I An Exploratory Study on Educators' Experiences of the Mental Health Needs of High School Learners in the North West Province Boitumelo Mziwakhe 2134255 Research Report Submitted in partial fulfilment of the requirements for the Degree of Master of Arts in Social and Psychological Research in the Department of Psychology, School of Human and Community Development, Faculty of Humanities, at the University of the Witwatersrand, Johannesburg, South Africa Supervisor: Professor Zaytoon Amod I Masters of Arts in Social and Psychological Research –Research Declaration Surname: Mziwakhe First name/s: Boitumelo Student no.: 2134255 Supervisor: Professor Zaytoon Amod Title: An Exploratory Study on Educators' Experiences of the Mental Health Needs of High School Learners in the North West Province Declaration I, Boitumelo Mziwakhe, know and accept that plagiarism (i.e., to use another's work and to pretend that it is one's own) is wrong. Consequently, I declare that the research proposal is my own work.  I understand what plagiarism is, and the importance of clearly and appropriately acknowledging my sources.  I understand that questions about plagiarism can arise in any piece of work I submit, regardless of whether that work is to be formally assessed or not.  I understand that a proper paraphrase or summary of ideas/ content from a particular source should be written in my own words with my own sentence structure, and be accompanied by an appropriate reference.  I have correctly acknowledged all direct quotations and paraphrased ideas/ content by way of appropriate, APA-style in-text references.  I have provided a complete, alphabetized reference list, as required by the APA method of referencing.  I understand that anti-plagiarism software (e.g. Turnitin) is a useful resource, but that such software does not provide definitive proof that a document is free of plagiarism. II  I have not allowed, and will not allow, anyone to copy my work with the intention of passing it off as his or her own work.  I am aware of and familiar with the University of the Witwatersrand's policy on plagiarism.  I understand that the University of the Witwatersrand may take disciplinary action against me if there is a belief that this is not my own unaided work, or that I failed to acknowledge the source of the ideas or words in my writing. Signed: Date: February 2023 III Abstract An Exploratory Study on Educators' Experiences of the Mental Health Needs of High School Learners in the North West Province In many developing countries, including South Africa, adolescents’ mental health receives little attention within the larger field of mental health. This is despite the probability that developing mental health problems is significantly higher during adolescence than in any other developmental period. In line with the interpretivist paradigm approach, this study employed a qualitative research approach and adopted an exploratory and descriptive research design. The study aimed to explore and describe educators' experiences of the mental health needs of high school learners in the North West province of South Africa (North West). A semi-structured interview was used to collect data from 11 high school educators. Data in this study were analysed using thematic analysis. Understanding psychosocial development in relation to identity development in adolescent mental health and the ecological systems theories served as a theoretical framework for understanding the phenomenon under study. This study's findings indicated that factors affecting learners' mental health include disrupted family structures, child-headed households, poverty, sexual abuse, school violence, bullying, and psychoactive substances among learners. The findings also highlighted the importance of establishing school-community partnerships and the essential role the school-based support team plays in addressing the psychosocial needs of learners. Conversely, mental health stigma, social worker delays in addressing the psychosocial needs of learners, and ancestral calling were identified as barriers to learners seeking and accessing psychosocial services in schools. Based on the findings from this study, some recommendations to contribute to the mental health of high school learners include the development of age-specific and appropriate mental health policies and interventions. Further contributions would be to increase education funding to employ school nurses and social workers and establish positive school-community partnerships. Keywords: mental health, educator experiences, high school learners IV Acknowledgments First and foremost, I would love to thank Jehovah-Jireh for His mercy and grace and for granting me the wisdom to complete this research report. “I can do all things through Christ who gives me strength” (Philippians 4:13, Prayer Bible). In addition to my sincere gratitude and appreciation, I would like to acknowledge the following people: My research supervisor, Prof. Zaytoon Amod. I would like to express my gratitude and appreciation for your patience, guidance, and knowledge. Without your support and encouragement, completing my research report and accomplishing this goal would not have been possible. Prof. Andrew Thatcher, the Chair of the School of Human and Community Development. Thank you for providing me with financial assistance to complete this research report. My research psychology internship mentor, Prof. Lusilda Schutte, at the North-West University. I am immensely grateful for your support, guidance, encouragement, and well wishes, and for always asking me how far I am with completing my research report. Prof. Petra Bester, the Director of the Africa Unit for Transdisciplinary Health Research (AUTHeR) at the North-West University. I would like to express my gratitude and appreciation for your support, encouragement, and constructive criticism. My language editor, Ms. Belinda Cuthbert. I am very grateful to you for thoroughly reviewing, editing, and proofreading this research report. The research participants. This research study would not have been possible without you. I would like to express my most profound appreciation to each of you for your willingness to share your experiences with me. My mother, Mokgothu Mziwakhe. Thank you for your unwavering love, support, continuous encouragement, and absolute trust in me to complete this research report and for always asking me how far I am with completing my research report. I am eternally grateful for V everything you have done for me over the years, and you will always be a strong pillar of support to me. My dearest niece, Keotshepile Mziwakhe, for always bringing laughter and so much joy to my life. Thank you for the kisses and warm hugs when I needed them the most. My dearest friend and younger sister, Keorapetse Mziwakhe. Your love, continuous support, and encouragement have been a great blessing to me. My grandmother, Mamoikgantsi Saane; my father, Motseoatile Mziwakhe; and my aunt, Dipuo Wesi. I appreciate your love, support, and encouragement. My colleagues at AUTHeR at the North-West University, thank you for the support and encouragement and for always asking me about my research progress. VI Table of Contents Masters of Arts in Social and Psychological Research –Research Declaration .......... I Abstract ..................................................................................................................... III An Exploratory Study on Educators' Experiences of the Mental Health Needs of High School Learners in the North West Province ............................................................. III Acknowledgments ..................................................................................................... IV List of Figures ......................................................................................................... XIV List of Tables ........................................................................................................... XV List of Abbreviations ............................................................................................... XVI An Exploratory Study on Educators’ Experiences of the Mental Health Needs of High School Learners in the North West Province .............................................................. 1 Chapter One ............................................................................................................... 1 Background, Rationale, and Scope of Study .............................................................. 1 1.1 Introduction .................................................................................................................. 1 1.2 The Mental Health Context .......................................................................................... 1 1.3 Rationale and Contextualisation of this Research Study .............................................. 3 1.4 Research Questions .................................................................................................... 4 1.5 Research Aim and Objectives ...................................................................................... 4 1.6 Research Design and Method ..................................................................................... 4 1.6.1 Research Approach and Design ............................................................................ 4 1.6.2 Data Collection Process ........................................................................................ 5 1.6.3 Data Analysis ........................................................................................................ 5 1.7 Outline of the Research Report ................................................................................... 5 VII Chapter Two ............................................................................................................... 6 Literature Review ....................................................................................................... 6 2.1 Introduction .................................................................................................................. 6 2.2 Definition of Key Concepts........................................................................................... 6 2.2.1 Definition of Mental Health .................................................................................... 6 2.2.2 Definition of Mental Health Problems .................................................................... 8 2.2.3 Definition of Mental Health Needs ......................................................................... 8 2.3 Adolescence and Mental Health .................................................................................. 9 2.3.1 Understanding Adolescent Mental Health ............................................................. 9 2.3.2 Good Mental Health and Poor Mental Health of Adolescents .............................. 10 2.4 Consequences of Learner Mental Health Problems ................................................... 11 2.4.1 Psychosocial Risk Factors and Learner Mental Health ........................................ 11 2.4.2 Internalising and Externalising Problems of Learners .......................................... 12 2.4.3 Prevalent Mental Health Problems in Learners ................................................... 13 2.5 Mental Health of Learners in Schools ........................................................................ 14 2.5.1 Academic Stress and Mental Health.................................................................... 14 2.5.2 School Violence and Bullying .............................................................................. 14 2.6 Mental Health of Learners from a Global and Local Perspective ................................ 16 2.6.1 International Context ........................................................................................... 16 2.6.2 The African Context ............................................................................................ 