Primary school teachers’ perceptions of mental health promotion in schools and factors explaining their commitment

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Mukala, Desire Tshala-Katumbayi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8497600/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Apr, 2026 Read the published version in BMC Public Health → Version 1 posted 13 You are reading this latest preprint version Abstract Background. In low- and middle-income countries, most primary school teachers still have negative perceptions of mental health, which may limit their key role in promoting mental health in schools. This study aimed to understand primary school teachers’ perceptions of mental health promotion in schools (MHPS) and the factors that are likely to explain their commitment to MHPS interventions. Method. This qualitative study, inspired by phenomenology and hermeneutics, was conducted in the megacity of Kinshasa, in the Democratic Republic of Congo. We collected data by conducting in-depth individual interviews with 24 primary school teachers from 12 schools (private, public and faith-based). We analysed the data according to Braun and Clarke’s reflexive thematic analysis approach, informed by a phenomenological perspective. The results were organised around the following themes: teachers’ understanding of mental health, factors explaining teachers’ commitment to MHPS, perceived obstacles, current practices, and mental health needs and expectations. Results. Most participants perceived mental health in school as a concept associated with “madness” or simply misinterpreted it. Participants stated that they perform mental health promotion activities based on their knowledge, including identifying pupils with mental health conditions, providing psychological first aid, and referring them to specialist services. Their commitment to promoting mental health in schools depended on their personal motivations and perceived institutional support. However, several factors, such as lack of training, lack of resources, and lack of sustained institutional support, were cited as perceived obstacles to their commitment. Participants highlighted the need for specific training in mental health promotion and advocated integrating mental health into school curricula to strengthen its promotion. Conclusion. The findings reveal that primary school teachers in Kinshasa still perceive mental health more as the presence of mental disorders than as positive mental health. Mental health promotion is not being implemented optimally in primary schools, as several perceived obstacles affect teachers’ commitment. These findings point to the need to revitalise mental health promotion in primary schools, particularly by establishing psychological support structures in schools and training teachers in mental health promotion. mental health promotion perceptions teacher commitment primary school qualitative study Democratic Republic of Congo Background Schools are a key setting for mental health promotion and prevention. They make it possible to reach not only schoolchildren but also those who are not in school and the entire community. Various evidence-based programmes can be implemented in schools, whether they focus on the school climate, the development of psychosocial skills, or the quality of teacher-pupil relationships [ 1 ]. These interventions contribute to the well-being of pupils, teachers, staff, and the community [ 2 ]. They are particularly beneficial for children, promoting their academic success and development, including those exposed to risks such as poverty, family stress, learning difficulties or behavioural problems [ 3 ]. The literature shows that mental health promotion and prevention interventions are particularly relevant during childhood and adolescence, two key periods for laying the foundations for healthy development [ 4 ]. Available data show that the scale of mental health problems in schools is a cause for concern worldwide, with an estimated prevalence of between 10% and over 20% [ 5 ]. In Zambia, a study revealed an overall prevalence of 37.7% among schoolchildren, including somatic complaints (29.6%), affective disorders (14.1%), and conduct disorders (12.5%) [ 6 ]. This situation contrasts sharply with the scarcity of MHPS interventions, particularly in sub-Saharan Africa, where such initiatives remain virtually non-existent [ 4 , 7 – 9 ]. The high prevalence of emotional and behavioural difficulties among schoolchildren highlights the importance of paying attention to pupils’ mental health [ 10 , 11 ]. These unaddressed problems have major consequences: poor school achievement, exclusion, dropping out, juvenile delinquency, physical disorders, and an increased risk of substance abuse [ 12 – 14 ]. In addition, it should be noted that behavioural issues among pupils may have a significant negative impact on teachers’ mental health, as they are likely to increase their workload and exacerbate the job-stress related to their role as educators [ 15 ]. Given that a correlation has been established between the mental health and wellbeing of teachers and those of pupils [ 16 ], the development of mental health conditions in pupils would have repercussions on the mental health of teachers, and vice versa [ 16 , 17 ]. Therefore, implementing a mental health promotion programme in schools would be beneficial for both teachers and pupils. The promotion of mental health in schools (MHPS) should mobilise both health and education professionals, as it is an essential condition for effective pupil learning [ 11 ]. It involves all school