Influence of barriers on mental health help-seeking behaviours

Across the reviewed research, the findings revealed that perceived stigma was the most frequently encountered barrier to accessing MH services (Mfidi Reference Mfidi2017; Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021; Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023). Other common barriers included low MHL (Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020), cost (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021), inaccessibility of services (Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020; Addy et al., Reference Addy, Agbozo, Runge-Ranzinger and Grys2021), issues related to confidentiality (Addy et al., Reference Addy, Agbozo, Runge-Ranzinger and Grys2021) and negative past experiences with the provider (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023). Parents’ attitudes (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023) and academic pressure (Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020) further inhibited adolescents from seeking help for MHPs. Table 4 summarises these barriers.

Table 4.

Barriers to mental health help-seeking

Table 4. Long description

The table consists of four columns and six numbered rows.

Row 1. Barrier Theme: Perceived stigma. Subthemes: Social or public stigma and cultural stigma. Number of Studies: 12.

Row 2. Barrier Theme: Gender norms as a barrier to help-seeking. Subthemes: Masculinity norms and stigma around emotional expression; gendered socialisation and structural constraints on help-seeking. Number of Studies: 9.

Row 3. Barrier Theme: Mental health literacy (Knowledge, misconceptions and awareness gaps). Subthemes: Poor recognition of M H P s; limited knowledge and misbeliefs about self-help and professional support options; negative attitudes hindering M H P recognition and help-seeking; limited knowledge of how to access mental health information. Number of Studies: 11.

Row 4. Barrier Theme: Privacy, trust and confidentiality concerns with M H professionals. Subthemes: Fear of confidentiality breaches; inadequate counselling environments and lack of privacy; distrust in mental health professionals. Number of Studies: 7.

Row 5. Barrier Theme: Lack of accessibility and availability of M H services. Subthemes: Distance to services; lack of mental health professionals; inadequate resources. Number of Studies: 9.

Row 6. Barrier Theme: Family and parental attitudes, peer influence and alternative support. Subthemes: Family control and restriction of help-seeking; preference for informal and relational support networks; cultural and normative beliefs shaping help-seeking. Number of Studies: 7.

Theme 1: Perceived stigma

All studies reviewed indicated perceived stigma as the most frequently cited barrier to MH help-seeking behaviours among school-going adolescents. Stigma was conceptualised across four interrelated dimensions: social/public stigma (negative reactions from others), anticipated stigma (fear of being judged if one seeks help), self-stigma (internalised shame and self-blame) and cultural stigma (beliefs linking mental distress to moral, spiritual or supernatural explanations). Adolescents who encounter stigma related to MH are less likely to acknowledge their potential MHPs and seek formal or informal help for their MH. This collectively creates an environment in which seeking help for MHPs is met with shame, fear and reluctance to seek help.

The pervasiveness of stigma and cultural standards has contributed to an atmosphere in which confronting problems related to MH elicits feelings of dread and shame. For example, in some schools and communities, adolescents who express emotional distress or seek MH support risk being labelled as weak or disobedient, especially where strength and emotional control are linked to respectability and maturity.

The stigma surrounding MH topics is often reinforced socially by peer groups, either explicitly or implicitly. Adolescents often face severe social/public stigma from their families, peers and communities in SSA (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021; Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023). This stigma usually stems from negative opinions and false beliefs about MHPs themselves, such that the fear of being ostracised or labelled as “weak” or “crazy” prevents adolescents from acknowledging their MHPs and seeking help. Evidence from one included study indicates that adolescents encounter overtly negative peer reactions to MH difficulties, as reflected in the following account: “Their response is unkind, and their behaviours can be shameful. They show emotions of fear and hate…” (Nkosi, Reference Nkosi2025, p. 27), demonstrating a deep-rooted fear of judgement.

Similarly, another study reported that female adolescents avoid disclosure due to fear of being labelled or judged: “When you let people know what you are going through, they will think you are mad. I just keep to myself” (Addy et al., Reference Addy, Agbozo, Runge-Ranzinger and Grys2021, p. 12). This demonstrates that adolescents, in their bid for acceptance, are sensitive to how their peer group may react, thus inhibiting them from seeking help (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018). For example, one study reported that peers often respond with ridicule or exclusion: “People would ‘[not] talk to them. They make fun of them,’ say, ‘you are crazy’ and ignore them, or ‘judge them.” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1091).

Adolescents are often worried about the disclosure of their MHPs, as it can lead to rumours and stigma among the public. For example, one study reported the following: “…I heard people in the community whispering my name about something I had said in the session, and it broke my trust…” (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023, p. 5).