18 2.6.3 South African Context ......................................................................................... 18 2.7 Child and Adolescent Mental Health Policy ................................................................ 19 2.8 The Promotion of the Mental Health of Learners ........................................................ 20 VIII 2.8.1 The Role of the School in Learner Mental Health Promotion ............................... 20 2.8.2 Understanding Educators’ Role in Learner Mental Health Promotion .................. 20 2.9 Psychosocial Services in Schools .............................................................................. 22 2.9.1 Definition of Psychosocial Services ..................................................................... 22 2.9.2 Psychosocial Services Available in Schools ........................................................ 22 2.9.3 The Value of Psychosocial Services in Schools .................................................. 23 2.9.4 The Importance of Inclusive Education and School-based Support Teams ......... 24 2.10 Barriers to Seeking and Accessing Psychosocial Services in Schools ..................... 25 2.10.1 Barriers Associated with Seeking Psychosocial Services .................................. 25 2.10.1.1 Stigma. ....................................................................................................... 25 2.10.1.2 Cultural Perceptions. .................................................................................. 26 2.10.1.3 Family Perceptions. .................................................................................... 27 2.10.1.4 Poor Mental Health Literacy. ....................................................................... 27 2.10.1.5 Confidentiality. ............................................................................................ 28 2.10.1.6 Mental Health Treatment. ........................................................................... 28 2.10.2 Barriers Associated with Accessing Psychosocial Services ............................... 28 2.10.3 Addressing Psychosocial Services Barriers ....................................................... 29 2.11 Theoretical Framework ............................................................................................ 30 2.11.1 The Psychosocial Development Theory: Understanding Identity Development in Adolescent Mental Health ............................................................................................ 30 2.11.2 The Ecological Systems Theory ........................................................................ 34 2.12 Conclusion ............................................................................................................... 38 Chapter Three .......................................................................................................... 39 IX Methods ................................................................................................................... 39 3.1 Introduction ................................................................................................................ 39 3.2 Research Design and Research Methodology ........................................................... 39 3.3 Research Paradigm ................................................................................................... 40 3.4 Quality Criteria for Validating Research within the Interpretivist Paradigm ................. 42 3.5 Study Context ............................................................................................................ 44 3.6 Sample ...................................................................................................................... 46 3.7 Sampling Techniques ................................................................................................ 49 3.8 Data Collection Method ............................................................................................. 50 3.9 The Role of the Researcher and Reflexivity ............................................................... 50 3.10 Data Collection Procedures ..................................................................................... 51 3.11 Data Analysis Procedures........................................................................................ 52 3.12 Ethical Considerations ............................................................................................. 53 3.12.1 Ethical Clearance .............................................................................................. 53 3.12.2 Voluntary Participation and the Right to Withdraw ............................................. 53 3.12.3 Protection of Research Participants’ Privacy and Confidentiality ....................... 54 3.12.4 Obtaining Informed Consent of Participants ...................................................... 54 3.12.5 Potential Study Risks and Benefits for Participants ........................................... 55 3.13 Data Management ................................................................................................... 56 3.14 Dissemination of Research Results ......................................................................... 56 3.15 Conclusion ............................................................................................................... 56 Chapter Four ............................................................................................................ 57 Presentation of Findings ........................................................................................... 57 X 4.1 Introduction ................................................................................................................ 57 4.2 Findings of the Study ................................................................................................. 57 4.2.1 Factors that Affect the Mental Health of Learners................................................ 59 4.2.1.1 Disrupted Family Structure. .......................................................................... 59 4.2.1.2 Child-headed Households............................................................................. 60 4.2.1.3 Poverty. ........................................................................................................ 61 4.2.1.4 Sexual Abuse. .............................................................................................. 62 4.2.1.5 School Violence. ........................................................................................... 62 4.2.1.6 Bullying. ........................................................................................................ 63 4.2.1.7 Psychoactive Substances among Learners. ................................................. 63 4.2.1.7.1 The Use of Psychoactive Substances. ................................................... 64 4.2.1.7.2 Psychoactive Substance Abuse and Dependency .................................. 65 4.2.1.7.3 The Selling of Psychoactive Substances at School. ............................... 65 4.2.2 Learners’ Needs for a Support System in Schools .............................................. 66 4.2.2.1 School-Community Partnerships................................................................... 66 4.2.2.1.1 School Nurses. ....................................................................................... 67 4.2.2.1.2 School Police Officers (Adopt-a-Cop) ..................................................... 67 4.2.3 Available Psychosocial Services in Schools ........................................................ 68 4.2.3.1 School-based Support Team (SBST). ........................................................... 68 4.2.4 Barriers to Seeking and Accessing Psychosocial Services in Schools ................ 69 4.2.4.1 Mental Health Stigma. .................................................................................. 69 4.2.4.2 Social Worker Delays in Addressing Psychosocial Needs of Learners.......... 71 4.2.4.3 Unique Barrier: Ancestral Calling. ................................................................. 72 XI 4.3 Conclusion ................................................................................................................. 72 Chapter Five ............................................................................................................. 73 Discussion of Findings ............................................................................................. 73 5.1 Introduction ................................................................................................................ 73 5.2 Factors that Affect the Mental Health of Learners ...................................................... 73 5.2.1 Disrupted Family Structure .................................................................................. 73 5.2.2 Child-headed Households ................................................................................... 74 5.2.3 Poverty ................................................................................................................ 74 5.2.4 Sexual Abuse ...................................................................................................... 76 5.2.5 School Violence .................................................................................................. 76 5.2.6 Bullying ............................................................................................................... 77 5.2.7 Psychoactive Substances among Learners ......................................................... 78 5.2.7.1 The Use of Psychoactive Substances. .......................................................... 78 5.2.7.2 Psychoactive Substance Abuse and Dependency. ....................................... 79 5.2.7.3 The Selling of Psychoactive Substances at School. ...................................... 79 5.3. Learners' Needs for a Support System in School ...................................................... 80 5.3.1 School-Community Partnerships ......................................................................... 80 5.3.1.1 School Nurses. ............................................................................................. 80 5.3.1.2 School Police Officers (Adopt-a-Cop). .......................................................... 81 5.4 Available Psychosocial Services in Schools .............................................................. 82 5.4.1 School-based Support Team (SBST) .................................................................. 82 5.5 Barriers to Seeking or Accessing Psychosocial Services in Schools .......................... 82 5.5.1 Mental Health Stigma .......................................................................................... 82 XII 5.5.2 Social Worker Delays in Addressing Psychosocial Needs of Learners ................ 83 5.5.3 Unique Barrier: Ancestral Calling ........................................................................ 84 5.6 Review of Findings from Multiple Theoretical Perspectives........................................ 84 5.6.1 The Psychosocial Development Theory: Understanding Identity Development in Adolescent Mental Health ............................................................................................ 85 5.6.2 The Ecological Systems Theory .......................................................................... 86 5.6.2.1 Microsystem. ................................................................................................ 86 5.6.2.2 Mesosystem. ................................................................................................ 87 5.6.2.3 Exosystem. ................................................................................................... 87 5.6.2.4 Macrosystem. ............................................................................................... 87 5.6.2.5 Chronosystem. ............................................................................................. 88 5.7 Conclusion ................................................................................................................. 