and community stakeholders, with teachers playing a central role. Teachers are key stakeholders in MHPS: they can identify pupils with mental or psychosocial difficulties and help refer them to appropriate services [ 18 , 19 ]. They also participate in the implementation of wellness promotion programmes and universal interventions while fostering an inclusive and welcoming school climate [ 20 ]. Their perception of MHPS is a determining factor in their commitment and participation in these interventions [ 21 ]. Research on the involvement of schools and teachers in supporting pupils’ mental health is strongly recommended. Conducted using a qualitative approach, such research provides an in-depth and nuanced understanding of the experiences and perceptions of the actors involved [ 18 ]. Teachers’ involvement and commitment to health promotion in schools have been extensively studied [ 22 ]. This research shows that the determinants of their participation fall into two categories: individual factors and organisational factors. Individual factors include a sense of competence, interest in the programme, a sense of personal effectiveness, and the programme’s alignment with the teacher’s values. Organisational factors refer to the existence of shared goals, effective leadership, and the local community. Furthermore, research indicates that most teachers recognise that promoting mental health is an integral part of their professional role [ 3 ]. In the Congolese context, a study on teachers’ perceptions of MHPS is part of the drive to relaunch or revitalise Health Promotion in Schools (HPS). The Democratic Republic of Congo (DRC) has a national school and university health programme, a national mental health programme, and a primary education programme that includes health-related content, such as personal hygiene, mental hygiene, environmental hygiene, domestic accidents, vaccination, and nutrition [ 23 ]. Despite this framework, services dedicated to MHPS remain virtually non-existent. In this context, the present study focused on teachers’ perceptions of their role and commitment in MHPS. It aims to understand how primary school teachers perceive mental health promotion in schools and identify factors that may influence their commitment to promotional interventions. Methods Study design This study adopted a qualitative phenomenological approach to gain an in-depth understanding of the meaning that teachers attribute to their experiences in MHPS. This approach was chosen because it is based on a hermeneutic perspective, according to which reality is composed of multiple mental constructs and subjective representations specific to the individuals involved in a given phenomenon [ 23 ]. Therefore, it does not seek to set aside assumptions, but rather recognises that interpretation is a necessary step towards understanding [ 24 ]. Phenomenology seeks to observe and describe the meaning that an individual attributes to an experience, based on their awareness of it. Applicable to various fields, particularly health, its objective is to capture human experience as it is lived, generally through in-depth interviews. In the context of this study, it allows us to explore teachers’ subjective experiences regarding mental health promotion in schools [ 25 ]. We therefore believe that this methodological approach is the most appropriate for our study, as it has enabled us to capture the meanings and significance that teachers attribute to their commitment in MHPS through multiple interpretations linked to their professional experience, educational values, and institutional contexts. The data collection period was set considering the school calendar in force in the DRC. This study took place between October 2024 and January 2025, depending on the availability of teachers and schools. The research team responsible for the interviews consisted of the principal investigator assisted by two interviewers. The principal investigator holds a master’s degree in public health and a master’s degree in nursing and is trained in qualitative methods. The other two, a man and a woman, hold master’s degrees in nursing and are also trained in qualitative methods. The principal investigator and team members had no connection with the teachers participating in the study. The teachers were informed of the study’s objective, which helped establish a relationship of trust. Study setting and participants Primary schools in the city of Kinshasa were our study setting. They met the following criteria: they are located in urban or semi-urban neighbourhoods, they may (or may not) be part of the healthy school’s network, and they are private, public, and faith-based schools. The study participants were primary school teachers. In accordance with the organisation of the Congolese education system, they belong to three levels of education: i) elementary level (1st and 2nd grades), ii) middle level (3rd and 4th grades), and iii) terminal level (5th and 6th grades). All of them applied the official curriculum, which includes certain subjects related to health promotion, such as health and environmental education, physical education, and sports. The teachers selected had proven teaching experience and regularly addressed topics related to health promotion in schools (HPS) in their teaching practices. This commitment was verified on the basis of their teaching documents (lesson plans, class journals, and subject forecasts), as well as through posters and other teaching aids present in the classroom. The evidence observed at these different levels demonstrates their commitment to HPS. The school