians who fail to cater for the child needs in terms of food, clothes and school fees.” (T2)
	Lack of funding to purchase reading material for both students and teachers	Participants cited that information on the reading material is vital for students and teachers but there is lack of funding to purchase the reading material.	“Lack of qualified resource personnel and reading material addressing cases of mental challenges will be happy if we get even pamphlets so that we can distribute to our learners and teachers so that they can learn more about mental health challenges.” (T1)
Substance use and abuse	Peer pressure	The respondents cited that due to peer pressure students are engaging in substance use and abuse which gives negative thoughts.	“Peer pressure if you do not conform to the norms of certain group you are bound to be out of the group and believing that In order to pass if you smoke marijuana it can help you to pass difficult subjects like maths.” (A1)
	Pressure of school work	The respondents cited that the students face a lot of pressure at school which make them turn to drugs thinking they will reduce the pressure.	“Have noted rampant drug due to pressure of work specially due to the introduction of calas ministry of education introduced five calas per subject so if you are taking 12 subjects it is 12x5 which around 60 if the learner lugs behind there is a lot of pressure and end up getting into a depression.” (HM1)
	Hereditary	The respondents cited that substance use and abuse can be the norm of the family and also the mental health challenges that occur might rundown the family generation.	“Some of the children are born and raised in families who consume alcohol and they view it as normal and when drunk they inherit the mood disorders and eating habits their families portray and in most cases end up being their habit even if not drunk causing different mental health challenges.” (HM2)

Substance use and abuse was another critical barrier, directly impairing the system’s effectiveness by reducing student engagement and receptiveness to interventions. Informants reported that substance use, driven by peer pressure and academic stress, leads to negative thoughts and disengagement. Peer pressure was a significant driver, with students believing substance use was a prerequisite for social acceptance and academic success, such as the false notion that “smoking marijuana can help you pass difficult subjects like maths” (A1). Furthermore, the intense pressure of a heavy academic workload was cited as a key trigger. A health master stated reported observing “rampant drug due to pressure of work,” explaining that students to turn to drugs “thinking they will reduce the pressure” (HM1), which in turn impairs their ability to benefit from support services (Table 5).

Strategies for Improving School Health Systems

Participants proposed multiple strategic improvements, which can be categorised into proactive engagement activities and systemic structural changes.

Key informants (staff) strongly advocated for increasing physical activities and institutional tours. They argued that physical activities serve multiple purposes: they “refresh the mind of students and foster interaction” (A2), keep students occupied, and reduce tendencies towards substance use. Institutional tours to mental health facilities were proposed as a powerful, tangible deterrent. The value was in making the consequences of poor mental health real for students by allowing them to “hear testimonies from others concerning consequences of mental health challenges” (A1) or to “actually see those who will be mentally challenged and they will be told how they got to be in this situation” (T1).

Students, when asked for improvement strategies, focused on structural enhancements to the system itself (Figure 3). The most frequent suggestion (54.84%) was the need for more trained staff, highlighting the perceived insufficiency of the current model where all teachers provide counselling. This was closely followed by a call for increased funding (40.32%) to address resource limitations, and the integration of social-emotional learning (SEL) programs (48.39%) into the curriculum for a more skills-based approach. Additionally, half of the students (50%) identified improved access to counselling as a key priority. Further details on suggested strategies, including workshops and awareness campaigns proposed by staff, are compiled in Table 6. Participants suggested various strategies to enhance the effectiveness of school health systems in managing mental health challenges. Key informants emphasised proactive strategies such as increasing physical activities and institutional tours to mental health facilities. They argued that physical activities “refresh the mind of students and foster interaction” (A2), keeping them occupied and reducing tendencies towards substance use. Tours to institutions like Ngomahuru were proposed so students could “hear testimonies from others concerning consequences of mental health challenges” (A1), making the risks more tangible. These strategies are detailed in Table 6.

Figure 3.

Strategies for improving school health systems.

Table 6.

Strategies for Improving School Health Systems and Aiding Their Performance in the Management of Mental Health Challenges.