88 Chapter Six .............................................................................................................. 89 Conclusion, Significance of the Study, and Recommendations ............................... 89 6.1 Introduction ................................................................................................................ 89 6.2 Overview and Conclusion of the Study ...................................................................... 89 6.3 Significance and Possible Contributions of the Study ................................................ 89 6.4 Recommendations ..................................................................................................... 91 6.5 Public Health Implications .......................................................................................... 93 6.6 Limitations of the Study ............................................................................................. 93 6.7 Suggestions for Future Research .............................................................................. 93 References ............................................................................................................... 95 Appendices ............................................................................................................ 128 XIII Appendix A ............................................................................................................. 128 Participation Information Sheet ...................................................................................... 128 Appendix B ............................................................................................................. 132 Participant Consent Form (Telephone interview) ........................................................... 132 Appendix C: ............................................................................................................ 134 Semi-Structured Interview Schedule .............................................................................. 134 Appendix D ............................................................................................................. 136 Ethical Clearance Certificate ......................................................................................... 136 Appendix E ............................................................................................................. 137 Turnitin Report ............................................................................................................... 137 Appendix F ............................................................................................................. 138 Language Editing Declaration ........................................................................................ 138 XIV List of Figures Figure 1 Erikson's Eight Stages of Psychosocial Development .......................................... 34 Figure 2 Bronfenbrenner's Ecological Systems Model ........................................................ 37 Figure 3 A Map of South Africa indicating the Location of Provinces and the Location of the Districts and Local Municipalities within North West ............................................................ 45 Figure 4 A Diagrammatic Representation of Themes and Sub-themes .............................. 58 XV List of Tables Table 1 Background Details of the Sample ......................................................................... 48 XVI List of Abbreviations Abbreviations Definitions CMHA Canadian Mental Health Association DBE DoE Department of Basic Education Department of Education DoH Department of Health GAD HPCSA Generalised Anxiety Disorder Health Professions Council of South Africa HOD LMICs Head of Department Low-Middle-Income Countries PTSD SAD Post-Traumatic Stress Disorder Social Anxiety Disorder SADAG South African Depression and Anxiety Group SAFMH South African Federation for Mental Health SAPS South African Police Service SBST School-Based Support Team Stats SA TA UN WHO Statistics South Africa Thematic Analysis United Nations World Health Organization 1 An Exploratory Study on Educators’ Experiences of the Mental Health Needs of High School Learners in the North West Province Chapter One Background, Rationale, and Scope of Study 1.1 Introduction The focus of this research study is on educators’ experiences of the mental health needs of high school learners in North West. According to the South African Schools Act 84 of 1996, a learner is any individual obtaining or required to acquire an education. Chapter 1 is used to describe the main ideas and consider the study’s relevance and potential contributions. The chapter also provides an overview of the research study, followed by the clearly defined research questions and research aim and objectives. The research approach, research design, research paradigm, data collection process, and data analysis used in the study are then discussed to provide a broad outline of the study. Finally, an outline of this research report is provided at the end of this chapter. 1.2 The Mental Health Context Global mental health is a grave concern (Ganasen et al., 2008; World Health Organization [WHO], 2003a). The United Nations (United Nations [UN], 2014) expressively maintains that in both underdeveloped and developing countries, mental health is not highly prioritised; thus, significantly fewer resources are dedicated to mental than to physical health. From this perspective, in many developing countries, including South Africa, adolescents' mental health receives little attention within the broader mental health field (Kleintjies et al., 2010; Muribwathoho, 2015; Plüddemann et al., 2014). It is worth noting that “there is no health without mental health” (Schneider et al., 2016, p. 153); therefore, the mental health of individuals forms an essential foundation for their physical, emotional, and social well-being (Meyer et al., 2019; Mfidi, 2017). To emphasise, approximately half of all mental health and substance-related problems begin by the age of 14 (Meyer et al., 2019; Paruk & Karim, 2016) or during high 2 school (Mazzer & Rickwood, 2015). Approximately three-quarters of mental health problems develop by the age of 18, which results in a substantial global socioeconomic burden (Radez et al., 2019). Approximately 20% of children and adolescents experience mental health concerns (Meyer et al., 2019; Mfidi, 2017; Reinke et al., 2011) and the prevalence of mental health concerns in children younger than 18 years increases to 25% in children from less than optimum environments (Reinke et al., 2011). Therefore, the adolescent years are crucial for identifying and addressing mental health problems and promoting mental well- being (Mazzer & Rickwood, 2015). Adolescence is, therefore, considered the most crucial psychosocial developmental stage because it is here that adolescents develop their identity, which forms a foundation for their future mental health (Lök et al., 2017). Considering this, the likelihood of developing mental health disorders during adolescence is much higher than in any other developmental period (Lök et al., 2017; Velasco et al., 2020). Given these circumstances, over the past 5 years, the Department of Health (DoH) has been collaborating with the Department of Basic Education (DBE) to develop an integrated school health policy for South African schools (Mfidi, 2017). However, learners continue to experience mental health challenges despite the developed framework that promotes learner health (Mfidi, 2017). In summary, the main points of this introductory chapter are: 1. Mental health is not given the same priority as physical health in developing and underdeveloped countries. 2. Within the larger field of mental health, adolescent mental health receives little attention in many developing nations, including South Africa. 3. The probability of developing mental health problems throughout adolescence is significantly higher than during any other developmental stage. 4. Half of mental health and substance-related problems have their onset around 14 years, and 75% of mental health problems begin before the age of 18, indicating that the first onset of mental health problems often occurs during high school years. 3 5. South African learners continue to face mental health issues despite the existence of an integrated school health framework. Given the grave concern for learners’ mental health, exploring and describing the mental health needs of learners will enable the understanding of the mental health needs of high school learners. Using this understanding, the researcher can make recommendations to be considered for promoting the mental health of high school learners within the South African context. 1.3 Rationale and Contextualisation of this Research Study There is a threefold rationale for this study. First, there is a significant gap in the global literature on school-based mental health practices and interventions (Reinke et al., 2011). Second, in most parts of Africa, there is a great paucity of information regarding the mental health of children and adolescents (Bella et al., 2011; Mokitimi et al., 2019). Similarly, as Reinke et al. (2011) maintained, there are few small-scale surveys on the perceptions of educators on the mental health needs of learners or their readiness and role in supporting learners with mental health needs. Last, Mokitimi et al. (2019) affirmed that child and adolescent mental health continues to be neglected at a policy level despite the burden of child and adolescent mental health disorders. Furthermore, Mokitimi et al. (2019) articulated that no provincial child and adolescent mental health policies or implementation plans in South Africa support the national Child and Adolescent Mental Health Policy. HIV/AIDS, tuberculosis, maternal health, and child mortality were the primary focus of the provincial health policies, while the provincial health policy made almost no mention of child and adolescent mental health services (Mokitimi et al., 2019). This study addresses the gap in research by exploring and describing the experiences of a sample of educators regarding their learners' mental health needs. The findings of this study provide information about contextual mental health needs, possible interventions to prevent and address mental health problems, and ways to promote mental health in schools. The study findings emphasise the urgent need to develop and implement mental health policies for children and adolescents, thus underlining the significant need to 4 develop specialised promotive, preventive, curative, and rehabilitative mental health interventions for learners. Furthermore, understanding the crucial role that schools play in learner mental health, the research findings have implications for the pre-service and in- service preparation of educators to address the mental health needs of learners. 1.4 Research Questions Considering the above context, the primary research question to better understand the mental health needs of high school learners is: ‘What are the educators’ experiences of the mental health needs of high school learners in the North West province of South Africa (North West)?’ The sub-questions drawn from the primary research question are: 1. What are the factors that might affect learners’ mental health? 2. What are learners’ needs for support services? 3. What psychosocial services are available in schools? 4. What are the barriers to seeking and accessing psychosocial services in schools? 1.5 Research Aim and Objectives This aim of the study was to explore and describe educators’ experiences of the mental health needs of high school learners in North West. The research objectives of this study were to explore and describe the following: 1. Factors that might affect learners’ mental health. 2. Learners’ needs for support services. 3. The availability of psychosocial services in schools. 4. Barriers to seeking and accessing psychosocial services in schools. 