administration also contributed to the selection process. After being informed of the study’s objectives, the researcher directed the researcher to the teachers considered most competent and likely to communicate their experience in promoting mental health at school in a detailed and relevant manner. Teachers were recruited according to a principle of theoretical representativeness, considering the characteristics described above. To be selected, each teacher had to meet the following criteria: i) be a practising primary school teacher (standing teacher), ii) have at least two years of experience, have already mastered the teaching programme, and have already obtained at least two good grades in the evaluation, iii) be able to clearly express and develop their ideas and experience (ability confirmed during the joint selection process with the management), and iv) have agreed to participate in the study. Sampling This study used a purposive (or theoretical) sample, meaning that participants were selected based on the needs of the research. The researcher chooses informants who have in-depth knowledge of the subject or who have had a typical experience of the phenomenon under study and are able to describe it in a clear and thoughtful manner [ 26 ]. This strategy enriches the quality of data by encouraging expression, reflection, and sharing of authentic and detailed experiences. The value of the data depends on the richness, relevance, and depth of the narratives provided [ 27 ]. The sample size was gradually established as the interviews yielded the information sought. Recruitment continued until the data became repetitive and no longer provided any new information, indicating that saturation had been reached. The interviews were therefore analysed as they were collected. In this qualitative approach, the sample size is not fixed in advance. A small but carefully constructed sample is sufficient to achieve a comprehensive understanding of the phenomenon [ 26 ]. The final size depends on the principle of saturation, which is reached when the categories are described exhaustively and no new relevant information emerges. Saturation is widely recognised as a key methodological benchmark in qualitative research: beyond this point, continuing to collect or analyse data no longer adds value. Therefore, it is a reference criterion for determining the size of intentional samples in health science [ 28 , 29 ]. However, it is important to distinguish between code saturation—often achieved with about nine interviews—and meaning saturation, which generally requires 16–24 interviews [ 28 ]. In this study, 24 teachers from 12 private, public, and faith-based schools were recruited. This number corresponds to the sample size obtained when data saturation was reached. Data collection method and tool The data for this study were collected through semi-structured face-to-face in-depth interviews (IDI) with primary school teachers. This method was chosen for several reasons: i) it allows for direct interaction between the researcher and the participants; (ii) it provides access to the components of their personal frame of reference—viewpoints, understandings, representations, experiences, and perceptions—in relation to the phenomenon under study; (iii) it promotes an in-depth exploration of their perspective, providing access to their experiences and understanding of the subject [ 30 ], in a context of exchange where the teacher is recognised as the holder of specific knowledge [ 31 ]. We developed for this study the interview guide (in French), appended as a supplementary file (Text S1), which enabled us to explore primary school teachers’ perceptions of MHPS and to highlight the factors explaining their commitment in HPS activities. Teachers’ perceptions were explored using open-ended questions about their representation, understanding, and knowledge of mental health promotion in schools, the factors explaining their commitment, obstacles, needs, and expectations. A total of seven questions were asked of participants, encouraging them to comment more extensively on the various topics. Follow-up questions were asked when certain topics were not addressed or were only briefly touched upon by participants. This interview guide was tested on two teachers at a school with characteristics similar to those of the schools selected for the survey. This pre-test helped improve the quality of the instrument and assess the time and conditions required for its administration. Each interview, lasting between 40 and 60 minutes, took place either in rooms reserved for teaching staff within the schools or, where more appropriate, in outdoor areas specially equipped to ensure the confidentiality and comfort of the participants. The interviews were recorded with the participants’ permission. The observation notes supplemented them. The transcripts were submitted to the participants for verification and validation of their accounts. A reflective journal was kept at the end of each day of the survey during the researchers’ meeting to improve the researcher’s posture and limit interpretation bias. Data analysis The analysis was conducted using QDA Miner software, following Braun and Clarke’s approach to reflexive thematic analysis [ 32 ]. This approach is understood as an easily accessible and theoretically flexible interpretive approach to qualitative data analysis, which facilitates the identification and analysis of trends or themes in a data set. This approach is a six-step process: familiarising oneself with the data, generating preliminary codes, searching for themes, reviewing themes, defining