A participant in another study reported a similar stigmatising experience: “I heard students saying they were making fun of themselves, and they said, ‘you, you have a mental problem, go and talk to the counsellor, go and see the counsellor’.” (Panford-Quainoo et al., Reference Panford-Quainoo, Oppong Asante and Osei-Tutu2024, p. 190). Overall, social and public stigma cumulatively contribute to an inhospitable atmosphere for adolescents, in turn discouraging them from seeking MH services. The widespread presence of these stigmas intensifies the lack of communication with others about one’s MHPs, further exacerbating isolation and the potential for more severe MHPs.

In addition to social and public stigma, SSA communities are confronted with cultural stigma that affects adolescent help-seeking (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023). Cultural stigma refers to the beliefs and views that connect MHPs with weakness or failure embedded within a cultural context (Codjoe et al., Reference Codjoe, Barber, Ahuja, Thornicroft, Henderson, Lempp and N’Danga-Koroma2021; Ojagbemi and Gureje, Reference Ojagbemi and Gureje2021). In many SSA cultures, MHPs are often seen as having a lack of will or a spiritual problem that causes families and communities great shame and humiliation. One secondary school student in a study from Ghana stated, “When you start hearing voices, it’s only the spiritualist like fetish priests who can help you” (Addy et al., Reference Addy, Agbozo, Runge-Ranzinger and Grys2021, p. 12). Additionally, another secondary school student perspective reflects this noting that“…these psychotic mental illnesses are said to be caused by evil spirits or to be a kind of retribution from supernatural spirits or beings” (Nkosi, Reference Nkosi2025, p. 28). A participant in another study reported, “My family… were like, ‘Counselling? Really?’… ‘Counselling is for White people only.’” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1092). As Brouwers (Reference Brouwers2020) propose, culture can also breed silence among MHPs.

Theme 2: Gender norms as a barrier to help-seeking

Gender norms play a significant role in adolescents’ decisions to seek MH help (Campbell et al., Reference Campbell, Bann and Patalay2021; Jörns-Presentati et al., Reference Jörns-Presentati, Napp, Dessauvagie, Stein, Jonker, Breet, Charles, Swart, Lahti, Suliman, Jansen, van den, Seedat and Groen2021). Studies have indicated that female students are generally more willing to seek professional help than their male counterparts (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023). This difference stems from societal norms that label emotional expression as a weakness, especially among boys (Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020; Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022). In many cultures, boys are expected to be stoic, making it difficult for them to acknowledge psychological distress or to seek help (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018; Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021; Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023).

In contrast, girls are socialised to be more open about their feelings and encouraged to seek support when needed (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023). Evidence from one included study illustrates how prior exposure to counselling can reinforce help-seeking among female students:“…female participants use more emotion-focused strategies, such as seeking emotional support from others than male participants” (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023, p. 3).

However, male students often avoid MH services due to fear of losing their dignity. For example, one study reported: “Seeking counselling is for women; men bottle their issues lest they lose their dignity.” Similarly, a participant from another study reported, “As a male, this thing of going to see someone to cry and talk to is taboo; it takes away my masculinity” (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023, p. 5). Similarly, another study reported a participant who stated, “I think the girls and boys experience things that they wouldn’t necessarily want to say in front of the other, or the boys are going to be too cool to say in front of the girls…” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 196). Societal pressure to conform to masculine ideals makes it harder for boys to seek help.

To further illustrate the impact of gender norms as a barrier to help-seeking, Abdulsalam et al. (Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023) found that both gender and age play a role in whether adolescents in Northeastern Nigeria seek help for MHPs. These patterns are further influenced by the interaction between cultural or religious norms and the student’s gender. For example, one study reported a participant who stated feeling uncomfortable when a young man was selected as a counsellor: “I don’t feel like going for counselling there. Our counsellor is a young male counsellor. In Islam, an unmarried girl should not sit alone with a man not from her family because something bad may happen between them.” (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p.12). Male counsellors also face difficulties due to religious beliefs. One counsellor noted, “There are insinuations and allegations if you are a young, unmarried chap as a counsellor. Because you sit with students, especially females, people suspect you, not that you are doing your counselling work” (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p.12). Identifying and managing gender dynamics is necessary to improve adolescents’ MH help-seeking behaviours.