1.6 Research Design and Method 1.6.1 Research Approach and Design This study employed a qualitative research approach involving an exploratory and descriptive research design. In addition, an interpretivist paradigm was used to investigate and comprehend educators' experiences of high school learners' mental health needs. 5 1.6.2 Data Collection Process The data in the study were collected using individual, telephonic semi-structured interviews. Interviews were recorded with permission of the participants. 1.6.3 Data Analysis Thematic analysis (TA) was used to analyse the data. First, interviews were transcribed, then the open-coding strategy was used to identify initial codes, working back and forth to produce a comprehensive set of themes from the different codes. 1.7 Outline of the Research Report Chapter 1 is an introduction to the study and its context, as well as the study rationale, aim, and research questions. The background literature relating to the study is presented in Chapter 2. Chapter 2 highlights some of the critical issues related to adolescent mental health, the role of educators in mental health promotion in schools, and the findings of previous research studies. Chapter 3 outlines the methods used to conduct the current research study. This chapter discusses the research approach, design used, and the applied research paradigm. Details are also provided about the study participants, data collection procedures, and ethical considerations taken while conducting the study. In Chapter 4, the results chapter, the data from the participants’ interview transcripts are analysed. Chapter 5 contains a discussion of the results of the findings presented in Chapter 4. This discussion chapter integrates the results of the current study with previous research findings. Chapter 6 is the concluding chapter of the research report. It includes a summary of the research findings and considers the study’s significance and implications. The limitations of the study are also considered, and recommendations are made for future research. 6 Chapter Two Literature Review 2.1 Introduction The purpose of Chapter 2 is to review the literature on the mental health of high school learners and their mental health needs. This chapter provides a general overview of the definition of key concepts of mental health. The chapter also contains a discussion on the mental health of learners in schools, the mental health of learners from a global and local perspective, and child and adolescent mental health policy. Psychosocial services in schools and barriers to seeking and accessing psychosocial services in schools are also described. Finally, this chapter concludes with a discussion of the theoretical framework underpinning the study. 2.2 Definition of Key Concepts 2.2.1 Definition of Mental Health Mental health can be supported and promoted in every individual, whether they have mental health problems or not (Kutcher & Wei, 2018). Mental health is vital for an individual’s overall health and their capability to succeed in their community, academic, and work settings (Swapnajaidupally, 2015). With this in mind, Mazzer and Rickwood (2015) expressly articulated that the concept of mental health has taken on incomplete meanings. For instance, the term mental health has been used to indicate both the presence or absence of mental illness. This is why mental health is often associated with mental health problems, with the emphasis placed on mental health problems instead of mental wholeness (Engelhardt, 2016). An integrated approach to mental health must consider human interactions and the humans’ ability to interact with their surroundings in ways that promote their overall health (Mazzer & Rickwood, 2015) In other words, the concept of mental health incorporates the whole context of mental health rather than only mental health illness (Engelhardt, 2016). 7 Engelhardt (2016) further added that mental health integrates positive and negative associations that contribute to an individual’s interaction with life’s challenges. To exacerbate the problem of an unclear meaning, the term mental health has multiple definitions. Multiple definitions make it challenging to provide an accurate meaning (Kutcher & Wei, 2018) as the term is socially constructed and socially defined based on the assumptions and values of societies (Engelhardt, 2016). In other words, different societal groups may have different assumptions about mental health, depending on their values. Fortunately, the literature cites plentiful studies focused on the positive aspects. Different definitions of mental health attempt to capture what mental health means by applying emotional, cognitive, and behavioural capacities to deal successfully with negative and positive life challenges (Kutcher & Wei, 2018). WHO defines mental health as a “state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (WHO, 2001, p. 1). Simply stated, mental health can be defined as a sense of well-being that enables individuals to recognise their own strengths, be resilient, productive, and successful, and positively contribute to their society. Additionally, WHO (2003a) maintained that concepts of mental health include welfare, self-belief, independence, interdependence, competency, and the ability to recognise one’s own intelligence and emotional intelligence. Furthermore, mental health is about promoting the accomplishment of personal and communal goals (WHO, 2003a). In a like manner, Galderisi et al. (2015) asserted that mental health is a state of balance, enabling individuals to have emotional and social intelligence, be resilient, and possess the ability to promote and maintain the interrelationship between one’s physical health and state of mind. In light of this, the comprehensive context of what mental health entails, definitions provided by WHO (2001, 2003a), and Galderisi et al. (2015) distinctly describe the term mental health and focus for the whole context of mental health. Notably, according to the DoH (n.d.), the mental health of children and adolescents refers to the ability to develop and maintain an optimal level of psychological functioning and 8 well-being. Within this view, the mental health of children and adolescents incorporates their sense of identity and self-worth, healthy relationships with family and peers, capacity to be productive, and capacity to optimally develop through cultural resources. More concisely, as stated in the above reference, adolescents’ mental health can be defined as their ability to obtain and sustain positive psychological and optimal human functioning. The preceding author maintained that the mental health of children and adolescents is defined by a sense of positive worth experienced through caring family relationships and friendships, demonstrating competence at school, and the ability to cope with daily challenges. Another critical point is that developing an individual’s emotional, social, physical, intellectual, and moral capabilities is essential to mental health promotion. 2.2.2 Definition of Mental Health Problems Several terms such as mental illness, mental health issues (Mind, 2017), mental disorders, and mental distress (Granrud, 2019) are used to define mental health problems. Mental health problems are common human experiences and can include conditions such as depression, anxiety (Mind, 2017), generalised anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder, and post-traumatic stress disorder (PTSD) (Mental Health Foundation, 2015, 2016). Mental illness is a health condition that significantly affects individuals' emotions, thought processes, perception, behaviour, daily functioning (American Psychiatric Association, 2022; Loreto, 2017), and empathy (Zartaloudi & Madianos, 2010). Loreto (2017) stated that mental health problems also interfere with an individual’s emotions, thoughts, and behaviour, but to a lesser degree than a mental illness. According to the Substance Abuse and Mental Health Services Administration (2016), mental illness is diagnosed using a standardised criterion. 2.2.3 Definition of Mental Health Needs Sartorius (2015) stated that, although vague, the term mental health needs is usually used when there is a need to develop mental health services or programmes for individuals 9 experiencing mental health problems. This author also stated that mental health needs could describe individuals' and communities' need for interventions for mental health conditions (Sartorius, 2015). With this knowledge in mind, in this research report, mental health problems refer to common human experiences that include a range of self-reported mental health symptoms described in the literature. These symptoms include anxiety, depression, social withdrawal, anti-social behaviour, self-harming behaviour, and PTSD. 2.3 Adolescence and Mental Health 2.3.1 Understanding Adolescent Mental Health Mental health problems can be experienced by anyone (Shung-King et al., 2019). According to the Mental Health Foundation (2016), mental health problems increase during middle and late adolescence. The onset of approximately 50% of mental health problems occur around age 14 (Chaulagain et al., 2019; DoH, 2013; Hosseinkhani et al., 2020; Sawyer & Patton, 2018; Velasco et al., 2020), and around 75% of cases begin before age 18 (Velasco et al., 2020). Adolescence is a developmental period between childhood and adulthood (Janicijevic et al., 2017; Hosseinkhani et al., 2020; Louw & Louw, 2014; National Academies of Sciences, Engineering, and Medicine, 2019; Weiten, 2013), which begins with the onset of puberty (Banati & Lansford, 2018; Louw & Louw, 2014; Sawyer & Patton, 2018; Sigelman & Rider, 2018). In line with Louw & Louw (2014), who maintained that depending on individual differences, and biological and sociocultural influences, adolescence can begin at any age between 11 and 13 years and end at any age between 17 and 21, the adolescent population, encompasses individuals aged 10-19 years (STATS SA, 2022, 2018d) or even up to 10-24 years (Sawyer et al., 2018). Additionally, according to Babicka-Wirkus et al. (2023), early adolescence encompasses the ages between 12 and 14. In like manner, Sokol (2009) maintained that adolescence begins roughly during middle and high school between ages 12 through 18. 10 The stage of adolescence is accompanied by profound biological, cognitive, emotional, and psychosocial development (Bornstein & Putnick, 2018; Janicijevic et al., 2017; Shung-King et al., 2019), hormonal changes, and moral and sexual development (WHO, 2017). These changes place adolescents at greater risk of developing mental health problems as they transition from childhood to adulthood (Chukwuere et al., 2021, 2022; UN, 2014). While this life stage is an exciting period of identity exploration, establishing self- identity, striving for autonomy, and exploring romantic relationships (Shung-King et al., 2019), it is also a period of emotional turmoil (Babicka-Wirkus et al., 2023; Lee et al., 2018; Demir et al., 2010; Fukuda et al., 2016) and significantly increased risk of developing mental health problems (Demir et al., 2010; Fukuda et al., 2016). The UN (2014) affirmed that mental health problems adversely affect adolescents’ development, socioeconomic integration, quality of life, and relationships with parents, peers, romantic partners and educators. Additionally, adolescents who experience mental health problems may be at a greater risk of poverty due to stigma, social exclusion, and fewer academic opportunities. 