Superordinate theme	Subordinate themes	Description of theme	Quotations
Physical activities	Refreshes the mind and promotes interaction	The respondents cited that physical activities help to refresh the mind from negative thoughts that will be generated in the mind and creates interaction with others through communication when taking part in sports.	“Physical activities like playing games refresh the mind of students and foster interaction between students and keeps them occupied.” (A2)
	Frequent exposure	The respondents concur that frequent exposure means more time of being occupied with activities and reduce tendencies of substance use and abuse which cause mental health challenges	“Exposing learners to games and other sporting activities more frequently will help withdraw from these drugs.” (HM1)
	Keep students occupied	There was a general consensus that keeping students occupied can make them concentrate on the activities and prevents other thoughts of experimenting since they will have activities occupying them	“Creating sport club to occupied the and give them knowledge on effects of drug abuse during these game sessions.” (N1)
	Entertain the mind	The respondents testify that activities help entertain the mind hence students will not have other thoughts of exploring into activities that trigger mental health challenges.	“Activities is number one for example children play soccer during their spare time that will at least entertain their mind they will start thinking of experimenting on such things like drugs. And also the students must be taught on the importance of physical fitness.” (N2)
Institutional tours	Hearing testimonies	The respondents confirm that hearing testimonies of people who have been in the situation of mental health challenges will also help to equip the students with the knowledge of through the real situation.	“Educational tours for example Ngomahuru which is near us so that students can hear testimonies from others concerning consequences of mental health challenges.” (A1)
Institutional tours	Looking and learning	The participants cited look and learn visits to mental health institution like Ngomahuru might be effective in helping students learn about mental health challenges and desist from activities that cause mental health challenges.	“Learners at this school need to be taken to places like Ngomahuru where they will actually see those who will be mentally challenged and they will be told how they got to be in this situation due to use of drugs abuse this will help the learners from not taking the drugs they may become those people at Ngomahuru who show the effects.” (T1)
Workshops	Improve services	The respondents confirmed that workshops can better improve services since knowledge would have been gained and can be effective when implemented.	“Workshops for guidance and counselling (GC) teachers and health masters to improve services to peers when saying peers lm referring to the students.” (A1)
Workshops	Equip with knowledge	The participant noted that knowledge gained will better equip teachers with knowledge which is vital to mental health among students.	“Need of workshops that help equip the teachers in giving vital knowledge to students and even include the students in workshops.” (HN3)
	Interaction with experts	The responded cited that since they are other experts in other sectors through interaction with them they will help in providing valuable information on mental health.	“Ministry of health can have workshops with teachers so that every teacher is equipped with information from interaction with experts on how to handle these mental health challenges.” (T2)
Awareness campaigns	Foster alert	The respondent confirmed that awareness campaigns help to foster alert which help the students know more on mental health challenges and how best to deal and identify them	“Awareness campaigns help to foster alert to the students on the mental health challenges that can be faced prevention and control when they come across them.” (HM2)
Awareness campaigns	Involve students	The respondent testifies that involving students in talk shows can help give awareness and also will be an exciting activities since they will be having t shirts.	“Talk shows by having people from the health centre coming and having lectures with students and learners have to be involved in these campaigns giving them t shirts and posters by so doing it is an effective way to raise mental health awareness.” (T1)
	Empower with knowledge	The respondent had a general feeling that the awareness campaigns will empower students with knowledge that they can also give to others and also help them	“Empower students with knowledge through awareness campaigns which have to be continuous to keep on reminding the students on the mental health challenges.” (A2)

Discussion

Mental Health Challenges Faced by Students

The results indicated that attention deficit disorder and low self-esteem were the two most frequently experienced mental health conditions among students. This finding aligns with recent research by Sella et al,²⁴ which reported similar prevalence rates for these conditions. However, the context differs, as our study focuses on a rural secondary school, suggesting these challenges are pervasive across both urban tertiary and rural secondary educational environments in different countries.²⁴ A cross-tabulation of attention deficit with gender revealed a higher proportion of female students experiencing attention deficit compared to male students. This gender disparity is consistent with findings by Rucklidge,²⁵ who reported a higher likelihood of attention deficit disorder among adolescents identifying as female. This similarity across studies from New Zealand and Zimbabwe indicates a potential transnational pattern in gender presentation of ADHD symptoms that merits further investigation.