Theme 3: Mental health literacy (knowledge, misconceptions and awareness gaps)

Due to low MHL, defined as “knowledge and beliefs about MHPs which aid their recognition, management or prevention” (Jorm et al., Reference Jorm, Korten, Jacomb, Christensen, Rodgers and Pollitt1997, p.182), adolescents do not always seek help for MHPs (Amone-P’Olak et al., Reference Amone-P’Olak, Kakinda, Kibedi and Omech2023; Ma et al., Reference Ma, A-M and Anderson2023; Clough et al., Reference Clough, Nazareth, Day and Casey2024). Four main components affect adolescents’ knowledge and behaviour regarding MH, including: poor recognition of MHPs; limited knowledge and misbeliefs about self-help and professional support; negative attitudes hindering MHP recognition and help-seeking; limited knowledge regarding how to access MH information.

Often, adolescents misunderstand or mislabel their MHPs due to, for example, parents mislabelling an adolescent’s MHPs as mere obstinacy or wilfulness. Many believe that their distress is temporary or normal and do not believe that it is a mental illness. One study reported a participant who highlighted, “Some of [the guardians] would not come… they did not understand the value of psychological treatment (PT).” (Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020, p. 6). Another study reported a participant who revealed, “Parents wouldn’t know what their children are going through. They are not even aware. They will just say it’s stress. They just take it for granted. So, they should attend those meetings” (Mushonga et al., Reference Mushonga, Jopling, Glozah, Kamvura, Dodd, Gudyanga, Maramba, Dambayi, Ayuure, Bere, Achana, Owusu, Chibanda, Abas, Weobong and Kumwenda2025, p. 7). This barrier was also found in teachers, as one student stated, “My teacher thinks I am lying about it [attending counselling]. Because I am too naughty, I don’t go to school” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1092).

Some adolescents reduce MH to only stress and emotional control, as one study reported the following: “Mental health is when you are stressed or anxious about certain things (s) in your life. Some learners may be able to handle them, some may not. When they do not, they may not behave well.” (Mukuna, Reference Mukuna2025, p. 15). Another study reported a teacher who confirmed the above narrative when she stated, “sometimes we may mistakenly label the adolescents as ill-disciplined or moody whereas it may be signs of an emotional problem” (Mfidi, Reference Mfidi2017, p.8). When distressed, adolescents usually do not seek help because they do not recognise that something is wrong with them.

Furthermore, adolescents do not often understand MHPs and their development. As a result, when they experience a MH concern, they may interpret these symptoms as personal weakness and feel compelled to manage them independently rather than seek support. This internalisation can interfere with their ability to concentrate and participate in academic activities, as distress remains unaddressed. For example, one study reported that distress can disrupt attention and engagement in classroom settings “:If that child is sitting with that blow… in class… and that teacher is explaining something here on the board and that child’s… attention is here with the pain… or with that person who hurt him…” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 194). Similarly, another study reported that limited awareness contributes to dismissive attitudes towards MH: “Learners at my school are nonchalant towards issues like mental health and behavioural problems. They are not well educated or well informed about these issues…” (Nkosi, Reference Nkosi2025, p. 30). In the absence of knowledge about the risk factors and causes, adolescents may fail to understand the gravity of the disorder and the urgent need for help to address it.

Adolescents often do not know where to go or how to help themselves effectively when MH issues arise. One study reported: “If I need some to talk to, I talk to my boyfriend who is always there to offer me advice and comfort when I am stressed, so I don’t think I need a counsellor or a psychologist to deal with my problems” (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023, P.6). Many would rather seek informal support than recognise and use self-help strategies or professional resources.

One major aspect of MHL is awareness of the professional help available. Many adolescents do not know how to seek help when they need it. One study reported that adolescents often experience uncertainty surrounding the help-seeking experience, stating: “The clinic… they are going to ask too many questions… They would just have told me to ‘just get it out of my mind’… and then told me to go home.” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1092). This lack of knowledge and subsequent mistrust was further reflected in another study where a participant expressed the following:

The lack of knowledge about available professionals contributes to adolescents’ unwillingness to seek prompt help due to a lack of understanding and trust. Adolescents often remain hindered by negative attitudes from both themselves and providers and an inability to recognise signs and symptoms of MHPs. Most adolescents blamed their MHPs on themselves instead of considering them a medical issue. One study reported, “…they will try for a day or two, like I said, but their attitude is already ‘it’s [the programme] not going to work, the children are broken, they come broken from home, so what should I now fix?’” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 193).