and naming themes, and producing the report [ 32 ]. This reflexive thematic analysis was compared with the initial manual analysis tested by the principal investigator (JNM) using the phenomenological reduction method described by Colaizzi, following these steps: i) familiarisation, ii) identification of significant statements, iii) formulation of meanings, iv) grouping of themes, v) development of an exhaustive description, vi) production of the fundamental structure, and vii) verification of the fundamental structure with participants [ 33 , 34 ]. To ensure the rigour of the analysis, the themes were developed inductively. We verified consistency between coders by successively comparing the code matrices. The discrepancies observed between the codings were discussed among researchers, helping to reinforce the validity of the analysis. The credibility of the results was confirmed by validation with the participants. Analyses were also discussed among the researchers to improve their interpretative quality. The transferability of the results was ensured by a detailed description of the characteristics of the target population—primary school teachers—which guided recruitment and made it possible to construct a theoretical sample reflecting their experience in MHPS. Finally, fidelity was ensured by a sustained presence in the field, in-depth analysis of the narratives, and the use of participant feedback [ 35 ]. Ethical considerations This study is part of a large doctoral research protocol whose protocol was approved by the Institutional Review Board of the Institut Supérieur des Techniques Médicales in Kinshasa (No. 0019/CBE/ISTM/KIN/RDC/PMBBL/2023). It was conducted according to the ethical principles of the Declaration of Helsinki. All study participants signed a free consent form. Results Socio-professional characteristics of the participants The study participants were aged between 20 and 80 years, with a mean age of 53.7 years. The majority were men (70%), 70% of whom were married. All were full-time teachers and held a secondary school diploma. In addition, 83% had received no training in mental health, and 96% had more than nine years of teaching experience. Primary school teachers’ perceptions By analysing primary school teachers’ perceptions of mental health promotion, the following five main themes emerged: i) teachers’ knowledge and understanding of mental health; ii) factors promoting their commitment in mental health promotion; iii) barriers to this commitment; iv) current practices related to mental health; and v) teachers’ needs and expectations in relation to mental health. Teachers’ knowledge and understanding of mental health Mental health was described as a new concept by most participants. Some interpreted it as “madness”, while others perceived it as something unknown. Furthermore, a minority seemed to be familiar with the concept, albeit vaguely. Three categories were identified in relation to this theme. Mental health, a little-known (or unknown) concept, a new initiative for teachers Most teachers described mental health by as an intellectual disability or mental retardation. Given that apparently normal pupils are admitted to school, teachers thought that this problem would affect other people but not in a school setting. A participant expressed it in these terms: “In our school, we do not have children with these problems. Even when I was teaching lower grades, I never noticed any pupils with this problem, and now that I am teaching upper grades, I do not see any pupils with this problem. I think that mental health problems are for mentally retarded people who are not intelligent enough to understand a lesson or to understand something that I have understood.” (IDI, Participant 4) For some participants, mental health is a new concept in their practices about which they do not have sufficient information. One of them stated it in these terms: “In any case, it is a new concept. I remember that a year ago, a psychologist came to conduct a study on children with problems, but I do not have any information about that. It is already a superb initiative. As you know, children are really different in their daily lives. We manage them, and we already realise that not all children have the same intellectual or comprehension abilities, so your fieldwork is a very good thing, especially if we were to set up something related to children in this regard.” (IDI, Participant 2) Teachers emphasise its importance in identifying and guiding pupils with specific needs. This is highlighted in the following statements from participants: “It is already a superb initiative, as you know, children are really different daily.” (IDI, Participant 2) “Promoting mental health is like you coming here to promote mental health, to see if we have such children in our school.” (IDI, Participant 7) Another stated that “I think it is important that this be implemented in schools because some children have problems with maths, while others do not apply themselves well in school due to family problems.” (IDI, Participant 13) Mental health is a problem linked to serious mental disorders, learning difficulties, and specific problems. Teachers’ understanding of mental health varies. Some perceive it as an issue related to serious mental disorders, while others associate it with learning difficulties or specific behaviours in pupils. Their statements are summarised as follows: “He is faced with a child who is not adapting to his teaching because he has no idea about the child’s mental health.” (IDI, Participant 1) “Mental health is in the head, is not it? I can take the