2.3.2 Good Mental Health and Poor Mental Health of Adolescents Kutcher and Wei (2017) articulated that stress, and negative emotions, thoughts, and behaviours are part of good mental health, and that a sign of good mental health is using coping strategies to deal with stressful life events, build resilience, and successfully overcome challenges. Good mental health enables individuals to have thoughts, emotions, and behaviours that help them cope with daily stress (Mind, 2017). Conversely, poor mental health may result in individuals experiencing difficulties in dealing with the everyday stresses of life (Mind, 2017). In the same light, when learners are ill-equipped to deal with stress, their flight-or-fight response might be triggered because the learner perceives normative stress as a danger, which can develop into mental health problems associated with anxiety (Engelhardt, 2016). The UN (2014) stated that stress and trauma have been associated with disrupted social interactions, decreased overall productivity, poor academic performance, and the onset of mental health problems such as 11 anxiety, depression, and PTSD. The authors of the UN report stated that approximately 50% of episodes of depression are due to a stressful life event. Notably, chronic social stress during adolescence can lead to episodes of anxiety and subsequent depression by age 20 (Loreto, 2017). 2.4 Consequences of Learner Mental Health Problems 2.4.1 Psychosocial Risk Factors and Learner Mental Health It is important to understand what factors may affect the mental health of learners in order to effectively address mental health needs and promote learners’ mental health. Inequality and lack of access to resources and services can intensify mental health problems (Shung-King et al., 2019). Mental health problems are associated with a vicious cycle of poverty (UN, 2014). Poverty can significantly impact learners' educational outcomes, as it can determine their school attendance, classroom participation, and ability to concentrate in classroom settings (South African Human Rights Commission [SAHRC], 2006). Equally important, adverse life events such as the termination of a romantic relationship have been associated with severe depression (UN, 2014). Nguyen et al. (2013) argued that, concerning their love life, adolescents have anxiety about their romantic relationships and parents prohibiting them from being romantically involved. Nguyen et al. (2013) affirmed that learners attracted to individuals of the same gender may develop poor mental health and attempt suicide because they are stigmatised and discriminated against. This could be partially attributed to the fact that same-gender attraction is a concept that is not clear to everyone, even though patterns and practices have evolved over the years (Nguyen et al., 2013). The development of mental health problems have been associated with unsafe sexual behaviour and communicable diseases (UN, 2014). In like manner, adolescent mental health problems are worsened by psychosocial factors such as HIV and AIDS (Mokitimi et al., 2018; SAHRC, 2019). Furthermore, Paruk and Karim (2016) articulated that 12 mental health problems in adolescents are associated with pregnancy and the potential of developing psychopathology later in adulthood. For this reason, adolescents may experience challenges transitioning from adolescence to adulthood (Bella et al., 2011; Mazzer & Rickwood, 2015; Swick & Powers, 2018). Substance use has profound negative implications on mental health (Mind, 2017; UN, 2014). In addition, drug and alcohol abuse is also linked to adolescent delinquency (DoH, 2003). Low resistance to peer pressure has been associated with drug and alcohol use and the development of mental illnesses during adolescence (Loreto, 2017). In some instances, adolescents may become dependent on alcohol as a coping mechanism for their mental health problems (DoH, 2003). 2.4.2 Internalising and Externalising Problems of Learners During their lifetime, approximately 20% of children and adolescents will have mental health concerns (Kleintjies et al., 2010; Lök et al., 2017; Meyer et al., 2019; Mfidi, 2017; Reinke et al., 2011; Schulte-Körne, 2016) in the form of interpersonal and emotional maladjustments (Mfidi, 2017). Furthermore, learners with emotional and interpersonal challenges usually display internalising or externalising problems (Marsh, 2016; Mfidi, 2017), Internalising problems include worrying (Bertills, 2010; Olivier et al., 2020) and feeling anxious and depressed (Babicka-Wirkus et al., 2023; Marsh, 2016; Mfidi, 2017; Nikstat & Riemann, 2020; Olivier et al., 2020), and being socially withdrawn (Babicka-Wirkus et al., 2023; Marsh, 2016; Mfidi, 2017). Internalising symptoms worsen with age (Pedersen et al., 2019). Externalising problems are characterised by impulsivity (Nikstat & Riemann, 2020), hostility, irritability, disobedience, violence (Marsh, 2016; Mfidi, 2017), and antisocial behaviour (Bertills, 2010). Marsh (2016) maintained that learners' mental health problems are characterised by difficulties in managing their thoughts, emotions, or behaviours. 13 2.4.3 Prevalent Mental Health Problems in Learners Engelhardt (2016), Nebhinani and Jain (2019), and Parodi et al. (2021) articulated that anxiety disorders are common in adolescents. This is why educators are more aware of the mental health problems such as anxiety experienced by their learners. Similarly, depression and psychological distress are the most common diagnoses in adolescents (Tomlinson et al., 2022; Velasco et al., 2020). Moreover, Fukuda et al. (2016) articulated that adolescents are more likely to develop mental health problems such as conduct disorders, violent behaviour, and eating disorders. Thus, learners who experience mental health problems may exhibit noticeable difficulties at school and in everyday functioning (Kutcher & Wei, 2017). Consequently, learners with a greater risk of developing mental health problems and committing suicide are at risk of poor academic performance (Nadeem et al., 2011). Suicide is one consequence of unfulfilled mental health needs of learners (Cooper & Hornby, 2018) and remains the top cause of death among adolescents (Bilsen, 2018; Cooper & Hornby, 2018). Another critical point is that mental health problems might result from untreated social, emotional, and behavioural problems (Mfidi, 2017). Untreated mental health problems may become severe and treatment-resistant, resulting in secondary psychiatric disorders (Loreto, 2017). Furthermore, untreated mental health problems in adolescents may make them more vulnerable to poor sexual and reproductive health, inadequate self-care, and unemployment (Fukuda et al., 2016). Additionally, Radez et al. (2019) stated that untreated mental health problems are associated with adverse health, academic and societal outcomes, and high levels of substance abuse, self-harm, and suicidal behaviour. Independent living and social integration are, therefore, negatively affected by the inability to transition to work due mainly to untreated mental health problems during adolescence. 14 2.5 Mental Health of Learners in Schools 2.5.1 Academic Stress and Mental Health Learners experience various stressors, such as academic stress and parents' increasing expectations to achieve exceptional academic performance. These stressors can be linked to the onset of mental health problems (Hosseinkhani et al., 2019; Subramani & Kadhiravan, 2017). Both Hosseinkhani et al. (2019) and Subramani and Kadhiravan (2017) have identified academic stress and parents' increased expectations for outstanding academic performance as stressors that burdening learners, resulting in mental health problems. With this in mind, mental health problems may hinder individuals' emotional, educational, and social success. Previous research indicates that learners with mental health problems are susceptible to having poor academic performance (Agnafors et al., 2020; Mfidi, 2017; Simelane et al., 2022), poor quality of life (Mfidi, 2017), and dropping out of school (Bella et al., 2011; Mazzer & Rickwood, 2015; Simelane et al., 2022; Swick & Powers, 2018). In contrast, academic excellence results in the positive mental health of learners (Subramani & Kadhiravan, 2017). Additionally, learners with good mental health are generally resilient, perform better academically, and have healthy relationships (Shah & Beinecke, 2009). 2.5.2 School Violence and Bullying According to the SAHRC (2006), school-based violence primarily manifests in bullying, which encompasses repetitive physical and non-physical behaviours. School-based violence may have far-reaching consequences such as increased school absenteeism, poor academic performance and achievement, increased school dropout, and increased suicide among learners. In addition, higher levels of anger and depression among learners exacerbate the risk of self-harming behaviour and perpetrating violence against others (Flannery et al., 2004). Flannery et al. (2004) argued that even though schools are relatively safe, witnessing or experiencing violence at school is associated with emotional and behavioural problems. 15 This violence can range from bullying and threats to homicide. These authors also stated that school violence is related to mental health problems, such as anxiety, dissociation, depression, PTSD, and self-destructive and aggressive behaviour. Similarly, the impact of school violence on victimised learners includes psychological trauma and various symptoms, such as poor self-esteem, feelings of loneliness, and humiliation. These symptoms might result in mental health problems in later life (SAHRC, 2006). Additionally, exposure to violence at school might result in bystanders avoiding responsibility and the victim experiencing irremediable harm, especially if the aggressive or violent behaviour persists over extended periods (Flannery et al., 2004). To illustrate, bullying refers to repeated physical, verbal, or psychological aggression, characterised by a power imbalance to cause harm, threats of ongoing aggression, and an instilled sense of terror in the victims (SAHRC, 2006). The preceding authors described the difference between physical and non-physical bullying. Physical forms of bullying are “pushing, hitting, kicking, biting, spitting, intentional damage to property, theft, and extortion.” Non-physical bullying involves “teasing, name-calling, whispering campaigns, exclusion, and threats of harm” (SAHRC, 2006, p. 6). Although bullying in the form of aggression and victimisation appears to decline in high school, it can have pervasive and long-lasting effects on learners' social and emotional functioning (UN, 2014). Notably, most bullying incidents tend to occur in the absence of educators or in unsupervised areas of the school, such as school restrooms and play fields (SAHRC, 2006). Over of the past years, just as the use of technology has evolved, so have bullying methods. This means that bullying does not only occur at school, but cyberbullying can happen in the learners’ safe space, 24 hours a day (Mental Health Foundation, 2016), increasing the risk of mental health issues such as depression and anxiety (National Academies of Sciences, Engineering, and Medicine, 2019). Bullying can have detrimental effects on adolescents’ mental health, making them prone to developing anxiety, depression (Fazel et al., 2014; Obregón-Cuesta et al., 2022; Owusu et al., 2022) , self- 16 harming behaviour (Fazel et al., 2014), and depression during adulthood (Mental Health Foundation, 2016; Owusu et al., 2022). Earlier research studies have shown that bullied learners have poor academic performance and are prone to increased insomnia (AlBuhairan et al., 2017; Obregón-Cuesta et al., 2022), hopelessness, loneliness, low self-esteem, depression, suicide ideation, and suicide attempts (AlBuhairan et al., 2017). Furthermore, research has suggested that learners exposed to violence at school can suffer psychological or academic harm, have feelings of powerlessness because they cannot help the victims, or become hyper-vigilant of their environment and the people around them (Flannery et al., 2004). Victims and witnesses of violence experience devastating impacts on their mental health (Mosome et al., 2011). The UN (2014) affirmed that, in most instances, more emphasis is given to victims of bullying, whereas perpetrators of bullying and violent events might also suffer from mental health problems. These authors further illustrated that victims of bullying are 12 times more likely than non-bullied adolescents to be gang members and more than 13 times more likely to have carried a weapon. In the case of victims, adverse effects of bullying might persist into adulthood in various forms, such as intimate partner violence, borderline personality disorder, antisocial personality, emotional disorders, and suicide ideation (AlBuhairan et al., 2017). 