Adolescents require further guidance when searching for correct MH information. One school administrator indicated that teachers and other staff lacked knowledge about MH in general: “Some teachers are unable to recognise and seek help for their learners’ MHPs due to lack of specific training on mental health” (Mfidi, Reference Mfidi2017, p. 10). Another study reported, “I may have studied psychology, but at times we are not skilled to deal with some of these social, emotional, and behavioural problems. We just have to refer them” (Mfidi, Reference Mfidi2017, p. 7). This perception is further illustrated by the following statement by a participant in another study: “The thought of talking about my life might bring up some problems I thought I had overcome, and that could increase my stress. So, whenever I hear about mental health issues, I just avoid them” (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p. 8).

This lack of awareness about existing MHPs applies to the school environment as well. Usually, teachers are the first point of contact for students experiencing MHPs, but teachers often do not receive adequate MH training. For example, in one study, a teacher noted, “I can help. I just do not know what it looks like when a child needs help” (Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020, p. 8). Similarly, another teacher remarked, “I feel unprepared to handle mental health issues among students because I haven’t received any training in this area” (Mfidi, Reference Mfidi2017, p.8). This lack of awareness from teachers, who are often the first critical point of contact for struggling students, further hinders student awareness, “I have never been to counselling before, so I never knew what counselling was about” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1093).

This MHL gap also applies to parents who may not be equipped to help, depending on their MHL. For example, A teacher in one study described that some caregivers are “…people who do not know how to handle their emotions themselves so they cannot help children…” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 6). Some adolescents and their parents may also not fully appreciate the usefulness of MH services. A study reported a participant who indicated a reluctance to seek professional help, stating: “…I don’t want to hear about psychological issues or having to go and see a counsellor, it really makes me sick.” (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023, p.5).

Many adolescents further believe that if their friends or partners support them, they do not need to seek help from professionals. This is reflected in one study: “I talk to my boyfriend…so I don’t think I need a counsellor” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 8), further illustrating the preference for informal support over professional help.

Collectively, these studies revealed that participants associated seeking help for MHPs from a MH practitioner with inferiority or weakness. These perceptions and the lack of knowledge and awareness collectively inhibit effective help-seeking behaviours, indicating a need for more MHL.

Theme 4: Privacy, trust and confidentiality concerns with mental health professionals

Concerns about privacy and confidentiality are significant barriers to adolescents seeking MH services in SSA (Mutahi et al., Reference Mutahi, Larsen, Cuijpers, Peterson, Unutzer, McKay, John-Stewart, Jewell, Kinuthia, Gohar, Lai, Wamalwa, Gachuno and Kumar2022; Hlophe et al., Reference Hlophe, Tamuzi, Shumba and Nyasulu2023). Adolescents frequently express fear that their disclosures might be revealed to others, such as teachers, parents or peers (Yao et al., Reference Yao, Li, Wang and Hui2021). For example, one study documented the following “:I know the school has a counselling unit. But ahhh… I will not go there. I am shy of the teachers” (Addy et al., Reference Addy, Agbozo, Runge-Ranzinger and Grys2021, p. 12).

The physical setting of counselling offices exacerbates these problems. Open or poorly designed spaces are perceived as unsafe, discouraging help-seeking behaviours. Inadequate infrastructure, such as counselling offices divided by plywood, creates an environment where adolescents feel exposed. One study documented the following: “Our counselling office is too open. They used plywood to divide the library and the office; I feel people hear what I discuss. To me, the place is not ok; it is not worth it” (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p. 10). Another study further described the experience of exposure: “It’s like the whole world is watching me; I feel I was doing something wrong… worried since the room is not hiding” (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p. 10). Alarmingly, these concerns are not unwarranted, as adolescents report a general lack of privacy related to MHP help-seeking: “They would call our names on the intercom, and all of the kids would be like ‘where are you going, what’s going on there?’” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1094).

Trust in the MH care provider is another critical issue. Adolescents often report negative experiences with professionals, leading to a lack of faith in counselling services. One study presented the following account:

A professional in one study confirmed the above by stating “From my encounter with those who came to me, initially, they were hesitant because of some previous experiences that students would share; they went to see a counsellor, and the next moment, somebody had heard their issues.” (Panford-Quainoo et al., Reference Panford-Quainoo, Oppong Asante and Osei-Tutu2024, p. 190). Another shared how a breach of confidentiality during group therapy destroyed their trust:

Adolescents also doubt counsellors’ capacity to understand their issues: “I do not believe the counsellors understand our problems; they just follow a script” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1091). One study provided the following account related to counsellors providing services internally within the schools: “I don’t think it should be internal because it helps them if it’s someone from outside… it’s delicate… not something that children [are] necessarily going to share with a teacher” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 195). This reveals another layer, such that students doubt that school counsellors will keep their MHPs private. Another study provided the following account of a student’s concerns related to counsellors sharing information: “She is going to speak about it with… other counsellors” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1091). Such perceptions, combined with stigma, encourage students to “sneak in” for counselling, as observed by one teacher–counsellor in another study: “Students who come for counselling don’t feel at ease… more like sneaking in, watching when to come… like it’s a taboo” (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p.10).