The study found that attention deficit disorder peaked in frequency around the age of 18, with higher prevalence in the 17 to 19 age group. This age-related pattern is supported by Zendarski et al (2017)²⁶, who observed a higher incidence of attention deficit among students in forms 5 to 6 (grade 12-13). This parallel suggests that academic pressure in critical exam years may be a universal trigger for attention difficulties, regardless of the country’s economic status. Regarding educational attainment, equal numbers of students in forms 3 to 4 (grade 11-12) and 5 to 6 exhibited attention deficit disorders. Cross-tabulation of self-esteem revealed higher levels among male students compared to female students. This finding is consistent with Gentile et al,²⁷ who reported significantly higher self-esteem levels in male adolescents. The replication of this finding in a rural African context underscores the robustness of this gender difference in self-esteem across diverse cultural settings. The study also found a substantial proportion of students with high self-esteem in the 17 to 19 age bracket, corroborating the work of Orth et al,²⁸ who identified this age range as having the highest levels of self-esteem relative to other age groups. This suggests a possible developmental universality in the trajectory of self-esteem. The results showed a higher prevalence of high self-esteem among students in forms 5 and 6, aligning with Poorthuis et al,²⁹ who reported stronger self-esteem in these advanced educational levels. This may be attributed to growing maturity and a stronger sense of identity, which appears to be a common experience for older adolescents across different educational systems.

School Health Systems’ Curriculum or Content Service Aimed at Addressing Mental Health Challenges

The findings highlighted health clubs as part of the curriculum service package addressing various mental health issues. This approach is supported by Kakunje,³⁰ who demonstrated the effectiveness of health clubs in increasing peer support, reducing stigma associated with mental health issues, and enhancing mental health awareness. Hurley et al³¹ further emphasised the role of health clubs in providing a space for peer support and education, particularly beneficial in addressing adolescent mental health concerns. The positive perception of health clubs in both a well-resourced country like Australia and a resource-constrained setting like rural Zimbabwe highlights their adaptability and potential as a low-cost, high-engagement intervention.

Guidance and counselling were also identified as key components of school health systems’ curricula for addressing mental health issues. This finding is supported by Subhan Iswahyudi et al,³² who emphasised the utility of guidance and counselling services in providing individualized support and interventions for mental health difficulties in Indonesia. A key difference, however, is the implementation. While the Indonesian study likely refers to specialised counsellors, the study found that “all teachers are giving guidance and counselling” (T2) due to a lack of dedicated personnel. This highlights a critical resource gap between policy aspiration and on the ground reality in rural Zimbabwe.

Barriers to Implementation and Optimal Functioning of School Health Systems

The results identified poverty as a significant barrier to the effective implementation of school health systems. This finding is consistent with Mohlabi et al,³³ who highlighted poverty as a major obstacle to accessing mental health care in schools, particularly for disadvantaged and marginalised groups. Substance use and abuse were also identified as hindrances to the implementation and effectiveness of school health systems. Waller et al³⁴ corroborated this finding, noting that substance use and abuse can significantly impede the efficacy. Substance abuse reduces student engagement and receptiveness, making them less likely to participate in or benefit from the existing support structures, like health clubs and counselling, thereby rendering the system less effective.³⁴

Strategies for Improving School Health Systems and Enhancing Their Performance

The study identified increasing physical activity as a strategy for improving the efficacy of school health systems. This approach is supported by Barcelona et al,³⁵ who emphasised the crucial role of physical activity in enhancing mental health and overall well-being among adolescents, particularly in educational settings.³⁵ This suggests that the mental health benefits of physical activity are a universal principle, though the infrastructure to support it may differ greatly between settings. Institutional visits were highlighted as a potential tactic for enhancing school health programs. Mann et al³⁶ support this finding, demonstrating that visits to mental health institutions can positively influence attitudes toward mental health in school health systems. Awareness campaigns were identified as another strategy to improve school health programs. This approach is endorsed by Kolbe³⁷ and Moussi et al,³⁸ who recognise the effectiveness of awareness campaigns in increasing knowledge and understanding of mental health issues among students and teachers. Implementing campaigns would thus serve to bridge the gap between the system’s existence and its accessibility to students.