example of children with disabilities who are not normal and do not think like everyone else.” (IDI, Participant 6) “Mental health is when pupils do not really understand what we teach at school.” (IDI, Participant 10) A nearly good understanding of mental health While the concept of mental health has been confused with illness or intellectual disability, some teachers have a fairly good understanding of the concept, even if action still needs to be taken. For them, mental health is a matter for psychology and psychiatry. This dimension point to a psychological problem. Participants equate mental health with the brain, memory and reasoning. They put it this way: “That is to say, the health of the mental faculties, brain, memory, etc. Regarding mental health, the child must be in a healthy psychological state and must have a good support system at home, where they live. They cannot be frustrated. All of this must be considered so that the child can do well in school.” (IDI, Participant 21) “It is the child’s reasoning. I sometimes see that the child has difficulty reasoning and answering questions. They give you the wrong answer. The child has difficulty understanding what others understand easily. I might think that something is wrong with their mind, but since I cannot just say anything, we call the parents to explain their child’s condition.” (IDI, Participant 23) Factors that may explain teachers’ commitment to mental health in schools According to the participants, the factors that facilitate their commitment to mental health in schools fall into two categories: on the one hand, personal motivation and, on the other hand, institutional support, establishing a comprehensive mechanism for promoting mental health in schools. Personal motivation For most teachers, mental health is a really important issue these days. Many people experience these problems, and express the need to and desire for improved management of mental health issues. One of participants expressed it as follows: “Personally, I can get involved because I agree with all of this. We may not have these children in our upper grades, but we may have them in other grades! We must come; it will help the school. There are pupils who are disruptive, maybe that is also a problem. Even if you correct them, they do not correct themselves. Some behave as if they were at home, when we are in an educational environment.” (IDI, Participant 4) While another stated that “What motivates us to get involved are the lives and homes of the children we have to help, give advice to, guide in class, and not hit because they are problem children.” (IDI, Participant 3) They are also motivated by their passion for education and their desire to help pupils in difficulty and ensure that they are healthy in the school environment. Some pupils from turbulent backgrounds attend school, but so do bullies. This situation provides further motivation to learn about and receive training in mental health. This is what they said during their interviews: “The desire to help and mentor children drives us to get involved because for me, mentoring is a passion.” (IDI, Participant 2) “What drives me personally with the children we have now, as this is a free school, is that we have taken in children from all over. The parents came to enrol them to benefit from this free education. Some of the pupils were Chegués (i.e., street children in the DRC) or Kuluna (i.e., delinquent children in the DRC), but now we have taken them in. We need to do this because it can correct them, tell them that what they are doing on the streets is not right and that now they have to get involved in this! Naturally, what motivates me, especially since we are in an environment where there are many Kuluna, is that perhaps with this promotion of mental health, we can educate them and change them, starting with their little brothers, when they tell them that we had this at our school. It will be like advice to them.” (IDI, Participant 4) Institutional support For teachers, institutional support is essential for promoting mental health. They stated that it is important to organise training sessions but also to provide the resources to do so. Some participants stated the following: “First of all, as a teacher and parent, I am very positive about this promotion, but we need to provide the resources. The problem here is that people have good ideas, but the resources are not there. Without resources, we cannot do anything good. Even just travelling requires resources, and caring for these children requires resources.” (IDI, Participant 1) “I believe that once we have the training, we will commit to supporting this initiative, regardless of how the study is ultimately conducted.” (IDI, Participant 2) A participant emphasised the need for a leader in this field: “In our community, we need a promoter, a leader, an agent who supports us; otherwise, there is no one here to help us promote mental health. Resources (financial and material) make our work in the area of mental health easier. What holds us back is training and an unsuitable environment.” (IDI, Participant 3) Barriers to teachers’ commitment to mental health in schools Despite their motivation, teachers identify several barriers to their commitment, including a lack of training, resources, and institutional support, as well as negative perceptions of mental health among some teachers. However, they place the greatest emphasis on financial resources. Financial obstacles Financial resources are a major obstacle to promoting mental health in schools. Teachers feel that resources are very necessary because any