According to the adolescents, such perceptions of confidentiality breaches profoundly impact their trust in MH services (Haraldsson et al., Reference Haraldsson, Pingel, Nordgren, Johnsson, Kristiansson and Tindberg2022; Kip et al., Reference Kip, Udedi, Kulisewa, Go and Gaynes2022). Thus, it is imperative to ensure that counselling takes place in a secluded location and that the counsellor faithfully adheres to confidentiality rules to build and keep trust with adolescent clients. Students must be informed about these confidentiality protocols ahead of sessions.

Theme 5: Lack of accessibility and availability of mental health services

Lack of access to MH services is another major barrier to help-seeking behaviours among adolescents, particularly in rural SSA (Sarikhani et al., Reference Sarikhani, Bastani, Rafiee, Kavosi and Ravangard2021; Mindu et al., Reference Mindu, Mutero, Ngcobo, Musesengwa and Chimbari2023). Owing to geographic proximity, adolescents in rural educational institutions often lack access to qualified MH professionals, such as counsellors or counselling psychologists. An administrator from one study stated, “Many rural schools have difficulty adopting and implementing school mental health systems… This is caused by insufficient specialised mental and behavioural health personnel such as school counsellors, psychologists, and social workers” (Nkosi, Reference Nkosi2025, p. 27). Similarly, an administrator from another school stated, “During the rainy season, heavy rain significantly increased transportation fees and made roadways to school impassable, posing a barrier to students and their parents’ attendance” (Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020, p.8).

In addition to issues associated with counselling accessibility at rural schools, another study reported institutional capacity constraints: “Well, I think the challenges, one is the fact that you’re playing a double role; you’re a counsellor, you’re a teacher. So, when you are in the classroom, and somebody needs you for counselling and you’re not available” (Panford-Quainoo et al., Reference Panford-Quainoo, Oppong Asante and Osei-Tutu2024, p. 190).

Financial constraints further exacerbate accessibility-related hurdles. Low-income communities and their respective schools sometimes experience substantial economic adversity, leading to a focus on meeting essential requirements such as food and school expenses rather than prioritising MH care. As one study reported, “We used to go together with health promoters… But now the transport we use cannot accommodate them” (Mfidi, Reference Mfidi2017, p. 8). Similarly, a participant from another study reported, “Currently they [school counsellors] are full to the ears… I just feel those children—I think some of our parents do not have the means to get professional help for them.” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 193). Many adolescents cannot afford MH services because of the costs involved, whether for the service itself or for the related expenses, such as transport. Many colleges also do not have adequate counselling facilities, nor educated professionals to ensure a standard of MH care for students. One study illustrated this by stating, “You could sit in the queue the whole day but not get the help you needed.” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1095). Thus, accessibility and availability issues prevent MH help-seeking among adolescents despite their intentions to do so.

Theme 6: Family and parental attitudes, peer influence and alternative support

It has been well-established that family and parental attitudes can serve as barriers to the MH help-seeking behaviour of adolescents. The attitudes of some parents become a barrier, blocking their children from seeking support. For instance, one study reported a participant who remarked, “Pressure from our peers can impact us negatively, including the abuse from guardians, parents… Abuse from our parents impacts us a lot, and it is not easy to talk about it…” (Nkosi, Reference Nkosi2025, p. 30). Despite the potential for negative attitudes, parents and families still provide alternative sources of emotional and financial support for adolescents, who often seek comfort from family instead of MH professionals. This is reflected in the following quote: “Parents are the first source of life to the child in terms of love and care. This is why students are homesick when they need advice… to discuss their problems closely, a kind of allegiance.” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p.6). Similarly, another study reported, “They feel it is their duty, a natural duty… they feel they are more obliged as parents or family to advise and guide the student. This perspective affects the sensitivity of the child; nearly in everything, including getting help” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p.6).

Siblings and extended families also play a significant role in help-seeking activities. Adolescents often discuss issues with their older siblings when they do not wish to reveal perceived confidential information to their parents. According to one study, older siblings counselled younger ones on choosing a career, higher institution and gender-related issues such as relationships and social expectations (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023). However, judgement from parents about MH can discourage treatment: “I don’t think parents truly understand what mental health issues entail. Mine don’t,” an adolescent remarked (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021, p. 8).