The study found that 54.84% of students believed that increasing staff would enhance the effectiveness of school health systems. This perception aligns with Brener et al,³⁹ who emphasised the importance of adequate school mental health staff in providing effective care. This suggestion from students directly tackles the barrier of overburdened staff identified by key informants, who noted that “all teachers are giving guidance and counselling” (T2) due to a lack of dedicated personnel. Hiring trained staff would professionalise the service and increase its capacity. Littlecott et al⁴⁰ further support this finding, noting that higher staff-to-student ratios in mental health at educational institutions are associated with improved quality of mental health services. Half of the students identified access to counselling as a strategy for enhancing school health systems. This finding is supported by Kolbe,³⁷ who reported that school-based counselling effectively reduced student behavioural issues, anxiety, and depression.

Conclusion and Recommendations

It can be concluded from the results obtained that students at Mapanzure High School are experiencing a significant burden of mental health symptoms, and key informants generally view the intended school health systems as helpful. However, the potential of the school health system to address this burden is limited by critical obstacles, including poverty and substance use and abuse, and a stark lack of awareness and resources, leading to low utilisation. These results may help create a supportive and inclusive environment that values student health and emotional wellbeing, that can lead to improved academic outcomes and a positive life for students.^41,42

Recommendations

To bridge the gap between these findings and the goal of creating a supportive and inclusive environment, several recommendations can be proposed.

Integrating mental health literacy into the core curriculum through structured Social-Emotional Learning (SEL) programs would directly address the lack of awareness, destigmatise help-seeking behaviour, and build student resilience.

Investing in specialised human resources by training and deploying dedicated guidance personnel, even if shared across school clusters, would provide more professional and consistent support than the current model of relying on all teachers as counsellors. Additionally, allocating targeted funding for resource-poor schools would enable the procurement of essential materials and sustain core activities like health clubs and awareness campaigns.

Formalising community-school partnerships with local health facilities and social services would create a holistic support system and referral pathway to help mitigate the impact of poverty on student attendance and access to care.

Implementing these recommendations would translate the study’s results into concrete actions, directly addressing the identified barriers and leveraging the existing system to promote a school environment that genuinely supports student wellbeing and academic success.

Limitations

This study has several limitations that should be considered when interpreting the results. The cross-sectional design provides a snapshot of the situation at a single point in time and cannot establish causality between the school health system and mental health outcomes. Additionally, the study was conducted in a single rural secondary school in Zimbabwe, which limits the generalisability of the findings to urban schools or other regions with different socio-economic and cultural contexts. The sampling frame also excluded adolescents who were not enrolled in or attending school, a group that may experience a disproportionate burden of mental health challenges and face even greater barriers to care. Their perspectives are therefore missing from this analysis.

The assessment of mental health challenges was based on self-reported symptoms using a screening tool, not a clinical diagnostic interview. This likely captures symptomatic burden but may not equate to formal diagnoses. Furthermore, the tool did not account for students who might already be on treatment and thus potentially less symptomatic. Finally, while the mixed-methods approach is a strength, the qualitative sample, though purposively selected, is small and represents the views of specific stakeholders within one school, which may not capture the full range of experiences and barriers.

Footnotes

Author Note

NNN is a former undergraduate student in the Department of Environmental Science and Health at NUST. MYK holds a MSc degree in Environmental Health and is a Lecturer in the Department of Environmental Health at the National University of Science and Technology (NUST) in Bulawayo in Zimbabwe. WNN is an Associate Professor in the Department of Environmental Health at the University of Botswana. The author is also a post-doctoral research fellow at the Department of Public Health at the University of the Free State, South Africa.

ORCID iDs

Methembe Yotamu Khozah

Wilfred Njabulo Nunu

Ethical Considerations

Ethical approval for this study was granted by the National University of Science and Technology in Bulawayo, Zimbabwe (NUST IRB). (Ethics Clearance Number: NUST/IRB/2024/035). Permission to conduct the survey was also sought from participating companies.

Consent to Participate

Written informed consent was obtained from all participants aged 18 years and above, while for minors (below 18 years), written consent was provided by parents or legally authorised representatives (LARs), along with written assent from the students themselves. Stakeholders, including teachers, nurses, and administrators, also provided written consent prior to participation. The consent process ensured participants were fully informed of the study’s purpose, procedures, confidentiality measures, and their right to withdraw without consequence.