2.6 Mental Health of Learners from a Global and Local Perspective 2.6.1 International Context A study conducted in Vietnam revealed that psychopathology and life stress contribute to the suicidal behaviours of adolescents in rural areas (Nguyen et al., 2013). Additional studies undertaken in Vietnam reported that in a year, 10% of learners had suicidal ideation (Nguyen et al., 2013). The preceding researchers affirmed that reports of suicidal ideation were more prevalent in female learners than male learners, and the prevailing rates of suicidal behaviour increased with age. 17 A study undertaken in China showed that 10% to 30% of adolescents in China have mental disorders (Zhang et al., 2011). Mental health problems were more prevalent in learners from disadvantaged backgrounds than learners from advantaged backgrounds (Zhang et al., 2011). However, the same authors highlighted that the prevalence of behavioural, emotional, and somatoform disorders among learners from less advantaged and advantaged backgrounds were similar. Other findings were documented in a study in India, showing that approximately 70% of adolescents suffered from mental health problems, and 50% of these learners did not complete high school (Venkataraman et al., 2019). A different Indian study on promoting the mental health of children and adolescents revealed that approximately 50 million Indian children and approximately 9.8 million Indian adolescents suffered from severe mental illnesses (Hossain & Purohit, 2019). Several studies reported that the prevalence rates of children and adolescents developing mental disorders fluctuated from 1.06% to 5.84% in rural areas and 0.8% to 29.4% in urban areas (Hossain & Purohit, 2019). These findings indicate that the prevalence of mental health problems among children and adolescents in urban areas is much higher than in rural areas. An American study revealed that suicide is the third leading cause of adolescent death (Nadeem et al., 2011). The Youth Risk Behaviour Survey (YRBS) conducted in 2007 indicated that in the 12 months before the survey was conducted, 15% of learners considered attempting suicide, and 7% of learners attempted suicide one or more times (Nadeem et al., 2011). Furthermore, these researchers found that 11% of learners planned to attempt suicide. A study undertaken in Canada revealed that approximately 1 in 5 young people have mental health disorders, and only 20% of those who require mental health care receive it (Wei et al., 2011). These researchers concluded that the poor mental health of Canadian learners results in poor educational achievement, dropping out of school, substance abuse, emotional and behavioural problems, increased mortality rates, and suicidal behaviour. 18 2.6.2 The African Context There is insufficient information on the mental health of children and adolescents in most parts of Africa (Bella et al., 2011). Bella et al. (2011) reported that a few studies have revealed that between 15% and 20% of children and adolescents have mental health disorders. These figures are similar to the established prevalence rates in other regions of the world. The authors stated that the range of mental health disorders described in a small scale of African studies includes anxiety disorders, depression, and conduct disorders. 2.6.3 South African Context Similarly, there is a paucity of literature on the prevalence of mental health concerns among South African adolescents (Mokitimi et al., 2019). Plüddemann et al. (2014) argued that the small number of studies conducted in South Africa tends to be characterised by limitations relating to sampling representativeness and accuracy of results as there are few valid psychological measuring assessments. Their study revealed that 14.9% of learners had a significantly increased risk of developing mental health illnesses. These findings were consistent with the research conducted by Cortina et al. (2012), which showed that 14.3% of children in Africa experience psychological challenges and mental health problems. Plüddemann et al.’s (2014) research also indicated that adolescent girls often develop internalising mental disorders and that adolescent boys are significantly at risk for developing externalising mental disorders. Their study also showed that adolescent girls have a greater risk of developing mental health disorders than adolescent boys. Consequently, the increased probability of female learners developing mental health problems (Schulte-Körne, 2016) might result in them being more frequently absent from school than male learners (Swick & Powers, 2018). According to Muribwathoho (2015), in another South African study conducted by the DoH and DBE in 2012, approximately 17% of children and adolescents between 6 and 16 years had poor mental health, with increased rates of various mental health disorders. The author mentioned above affirmed that, based on the 2014 results by the South African 19 Depression and Anxiety Group (SADAG), the leading cause of death among adolescents is suicide, and approximately 5% of adolescents commit suicide every month. Furthermore, the author stated that depression, which occurs in 8.3% of adolescents, is the leading cause of suicidal ideation in this developmental group (Muribwathoho (2015). In like manner, Meyer et al. (2019) indicated that in South Africa, one in five high school learners have attempted or had thoughts of suicide. A study conducted by the South African Federation for Mental Health (SAFMH) in 2018 revealed that 25% of learners between the ages of 15 and 19 reported having experienced feelings of hopelessness, 18% had suicidal ideation, and 18% had attempted to commit suicide (Statistics South Africa [Stats SA], 2020). Notably, in South Africa, childhood adversity increases the probability of developing mood disorders, PTSD, major depression, and substance-related disorders, each contributing to learners dropping out of school (DoH, 2013). Reddy et al. (2010) conducted a South African study on the risk behaviours of secondary school learners attending public schools in South Africa. The study revealed that nationally, approximately 1 in 8 learners had used alcohol before age 13. The same study showed that nationally, approximately 5.2% of learners used marijuana before age 13, with grade 10 learners having a significantly higher prevalence of marijuana use. 2.7 Child and Adolescent Mental Health Policy Worth noting, WHO (2017) stated that as the most rapid and formative stage of human development, adolescence has profound implications for national policies and programmes. According to the DoH (2013), South Africa continues to face challenges regarding mental health. Nevertheless, there were no officially endorsed documents on the National Mental Health Policy for South Africa before the development of the National Mental Health Policy Framework and Strategic Plan 2013-2020. Compared to other health priorities in South Africa, mental health services still do not receive adequate resources and funding (DoH, 2013). To emphasise, a study conducted by 20 Mokitimi et al. (2018) reinforced the evidence of previous studies regarding the neglect of child and adolescent mental health despite mental health problems among children and adolescents being the most significant global burden of disease. With this in mind, the National Child and Adolescent Mental Health Policy of 2003 provided a framework for the policy development and implementation plans regarding child and adolescent mental health across all nine South African provinces. However, current provincial child and adolescent mental health policies are publicly unavailable (Mokitimi et al., 2018). 2.8 The Promotion of the Mental Health of Learners 2.8.1 The Role of the School in Learner Mental Health Promotion Learners spend more than half their day time in school (Fazel et al., 2014; Hosseinkhani et al., 2020; Kumar et al., 2011; Mazzer & Rickwood, 2015; Reinke et al., 2011) ; making the school environment crucial for nurturing learners’ mental health and well- being (Fazel et al., 2014; Kumar et al., 2011; Mazzer & Rickwood, 2015; Reinke et al., 2011). Because of their crucial role in learner mental health (Bella et al., 2011; Mfidi, 2017), schools can help address mental health needs on various levels (DoH & DBE, 2012; National Academies of Sciences, Engineering, and Medicine, 2019). Moreover, schools can provide their learners with cost-effective mental health services (DoH, 2003; National Academies of Sciences, Engineering, and Medicine, 2019). Therefore, schools are an appropriate environment to identify and address the mental health needs of learners (Engelhardt, 2016), promote mental health, and provide interventions that bridge the gaps of unmet mental health service needs (Bella et al., 2011). Additionally, schools can help learners become resilient and equip them with coping skills (Weare & Nind, 2011). 2.8.2 Understanding Educators’ Role in Learner Mental Health Promotion According to the Education Laws Amendment Act 4 (1999), an educator is any person appointed at a school to teach and provide educational and psychological services. Educators can identify learners with mental health problems (Johnson et al., 2011; Mazzer & 21 Rickwood, 2015; Mfidi, 2017; Shelemy et al., 2019; Swapnajaidupally, 2015; Zurakat, 2015) since they interact with learners daily (Mellin et al., 2017; Venkataraman et al., 2019). The role of the educator is also to support the learners’ needs as part of the integrated response of the school and to refer learners to mental health professionals such as school counsellors, social workers, or psychologists (Kutcher & Wei, 2017); keeping in mind that social workers are more likely than psychologists to provide school-based mental health services (Fazel et al., 2014). Educators are excellent gatekeepers and referral sources for mental health services because they are skilled at identifying mental health problems in learners (Fazel et al., 2014). Additionally, educators can promote the mental health of learners by providing mental health interventions (Johnson et al., 2011; Mazzer & Rickwood, 2015; Mfidi, 2017). However, Fazel et al. (2014) affirmed that educators are frequently required to prioritise educational targets. Educators are restricted by school policies that limit the type of services they can provide. This restriction consequently limits their ability to meet specific learners’ needs. With no further training, educators may not feel confident identifying and addressing mental health problems and providing learners with the support they require (Shelemy et al., 2019). Regardless of how appropriate preventive measures are in promoting mental health, mental health challenges are inevitable; thus, educators should receive sufficient mental health training to provide effective support to learners (Engelhardt, 2016). The perceived self-efficacy of educators influences how they respond to mental health problems in educational institutions and how they address the mental health needs of learners (Mazzer & Rickwood, 2015). Perceived self-efficacy refers to a person’s confidence in their abilities to succeed (Bandura, 1977; Mazzer & Rickwood, 2015). Previous studies have revealed that educators are usually uncomfortable discussing mental health with learners and are unsure how to help learners with emotional problems (Shelemy et al., 2019). Educators with positive self-efficacy are more confident in identifying and supporting learners with mental health needs (Mazzer & Rickwood, 2015). 