During adolescence, when we rely on our social networks, peers may also have considerable influence over one another, as they have established trusting relationships. Some peers function as a barrier to help-seeking; for example, as one participant shared, “I was embarrassed to go to therapy, especially when my school friends asked about it” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1092), whereas other peers function as an informal help-seeking pathway. For instance, one adolescent reported, “My boyfriend is the one who comforts me because I do not trust anybody” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p.1092). According to Khombo et al. (Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023), most adolescents prefer informal support systems over professional services. One of the main reasons for this is the stigma associated with using professional services.

A preference for familiar connections may subsequently result in reduced engagement with supportive services (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023). As one participant noted, “If I need some to talk to, I talk to my boyfriend who is always there to offer me advice and comfort… I don’t think I need a counsellor or a psychologist to deal with my problems.” (Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023, p.6).

Some parents prioritise academic and other responsibilities over MH, which may further discourage adolescents from seeking help for MHPs. As reported in one study, a student presented the following account, “Because some of them are the ones who ill-treat us. If they knew that we are getting help somewhere, they might even hate us. That would become a disadvantage to us.” (Mushonga et al., Reference Mushonga, Jopling, Glozah, Kamvura, Dodd, Gudyanga, Maramba, Dambayi, Ayuure, Bere, Achana, Owusu, Chibanda, Abas, Weobong and Kumwenda2025, p. 10). Such an attitude of overlooking MHPs can fuel the notion that one’s problems may not be serious, so the adolescent avoids professional help. Another study reported a student’s account who shared their experience of their parents’ hurtful and unsupportive behaviour during a traumatic incident, stating:

Religious beliefs and practices are another factor affecting the help-seeking behaviours of school-going adolescents. Some students draw upon their religious communities or spiritual tools instead of counselling for support. According to one study, a participant stated, “ students seek spiritual guidance if they sense the matter is between them and God… strictly spiritual “(Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p. 1305). This sentiment was echoed by another study which reported, “When you start hearing voices, it’s only the spiritualists like fetish priests who can help you” (Addy et al., Reference Addy, Agbozo, Runge-Ranzinger and Grys2021, p. 12).

Facilitators of mental health help-seeking behaviours

The reported facilitators of MH help-seeking among adolescents included supportive family dynamics, positive peer influence, accessible informal networks and cultural or community resources (see Table 5).

Table 5.

Facilitators of mental health help-seeking

Table 5. Long description

The table consists of four columns: an index number, Facilitator theme, Sub-themes, and Number of studies.

* Row 1: Mental health education and literacy enhancement. Sub-themes include promotion of mental health literacy, access to information and resources, integration into the school curriculum, and parental mental health education. Supported by 12 studies.

* Row 2: Supportive school environment or climate. Sub-themes include school mental health initiatives, school mental health policies, and institutional commitment. Supported by 10 studies.

* Row 3: Improved professional services. Sub-themes include availability of trained and specialized mental health professionals, and confidential, gender-sensitive, and culturally appropriate care. Supported by 8 studies.

* Row 4: Family, community involvement and peer support. Sub-themes include family communication and emotional support, peer support and shared coping, and community-based support and outreach. Supported by 8 studies.

* Row 5: Improved service accessibility and affordability. Sub-themes include policy and financial investment in mental health services, and school-based integration of mental health services. Supported by 6 studies.

Theme 1: Mental health education and literacy enhancement

All 12 studies identified increased awareness and MH education as the main driver of help-seeking behaviours among school-going adolescents in SSA. When adolescents receive MH information that is both clear and culturally relevant, they display higher rates of early symptom recognition and are more willing to pursue help while talking openly about their MHPs. Adolescents are also more likely to seek help when MH education is integrated into life skills training by teachers and when peer leaders facilitate open discussions with students. Promotion of MHL at the school and community level was identified as an important facilitator for enhancing help-seeking behaviour among school-going adolescents (Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020; Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021; Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022). To illustrate this, one participant (female caregiver) noted:

Another study noted the benefits of MHL, stating that “Learning about mental health in school made it easier to talk about my problems” (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021, p. 7). Similarly, interdisciplinary collaboration within school settings was also identified as a mechanism for strengthening MH support, particularly through coordinated involvement of teachers, parents and school leadership. As one school stakeholder emphasised, “The promotion of mental health through interdisciplinary collaboration in schools was also deemed essential” (Mfidi, Reference Mfidi2017, p. 8).