Author Contributions

NNN conceptualised the research idea, collected the data, and drafted the initial manuscript. MYK coordinated the research, guided the data analysis, and coordinated the manuscript writing process. WNN and MYK provided significant intellectual input in the interpretation of data, restructuring, and critical revision of the manuscript for important academic content. All authors reviewed, edited, and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Telhaj

Mental health of adolescents and youth. J Cult Relig Stud. 2019;7(3):1-7.

Loades

Coetzee

Osborn

Human

Venturo-Conerly

Lessons learned from conducting mental health intervention research in schools in the global south: our experiences in South Africa and Kenya. Clin Child Psychol Psych. 2023;29(1):187-197.

Auerbach

Mortier

Bruffaerts

, et al. WHO world mental health surveys international college student project: prevalence and distribution of mental disorders. J Abnorm Psychol. 2018;127(7):623-638.

Pham

Adesman

Teen victimization: prevalence and consequences of traditional and cyberbullying. Curr Opin Pediatr. 2015;27(6):748-756.

Baffsky

Ivers

Cullen

Wang

McGillivray

Torok

Strategies for enhancing the implementation of universal mental health prevention programs in schools: a systematic review. Prev Sci. 2023;24(2):337-352.

Malla

Iyer

McGorry

, et al. From early intervention in psychosis to youth mental health reform: a review of the evolution and transformation of mental health services for young people. Soc Psychiatry Psychiatr Epidemiol. 2016;51(3):319-326.

Junttila

Annevirta

Salminen

Enhancing children’s and adolescents’ learning, engagement and well-being in schools via well-being in schools-specialization program for teachers. Int J Integr Care. 2019;19(4):336.

Paulus

Ohmann

Popow

Practitioner review: school-based interventions in child mental health. J Child Psychol Psychiatry. 2016;57(12):1337-1359.

Sequeira

Singh

Fernandes

, et al. Adolescent health series: the status of adolescent mental health research, practice and policy in sub-Saharan Africa: a narrative review. Trop Med Int Health. 2022;27(9):758-766.

10.

Weybright

Caldwell

Xie

Wegner

Smith

EA.

Predicting secondary school dropout among South African adolescents: a survival analysis approach. S Afr J Educ. 2017;37(2):1-11.

11.

Hodgkinson

Godoy

Beers

Lewin

Improving mental health access for low-income children and families in the primary care setting. Pediatrics. 2017;139(1):1175.

12.

Ojeahere

Kiburi

Agbo

Kumar

Jaguga

Telehealth interventions for substance use disorders in low- and- middle income countries: a scoping review. PLoS Dig Health. 2022;1(11):e0000125.

13.

Sorsdahl

Davies

Jensel

Oberholzer

Gelberg

van der Westhuizen

Experiences and perceived benefits of a youth skateboarding program in South Africa: from the physical to emotional and beyond. J Adoles Res. 2021;39(3):770-795.

14.

Kutcher

Perkins

Gilberds

, et al. Creating evidence-based youth mental health policy in sub-Saharan Africa: a description of the integrated approach to addressing the issue of youth depression in Malawi and Tanzania. Front Psychiatry. 2019;10:542.

15.

Haney

Singh

Nyamukapa

, et al. One size does not fit all: psychometric properties of the Shona Symptom Questionnaire (SSQ) among adolescents and young adults in Zimbabwe. J Affect Disord. 2014;167:358-367.

16.

UNICEF. Child and Adolescent Mental Health and Psychosocial Support Interventions M in D the Gap an Evidence and Gap Map of Low-and Middle-Income Countries. Published online 2022. Accessed February 4, 2025. www.unicef-irc.org

17.

Lund

Mental health innovations in Africa: lessons from Ethiopia and Zimbabwe. Epidemiol Psychiatr Sci. 2017;26(4):339-341.

18.

McLeod

Uemura

Rohrman

Adolescent mental health, behavior problems, and academic achievement. J Health Soc Behav. 2012;53(4):482-497.

19.

UNESCO. Zimbabwe School Health Policy. Health and Education Resource Centre. 2018. Accessed August 22, 2025. https://healtheducationresources.unesco.org/library/documents/zimbabwe-school-health-policy

20.

Larson

Caldwell

Teachers’ perception of mental health in the school system. J Counsel Illinois. Published online 2020.

21.