initiative would require financial resources, particularly for training, awareness-raising, curriculum programmes, and treatment centres. For example, the tools needed to promote mental health in schools require financial resources. This is what emerges from the following statements: “Even just your travel requires resources, caring for these children requires resources, the studies we have to do, how to guide these children requires resources, so the state must provide the resources if we want young people who can help this country tomorrow.” (IDI, Participant 1) A participant highlighted the lack of tools for mental health screening: “We need the right tools to identify whether a child is sick or not because parents have to tell us about their child’s health, as some children do not like to say they are sick for fear of being insulted. Referrals are made at the centres, but we do not have a centre here.” (IDI, Participant 3) Negative perceptions of mental health The belief that mental health is linked to insanity limits teachers’ ability to promote it. As a result, this concept is seen as the preserve of those who can treat insanity and who do not see the importance of promoting mental health. A participant expressed it in these terms: “In our school, we do not have children with these problems. Even when I was teaching lower grades, I never noticed any pupils with this problem, and now that I am teaching upper grades, I do not see any pupils with this problem. I think mental health is for the mentally retarded.” (IDI, Participant 4) Current practices related to mental health at school Identification of problem pupils The identification of pupils with mental health problems is based mainly on observation of behaviour and interactions with parents. However, teachers often lack the tools and training to perform this screening systematically. The participants expressed themselves differently as follows: “Normally here at school, pupils have to be really normal. If we see a pupil who is a little abnormal, we can send them to a school that treats abnormal pupils.” (IDI, Participant 12) “For me, the components of health are: identifying children with mental health issues in each class.” (IDI, Participant 7) “We identify pupils with mental health issues, as I mentioned earlier, and we have been able to detect a few children.” (IDI, Participant 11) Psychological support and guidance The lack of resources and appropriate facilities limits access to psychological support and counselling for pupils with psychological issues. Teachers turn to parents or refer pupils to specialised schools. The participants expressed differently their support for pupils affected by psychological and behavioural issues in the following terms: “For the guidance of children with problems, we deal with the parents, we give them advice to change schools, and we often send them to Bondeko Villages.” (IDI, Participant 6) “We want you to be able to provide us with assistance for these children.” (IDI Participant 20) “When a child is sick, we call the parents and tell them that the child is sick and that they need to take him or her to the hospital.” (IDI, Participant 18) Teachers’ needs and expectations Need for teacher training on mental health Teachers need to be trained on mental health so that they understand the concept and can apply mental health concepts in the school environment. Some teachers have never heard of this concept, and it is critical to improve their knowledge of it to help them detect certain signs even in a school setting. This is what three of the respondents stated in the following: “First, I will tell you the truth: teachers who work with these children on a daily basis need to be trained in mental health because if we do not know anything about it, what can we teach the children? Those who work with children need to be given training in mental health, and then we can do something about it.” (IDI, Participant 1) “These situations are very rarely addressed in schools, which is why many teachers currently have difficulty monitoring children. They are faced with children who do not adapt to their teaching because they have no idea about children’s mental health. In our village, when we were still young, if you went into the principal’s office, you would see that each child had a medical file with information about everything related to the child’s health.” (IDI, Participant 1) “At our school, the truth is that we do not even talk about promoting mental health, and we do not even mention it.” (IDI, Participant 15) In addition, teachers expressed the need to set up mental health care institutions with all the necessary resources. A respondent put it this way: “Our needs, if you have the means to promote them, set up a centre here, bring us medicine, specialists who know how to deal with children with problems. Unless we have training in mental health, we will not know how to identify children who are ill. To promote health, we need lots of seminars and training on mental health, lots of dialogue between parents and pupils, between teachers and parents, teachers and pupils, and principals and parents.” (IDI, Participant 3) While another stated that “We need to ask the authorities to provide us with the necessary equipment to support children in case of illness, such as a school infirmary, because it is a large school. If we had a nurse who could treat children in serious cases, that is what we would like the state to help us with.” (IDI, Participant 5) Participants proposed concrete solutions to improve mental health promotion, including organising seminars and integrating