In addition to increasing MHL as a facilitator of help-seeking, visibility of MH services for adolescents helps to clarify available resources and enhance the likelihood of their utilisation (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018). For example, flyer distribution, community programming and information dissemination through the internet may enhance awareness of MH services for school-going adolescents. As one student indicated, “It was through the support and information I received during the trial that I learned about PTSD and the available treatments. This knowledge motivated me to seek help when my symptoms worsened” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1091). Another participant remarked on the helpfulness of peer education, “Peer education programme undertaken by the provincial department is not regularly done, but it does help” (Mfidi, Reference Mfidi2017, p. 7). Integrating MH education into the school curriculum was noted as another critical facilitator of help-seeking (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021; Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022). Incorporating MH education into the curriculum gives adolescents a platform to express themselves and encourages them to seek help for MHPs. One study reported, “School counsellors recommended that the content of such a programme should be psychoeducational and in-line with the current school-curriculum.” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 195).

One study provided the following account of a teacher who stated that MH education could be beneficial in preventing suicide ideation and behaviours, suggesting the following: “Just like we have this sex education thing, I think it [mental health education] should be added because of the way people are even committing suicide today because of some trivial issues” (Addy et al., Reference Addy, Agbozo, Runge-Ranzinger and Grys2021, p. 13). Another adolescent noted the benefits of MHL in school, stating “Learning about mental health in school showed me it’s important to seek help” (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021, p. 8). Therefore, introducing MH education into the school curriculum can help enhance the students’ knowledge and outlook towards MH, which in turn encourages them to ask for help when needed (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018; Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021; Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023).

Despite issues related to the lack of MH education and literacy, findings showed that education programmes can help families and parents understand the mental wellness needs of adolescents. Workshops and seminars for parents, for example, can create a bridge between home and school activities that further facilitate a positive environment for adolescents. As a study reported, “The workshops assisted my parents in understanding what I am facing and how I could be assisted” (Addy et al., Reference Addy, Agbozo, Runge-Ranzinger and Grys2021, p. 13). Another participant remarked, “The only way you can get most of the parents is usually when there is a PTA meeting. So that is a way that you can get them and give them that education concerning mental health issues.” (Mushonga et al., Reference Mushonga, Jopling, Glozah, Kamvura, Dodd, Gudyanga, Maramba, Dambayi, Ayuure, Bere, Achana, Owusu, Chibanda, Abas, Weobong and Kumwenda2025, p. 6). These educational programmes for parents can equip families with the skills to identify and deal with MHPs.

Theme 2: Supportive school environment or climate

The second facilitator theme that emerged from the QES was a supportive school climate, which can motivate school-going adolescents from SSA to seek help for their MH. A school’s climate is defined as the socio-cultural, psychological, safety and educational environment that stimulates learning, social growth and emotional well-being (Wang & Degol, Reference Wang and Degol2016). Across studies, participants noted that programmes designed to support student MH would be beneficial: “Teachers and school counsellors explained that a programme like this would help them meet the demand for mental health and behavioural support in the schools” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 193). Among studies of schools where such programmes have been implemented, participants generally report positive feedback, with one noting that it was “a surprise to find ‘someone out there that cares’” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1094).

Our review further found that a positive school climate is reflected in the fair implementation of rules and regulations, the promotion of norms and values, student engagement, attachment to school and teaching activities that enhance learner agency (Thapa et al., Reference Thapa, Cohen, Guffey and Higgins-D’Alessandro2013). Schools that offer counselling services and maintain a positive environment can help students to deal with their MHPs (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021; Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022). Involving MH experts in providing support for students, such as counsellors and educational psychologists, rather than relying solely on teachers, is highly effective (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022). Teachers and parents should serve as the first point of contact and a referral pathway to these specialists.

Our findings also demonstrated that to develop a positive school climate that encourages adolescents to seek help, policies surrounding MH must be created (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022). In schools, where guidance and counselling units are well established, students and teachers understand the importance of strong support systems in promoting adolescent MH (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021). One participant in a study stated, “For me, I see them having a positive view about counselling in general… the trust has been built; freshers learn from those who are already in the system, and those in that system speak well about my office” (Panford-Quainoo et al., Reference Panford-Quainoo, Oppong Asante and Osei-Tutu2024, p. 191). According to another teacher, providing a source of support by actively listening to students’ concerns is also helpful in enhancing school climate:

Theme 3: Improved professional services

Schools require the presence of trained MH professionals, such as counsellors and psychologists, to take care of the MH of adolescents. Students should not receive counselling services from teachers. Rather, teachers should refer students to a MH professional, who can refer them to proper interventions (Panford-Quainoo et al., Reference Panford-Quainoo, Oppong Asante and Osei-Tutu2024; Nkosi, Reference Nkosi2025). Support for counselling services was noted across studies. For example, a participant from one study noted: “Having a professional counsellor at school makes me feel like my problems are taken seriously” (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p. 1202). This is similarly reflected in another study, “It was a surprise to find ‘someone out there that really cares’” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1093). These perceptions speak to the faith students have in MH professionals working within school settings, as well as the positive outcomes for students with access to these professionals.