Williams

Vaisey

Patton

Sanci

The effectiveness, feasibility and scalability of the school platform in adolescent mental healthcare. Curr Opin Psychiatry. 2020;33(4):391-396.

22.

Khumalo

Appiah

Wilson Fadiji

Measuring positive mental health and depression in Africa: a variable-based and person-centred analysis of the dual-continua model. Front Psychol. 2022;13:885278.

23.

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706QP063OA

24.

Sella

Adamopoulou

Georgiou

Konstantopoulou

Social anxiety disorder and low self-esteem among university students. Eur J Public Health Stud. 2024;7(3):1-8.

25.

Rucklidge

JJ.

Gender differences in attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2010;33(2):357-373.

26.

Zendarski

Sciberras

Mensah

Hiscock

(2017). Academic Achievement and Risk Factors for Adolescents with Attention-Deficit Hyperactivity Disorder in Middle School and Early High School. Journal of Developmental and Behavioral Pediatrics: JDBP, 38(6), 358-368. https://doi.org/10.1097/DBP.0000000000000460

27.

Gentile

Grabe

Dolan-Pascoe

Twenge

Wells

Maitino

Gender differences in domain-specific self-esteem: a meta-analysis. Rev Gener Psychol. 2009;13(1):34-45.

28.

Orth

Erol

Luciano

EC.

Development of self-esteem from age 4 to 94 years: a meta-analysis of longitudinal studies. Psychol Bull. 2018;144(10):1045-1080.

29.

Poorthuis

AMG

Thomaes

van Aken

MAG

Denissen

JJA

de Castro

. Dashed hopes, dashed selves? A sociometer perspective on self-esteem change across the transition to secondary school. Social Dev. 2014;23(4):770-783.

30.

Kakunje

Mental health education integration into the school curriculum needs to be implemented. Arch Med Health Sci. 2023;11(1):1-2.

31.

Hurley

Swann

Allen

Okely

Vella

SA.

The role of community sports clubs in adolescent mental health: the perspectives of adolescent males’ parents. Qual Res Sport Exerc Health. 2017;9(3):372-388.

32.

Subhan Iswahyudi

Dannur

Moh

Malini Lubis

Muhammadong

Problems faced by high school students in planning career further study and work. J Konsel Pendid Islam. 2023;4(2):287-294.

33.

Mohlabi

Aswegen

Van, Mokoena

Barriers to the successful implementation of school health services in the Mpumalanga and Gauteng provinces. S Afr Fam Pract. 2010;52(3):249-254.

34.

Waller

Finch

Giles

Newbury-Birch

Exploring the factors affecting the implementation of tobacco and substance use interventions within a secondary school setting: a systematic review. Implement Sci. 2017;12(1):1-18.

35.

Barcelona

Centeio

Hijazi

Pedder

Classroom teacher efficacy toward implementation of physical activity in the D-SHINES intervention. J Sch Health. 2022;92(6):619-628.

36.

Mann

Kristjansson

Smith

Daily

Thomas

Murray

From tactics to strategy: creating and sustaining social conditions that demand and deliver effective school health programs. J Sch Health. 2018;88(5):333-336.

37.

Kolbe

LJ.

School health as a strategy to improve both public health and education. Annu Rev Public Health. 2019;40:443-463.

38.

Moussi

Tahan

Habchy

, et al. School-based pre- and post-intervention tests assessing knowledge about healthy lifestyles: a national school health awareness campaign on children aged between 3 and 12 years old. Children (Basel). 2024;11(2):213.

39.

Brener

Wheeler

Wolfe

Vernon-Smiley

Caldart-Olson

Health services: results from the school health policies and programs study 2006. J Sch Health. 2007;77(8):464-485.

40.

Littlecott

Moore

Murphy

SM.

Student health and well-being in secondary schools: the role of school support staff alongside teaching staff. Pastor Care Educ. 2018;36(4):297-312.

41.

Wattanawongwan

Smith

Vannest

KJ.

Cooperative learning strategies for building relationship skills in students with emotional and behavioral disorders. Beyond Behav. 2021;30(1):32-40.

42.

Konishi

Wong

TKY

. Relationships and school success: from a social-emotional learning perspective. Health Acad Achiev. Published online September 19, 2018. doi:10.5772/INTECHOPEN.75012