22 Equally important is a positive educator-learner relationship. The positive relationship is pivotal for a learner’s enhanced academic performance and the positive development of a learner’s social skills, self-esteem, and well-being (Mental Health Foundation, 2016). In addition, educators can contribute to adolescents’ formation of positive identity (Kasinath, 2013; Verhoeven et al., 2018). There should be a balance between the psychological needs of adolescents and the social demands made on them in order for them to achieve a mature identity (Chen et al., 2007).When there is a conflict or a lack of support from adults at home, the high-quality educator-learner relationship becomes even more crucial as it provides the learners with the sense of security and social support crucial for positive mental health (Mental Health Foundation, 2016). 2.9 Psychosocial Services in Schools 2.9.1 Definition of Psychosocial Services During adolescence, mental health problem management includes early intervention, support, and appropriate mental health care (Venkataraman et al., 2019). According to the International Federation of Red Cross and Red Crescent Societies (IRFC, 2009), psychosocial services are the provision of interventions that address the psychological needs of individuals and communities and integrates psychological, social, and cultural dimensions of well-being. Simply stated, psychosocial services aim to meet individuals' ongoing psychological and social needs (Australian Institute of Health and Welfare, 2014). According to the IRFC (2009), psychosocial services can be preventive and curative simultaneously. Preventive care minimises the risks of developing mental health problems, whereas curative care helps individuals address and overcome psychosocial problems. 2.9.2 Psychosocial Services Available in Schools While the literature clearly supports the need to offer school-based mental health and psychosocial support services, there appears to be a widening gap between learners' increasing mental health needs and access to such services (Splett et al., 2011). In the South African context, Muribwathoho (2015) pointed out that the differences in wealth, 23 access to resources, and social class give some South African schools an advantage over other schools in accessing psychosocial support services. This author stated that in most poorly resourced schools that serve Black learners, there is a lack of school counsellors, and schools do not have trauma and counselling services. Moreover, public schools usually cannot employ school social workers because the school cannot afford their services (Masilo, 2018). Muribwathoho (2015) reported that South African educators often provide counselling services to learners out of their sense of responsibility despite inadequate resources. There are significant variations between mental health services and the criteria used to determine a learner’s eligibility for mental health interventions and outcomes (Fazel et al., 2014). From this perspective, the same learners might be interpreted differently by different people; thus, a learner with depression may be regarded as failing academically, disinterested, or cognitively impaired, or perceived as lacking motivation or low self-esteem (Fazel et al., 2014). Additionally, educators may harshly punish learners or send them out of the classroom, increasing the risk of deviant behaviour and aggressiveness (Shung-King et al., 2019). WHO (2003b) stipulates that harsh punishment of learners may lead to increased mental health problems and substance abuse later in adulthood. 2.9.3 The Value of Psychosocial Services in Schools Child and adolescent mental health services are essential to prevent mental health problems and mental disorders, and enhance the mental well-being of children and adolescents (Mokitimi et al., 2018). More specifically, school-based interventions can be a turning point for many learners who come from adverse environments (Weare & Nind, 2011). Research suggests that the delivery of school mental health care promotes school attendance, improves academic achievement, reduces suicide-related behaviours, and decreases juvenile arrests (Splett et al., 2011). Mental health professionals can also use mental health care in schools as a way to enable educators to follow up on learners’ therapy in the classroom (Heller, 2015). 24 Finally, learners may perceive the educational setting as more familiar and less threatening for seeking and receiving mental health care (Swick & Powers, 2018). For this reason, learners who need mental health support are more likely to seek mental health services at school than at a mental health facility within the community (Heller, 2015; King- White, 2019; National Academies of Sciences, Engineering, and Medicine, 2019). School- based mental health services improve access to mental health services for learners and are recommended to increase access to evidence-based treatment methods for mental health (Gronholm et al., 2018). 2.9.4 The Importance of Inclusive Education and School-based Support Teams According to the Department of Education (DoE, 2001), providing more intense and specialised support may be necessary for learners to develop to their full potential. Learners may experience difficulties learning effectively or may be excluded from the learning system altogether when their different learning needs are not met (DoE, 2001). Many learners experience learning challenges or drop out of school because the education system cannot recognise and address diverse learning and because of inaccessible educational facilities, curriculums, assessments, learning resources, and learning strategies. This is why the DoE established an inclusive education and training system framework. The DoE 2001 White Paper 6 on Special Needs Education: Building an Inclusive Education and Training System outlined a model for inclusive education. It was designed to provide institutions and structures of support and to ensure that all learners receive a high-quality education (DoE, 2001). The White Paper 6 objectives were to achieve equity and reduce exclusionary pressures in schools by promoting access to the curriculum and facilitating the inclusion and participation of diverse learners with disabilities in school and other learning environments (Masango, 2013). According to the DoE (2001), an inclusive education and training system provides learners with various types and levels of support. First, inclusive education acknowledges and respects the differences among learners while embracing their 25 similarities. Second, it comprehensively supports all learners, educators, and the education system to ensure that various learning needs are met, with an emphasis on developing effective teaching practices that will benefit all learners. Last, it aims to address barriers to the education system that impede the system from serving the entire spectrum of learning requirements. It addresses these barriers by highlighting the adaptability and support systems that are accessible in classrooms. Another critical point according to the DBE (2014), is that support services at the school level are primarily delivered by the School-based Support Team (SBST). SBSTs are established by schools primarily to provide school-based support services to schools, learners, and educators (DBE, 2014). The SBST is comprised of educators from various levels of education and plays a vital role in identifying barriers in the educational system and ensuring that the needs of all learners are addressed (DBE, 2014; Nong, 2020). As part of their responsibilities, the SBST interacts with their District-based Support Teams (DBST), which provide integrated and specialised services as needed (Nong, 2020). The DBSTs are multifunctional and interdisciplinary groups of professionals from the department. These groups are responsible for promoting inclusive education for training, delivering curriculum, resource distribution, and identifying, assessing, and addressing learning barriers (DBE, 2014). In light of this, the DBSTs should empower educators to address education barriers (Nong, 2020). The DBSTs, assist SBSTs through collaborative consultations (Amod, 2018). 2.10 Barriers to Seeking and Accessing Psychosocial Services in Schools 2.10.1 Barriers Associated with Seeking Psychosocial Services Multiple barriers may prevent learners from seeking school-based mental health services. Barriers to mental health help-seeking minimise the probability of individuals seeking mental health services (Vidourek et al., 2014; Radez et al., 2020). These barriers are discussed below. 2.10.1.1 Stigma. Stigma is the most prominent barrier to seeking mental health services among adolescents (Loreto, 2017; Velasco et al., 2020). Stigma refers to negative 26 attitudes and beliefs that result in society fearing, rejecting, avoiding, or discriminating against individuals with mental health problems (Kutcher & Wei, 2017). For example, Zartaloudi and Madianos (2010) maintained that stigma involves negative labels and separation, and that stigma comprises distinct constructs such as stereotypes, prejudice, and discrimination. The most common form of stigma is the perceived negative attitudes, such as believing that individuals with mental health problems are weak, incompetent, less intelligent, and incapable. These negative attitudes might increase discriminatory behaviour, alienation, and social isolation against individuals with mental health problems (Ke et al., 2014; Vidourek et al., 2014). Individuals often feel ashamed and embarrassed to seek psychological services because of the fear of being stigmatised and discriminated against (Ganasen et al., 2008; Radez et al., 2019; Swick & Powers, 2018). This is why individuals may seek help from family and friends, and only lastly from professionals (Zartaloudi & Madianos, 2010; Radez et al., 2020). Engelhardt (2016) articulated that stigma may also exist because society associates mental health with mental illness. As a result, adolescents with mental health problems face stigma, which inhibits help-seeking behaviour (UN, 2014; Radez et al., 2020). Mental health stigma might result in individuals’ denial of mental health problems and the reluctance to seek mental health services (Owens et al., 2002; Watson et al., 2004). Consequently, stigma and discrimination against individuals with mental disorders increase the burden of mental disorders among children and adolescents (Kleintjies et al., 2010). 2.10.1.2 Cultural Perceptions. Cultural perceptions is another obstacle to help- seeking behaviours among adolescents (Loreto, 2017). The UN (2014) stated that cultural factors directly impact individuals' help-seeking behaviour and, to some extent, account for the differences across countries in help-seeking and using mental health services. Furthermore, cultural perceptions influence the reaction and response to mental illness and the attitudes and beliefs of individuals regarding mental health services, and help-seeking behaviour (Loreto, 2017). Previous research also shows that internalised stigma, and other 27 demographic factors influence individuals' willingness to seek mental health interventions (Morris, 2018). Combined with erroneous beliefs about mental health problems (Brooks et al., 2021), mental health stigma contributes further to delays in accessing effective mental health treatment (Brooks et al., 2021; Simkiss, 2020). In some ethnic groups, for example, the expression of emotions is discouraged and restricted, which inhibits adolescents from seeking help for mental health problems (Loreto, 2017). 2.10.1.3 Family Perceptions. The beliefs of the adolescents’ family regarding mental health services and treatment (Velasco et al., 2020), adverse reactions from family and friends, social stigmatisation (Zartaloudi & Madianos, 2010), family expectations, and societal norms and attitudes are some of the barriers to addressing the mental health needs of adolescents (Heller, 2015). The adolescents’ family perceptions associated with a lack of cultural sensitivity, miscommunication, lack of trust in mental health professionals, past negative experiences with mental health care professionals, and lack of confidence in the treatment are obstacles to help-seeking behaviours in adolescents (Velasco et al., 2020). Additionally, these cultural differences may include adolescent and caregiver perceptions regarding mental health problems, the stigma associated with the mental health problem, or the seeking of mental health care (UN, 2014). 