One of the most important components of MH services offered in schools involves the assurance of confidentiality. Our review revealed that assured confidentiality enhances trust, as users feel less at risk of negative judgement, stigma or exposure to their peers and family (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018; Meza et al., Reference Meza, Kiche, Soi, Khairuzzaman, Nales, Whetten, Wasonga, Amanya and Dorsey2020). For instance, one participant from van de Water et al. (2018) remarked: “I was relieved to share my secret with the nurse counsellor because she’s not my friend and she’s not part of my family” (van de Water et al., Reference van de Water, Rossouw, van der Watt, Yadin and Seedat2018, p. 1094). Similarly, another study reported, “I can speak about my issues easily because our school keeps everything private.” (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021, p. 7).

Theme 4: Family, community involvement and peer support

Family, community and peer involvement encourage school-going adolescents in SSA to seek help for their MHPs (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022). These types of involvement include open communication, peer support and encouragement and community outreach. Open communication within the family was important in helping adolescents to seek MH help. Regular and open discussions within families about MH can be effective in reducing stigma and encouraging adolescents to seek help. As one study reported,

In addition to family, a peer participant described offering sustained emotional support:

Similarly, a teacher highlighted the positive role of families in adolescents’ help-seeking, stating, “Parents are the first source of life to the child in terms of love and care. This is why students are homesick when they need advice … to discuss their problems closely, a kind of allegiance (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p. 5).

Student-led peer support groups and peer counselling initiatives are also powerful facilitators of MH help-seeking. Specifically, help-seeking programmes facilitate and motivate a culture of seeking help among adolescents and further create a conducive environment for them to relate to and empathise with each other. For instance, a teacher from a study conducted in Uganda revealed:

In addition to family and peer support, organisations within the community offer outreach programmes to make MH services accessible. These initiatives help link formal MH services with the community. A representative of one of the local schools revealed in a study how local Non-Government Organisations (NGOs) have been helpful to them by providing free services to students: “Local organisations run mental health workshops that are helpful to our students, especially to our schools, who are still struggling with having mental health budgets” (Abdulsalam et al., Reference Abdulsalam, Ahmed Tharbe and Mohd Jaladin2023, p. 8). Culturally appropriate MH services must be ensured through outreach services and appropriate community programmes. These programmes allow adolescents and their families to access the necessary help in their communities, reducing barriers to help-seeking.

Theme 5: Improved service accessibility and affordability

Adolescents showed increased readiness to seek MH help when they could access affordable services. This QES revealed that students showed increased participation in MH programmes, which were located near their schools or communities, when these services had reduced or no associated costs. Research demonstrated that school-based MH programmes significantly affected students’ willingness to pursue MH support (Carlson et al., Reference Carlson, Namy, Nakuti, Mufson, Ikenberg, Musoni, Hopson, Anton-Erxleben, Naker and Wainberg2021; Khombo et al., Reference Khombo, Khombo, Stoddart, Sifelani and Sibanda2023; Panford-Quainoo et al., Reference Panford-Quainoo, Oppong Asante and Osei-Tutu2024). Adolescents encountered fewer logistical and financial obstacles when MH services were integrated into their school environments. We found that policies developed to increase the funding available for MH initiatives in schools and communities have the potential to significantly improve services. Despite this, a lack of focus on the funding of MH interventions limits their success and hinders progress. However, it has been revealed that communities where the government has deliberately supported MH initiatives have yielded positive MH outcomes.

A viable strategy for improving accessibility and affordability of MH services is through their integration into schools. If MH specialists are integrated into schools, they could provide counselling to the students as well as the community. This approach addresses accessibility issues with on-site services, which are cost-effective and easier to use. A participant from one study emphasised the importance of accessible support within schools, stating, “It’s very necessary… because they don’t have support at home… they need someone or a programme like that to help them.” (Coetzee et al., Reference Coetzee, Gericke, Human, Stallard and Loades2022, p. 193).