2.10.1.4 Poor Mental Health Literacy. Poor mental health literacy is another significant help-seeking barrier (Johnson et al., 2020; Velasco et al., 2020). Bonabi et al. (2016), Brooks et al. (2021), and Loreto (2017) described mental health literacy as knowledge and attitudes about recognising, managing, and preventing mental disorders. Mental health literacy is about being aware of different mental illnesses, biopsychosocial factors contributing to the onset of mental illnesses, the stigma surrounding mental health, and the importance of early mental health interventions (Loreto, 2017). Poor mental health literacy also leads to young people’s inability to perceive their problems as mental health-related, uncertainty about whether or not their problems are severe enough to require mental health services, being unsure of where to seek help, and 28 the refusal to seek help due to the desire to manage their problems independently (Radez et al., 2019; Vidourek et al., 2014). Adolescents often feel inclined to cope with mental health problems on their own; however, when they seek support, it is usually in the form of more informal service systems such as friends and family before consulting a mental health professional (Radez et al., 2020; UN, 2014). Consequently, insufficient knowledge about mental health care in society and among professionals such as educators can contribute to the stigma associated with mental health problems (Fukuda et al., 2016). 2.10.1.5 Confidentiality. The CMHA (n.d.) maintained that the issues of privacy and confidentiality breaches may hinder learners from seeking help. Furthermore, learners may be reluctant to seek psychosocial services because they are concerned about confidentiality (Meyer et al., 2019; Muribwathoho, 2015; Radez et al., 2020; Smit, 2015), perceptions of learned helplessness, and cultural differences (Muribwathoho, 2015; Smit, 2015). 2.10.1.6 Mental Health Treatment. The fear of mental health treatments and adverse medication effects are barriers that inhibit help-seeking behaviour (Johnson et al., 2020). Furthermore, previous negative experiences with mental health services may also prevent individuals from re-seeking mental health services (Smit, 2015; Swick & Powers, 2018). Adolescents under mental health management for depression (which can include prescribed treatments and activities for adolescents and their parents, which facilitate the adolescents' recovery from depression) are fearful that they may relapse into depression. This fear consequently interferes with their sense of identity and self-perception (Chukwuere et al., 2022). Moreover, Chukwuere et al. (2022) affirmed that adolescents who suffer from depression, regardless of mental health management, tend to self-alienate, which also negatively impacts their family and friends. 2.10.2 Barriers Associated with Accessing Psychosocial Services A number of barriers may hinder access to school-based mental health services. Owens et al. (2002) identified three barriers to accessing mental health services in schools. The first is the structural barrier, which includes a lack of resources and long 29 waitlists. The second barrier is associated with perceptions about mental health problems. This barrier relates to educators, healthcare providers, and parents' inability to identify learners' mental health needs. It also relates to their deniability of the seriousness of the mental health problem. Finally, the third barrier is inextricably linked with perceptions about mental health services. For example, it may be learners’ lack of desire to receive mental health care, negative experiences with mental health professionals, or stigma associated with receiving mental health services. Additionally, stigma inhibits individuals from participating in mental health services (Ganasen et al., 2008; Martin, 2010; Smit, 2015; Swick & Powers, 2018; Thorley, 2016). Moreover, Zartaloudi and Madianos (2010) pointed out that stigma is associated with the denial of treatment for mental illness and a lack of recognition and autonomy regarding addressing personal challenges. Vidourek et al. (2014) proposed that the perception of ineffective mental health services and the difficulty of accessing mental health care could undermine the ability to access mental health services. 2.10.3 Addressing Psychosocial Services Barriers There is no straightforward strategy to eliminate the stigma barrier associated with mental health problems (Kutcher & Wei, 2017). However, increased mental health literacy and awareness of mental health conditions may reduce the perceived stigma associated with seeking mental health care and disclosing symptoms to professionals and adults in positions to assist (UN, 2014). The main facilitators of help-seeking behaviour include emotional competence, mental health literacy, and past positive experiences with mental health care professionals (Velasco et al., 2020). Bonabi et al. (2016) maintained that the perceived need for mental health services and positive attitudes about mental health services enhances help-seeking behaviours. Here, schools can play a crucial role in addressing mental health problems in society as a whole by breaking down the mental health stigma (Engelhardt, 2016). The preceding author pointed out that schools can provide mental health literacy programmes that incorporate 30 mental health concepts. These programmes can be delivered by educators in a manner that is familiar and comprehensible for the learners. Engelhardt (2016) also maintained that educational programmes on mental health are crucial for two reasons. First, to enlighten learners, educators, and parents on mental health challenges. Second, to provide strategies and skills to help reduce and address mental health problems among learners before they negatively affect learners' academic performance. Effective and appropriate mental health interventions that promote help-seeking behaviour can enhance mental health knowledge and early mental health interventions (Velasco et al., 2020). Thus, mental health services offered in schools can normalise help- seeking behaviour, facilitate access to mental health services, and reduce stigma around mental illnesses (Gronholm et al., 2018). 2.11 Theoretical Framework The term theoretical framework refers to a specific perspective used by a researcher to underpin a study (Green, 2014; Imenda, 2014). Thus, a theoretical framework involves the application of a theory to explore, explain, or interpret the phenomenon under study (Imenda, 2014). Green (2014) articulated that a theoretical framework guides a researcher in formulating a rationale, research question, and literature review. Simply stated, Merriam (2001, p. 45) asserted that a theoretical framework is “the structure, the scaffolding, the framework of your study”. The two theories that underpinned the present study are the psychosocial development theory in relation to understanding identity development in adolescent mental health and the ecological systems theory. 2.11.1 The Psychosocial Development Theory: Understanding Identity Development in Adolescent Mental Health Erik Erikson proposed eight psychosocial stages of development, each characterised by a psychosocial crisis (Kroger & Marcia, 2011; Meyer et al., 2008; Weiten, 2013). Adolescence is the fifth psychosocial stage (Gillbrand et al., 2016; Louw & Louw, 2014; Weiten, 2013, 2017). Distinctly, forming a stable identity is one of the significant 31 developmental tasks during adolescence (Bornstein & Putnick, 2018; Branje et al., 2021; Jung et al., 2013; Ragelienė, 2016; Sharifi, 2015; Sokol, 2009). At the same time, identity versus role confusion is the psychosocial crisis that occurs during adolescence (Kroger & Marcia, 2011; Louw & Louw, 2014; Weiten, 2013, 2017). Meyer et al. (2008) defined identity as an individual’s self-image and unique sense of self and that their self-image is consistent with the perceptions of others regarding the individual’s self-image. In plain terms, identity is a unique combination of personality traits and the social style through which individuals define themselves and are characterised by others (Branje et al., 2021; Tsang et al., 2012). Identity versus role confusion is resolved when adolescents attain an identity by understanding who they are as unique individuals and thoroughly evaluating, accepting, and rejecting specific goals and values (Block, 2011; Upeti, 2017). Kroger and Marcia (2011) maintained that the absence or presence of identity could not be observed; however, elicited behaviour resulting from an identity that has or has not been formed can be observed and measured. In the absence of a strong identity during adolescence, a shared identity cannot be developed, which could result in instability in many areas as an adult (Upeti, 2017). The psychosocial task of forming a stable identity requires adolescents to integrate their childhood identities in their own unique way to establish a mutual relationship with their society and maintain a sense of continuity within themselves (Kroger & Marcia, 2011; National Academies of Sciences, Engineering, and Medicine, 2019). Erikson (1962) articulated that identity formation is associated with developing mental health problems. With this in mind, forming a firm sense of identity is associated with better mental health, psychological well-being, improved emotional adjustment, emotional stability, and reduced anxiety, depression, and suicidal behaviours (Ragelienė, 2016). The identity search process during adolescence often results in discrepancies. These discrepancies can either be between the adolescents' ideal, authentic, and self-perceived selves, and how others perceive them or between their social and personal identities. Both discrepancies make them more susceptible to psychosocial risks (Tsang et al., 2012). 32 Additionally, the association between self-image, negative thoughts, and mental health problems is prominent among adolescents (Leve, 2015). Self- discrepancies can trigger negative emotions such as resentment, distress, agitation, frustration, and even adverse psychological outcomes (Rickwood & Ferry, 2018). Demir et al. (2010) maintained that identity confusion occurs when adolescents fail to develop a sense of self, solve role confusion, and experience challenges in establishing values. Erikson (1970) stated that adolescents undergoing identity confusion are prone to developing mental health problems. Consequently, mental health problems adversely affect adolescents’ development, quality of life, socioeconomic integration, and their relationships with parents, peers, romantic partners and educators, (UN, 2014). If the identity versus role confusion crisis is not resolved, adolescents might experience confusion and struggle to figure out their plans in adulthood, especially concerning roles and responsibilities (Upeti, 2017). Positive peer relationships are crucial for adolescents’ social development, enhanced well-being, self-esteem, and identity development (Mental Health Foundation, 2016). Although relationships with parents are still crucial for adolescents, healthy peer relationships have been associated with better mental health, low social anxiety, and depression during adolescence (Ragelienė. 2016). From this perspective, the Mental Health Foundation (2016) highlighted that peer exclusion or rejection can negatively impact self- esteem and sense of worth. Furthermore, social rejection, social withdrawal, and isolation during adolescence have been associated with mental health problems such as depression, anxiety disorders, and eating disorders, which interrupt adolescents’ so