mental health into school curricula. Three of them expressed this in turn as follows: “Organise a seminar for each district or municipality, bringing together schools from a municipality in one place.” (IDI, Participant 13) “We want the government to include this course in the curriculum.” (IDI, Participant 9) “We expect the government to take full responsibility for this so that pupils and parents know that support is available.” (IDI, Participant 24) Discussion The results of this study, which aimed to understand primary school teachers’ perceptions towards MHPS and the factors that may explain their commitment to promoting it, suggest that the study participants still perceive mental health much more as mental disorders than as positive mental health, and that they are not very committed to promoting it in schools. Knowledge and understanding of mental health The knowledge and understanding of mental health among the teachers participating in the study indicate that the majority of them perceive it as a new concept that sometimes refers to insanity and sometimes as something unknown, a new initiative to identify and refer pupils with specific needs. However, a minority perceives it in terms of positive mental health. Our findings corroborate those of some studies published on this subject. This is the case, for example, in Ekornes’ study [ 36 ], which indicates that mental health is an unfamiliar term in schools and often has negative connotations. This widely cited understanding remains somewhat diverse depending on the author. For Isaksson et al. [ 13 ], the teachers participating in his study understand the promotion of mental health in schools as structured work involving monitoring and collaboration with parents and the creation of a pleasant atmosphere within the school that includes enjoyment, interaction through play, peace and tranquillity, and team spirit. In another study by Soares et al. [ 37 ], mental health is understood as the balance between mind and body, as a requirement for happiness. Teachers recognise the importance of developing mental health services in schools. They consider promoting mental health at school part of their professional identity [ 18 ]. They identify with the role of first responders in mental health at school [ 36 , 38 , 39 ]. They develop a school culture that considers schools to be in a unique position to encourage positive relationships between teachers and pupils and positively influence pupils’ mental health [ 8 , 40 ]. Greater knowledge of mental health among teachers could increase their willingness to help pupils with specific problems [ 41 ]. Factors promoting teachers’ commitment to mental health promotion According to the participants, the factors facilitating their commitment to mental health in schools may stem from personal motivations on the one hand, but on the other hand from institutional support, putting in place a whole mechanism for the promotion of mental health in schools. This understanding is widely discussed in the literature. Felipe Julian Flores II notes that the self-efficacy factors perceived by participants in his study were: administrative support to ensure practical application and integration in the classroom, confidence in supporting pupils, the establishment of a climate of trust and connection, a safe and stimulating environment, recognition of limitations, and the pursuit of improvement [ 42 ]. Mazzer & Rickwood [ 18 ] indicated that additional training in mental health and a clear definition of roles within the institution could motivate teachers to feel better prepared to effectively and adequately support pupils’ mental health. Barriers to promoting mental health in schools Despite their motivation, teachers identify several barriers to their commitment, including a lack of training, resources, and institutional support, as well as negative perceptions of mental health among some teachers. However, they place the greatest emphasis on financial resources. These findings regarding barriers also corroborate those of other studies. This is the case for lack of training, identified as a major obstacle to the implementation of adequate support and screening, role conflict, lack of resources, time constraints [ 43 – 45 ], lack of time allocated to the programme, insufficient training, and inadequate inter-institutional support [ 20 ]. Teachers do not feel sufficiently prepared to adequately support pupils’ mental health due to a lack of adequate training in this area [ 46 ]. Teachers feel they lack specific knowledge and skills to promote positive mental health [ 43 ]. In another study, participants identified the following barriers to promoting mental health in schools: feeling that they lack the experience or training necessary to help or that they are not in the best position to do so [ 41 ]. Aya Abd El Latif et al. [ 39 ] conducted a study on the role of teachers in promoting pupil mental health and identified the following obstacles: inadequate training in recognising the early signs of mental disorders in pupils, concerns about workload, and a lack of mental health services for teachers aimed at lightening their workload before expecting them to promote pupil mental health. Current practices related to mental health in schools The current practices carried out by the study participants in promoting mental health in schools mainly consisted of identifying mental health issues among pupils, providing them with psychological support and referring them to mental health professionals. These practices have also been reported in other studies and be part of the daily routine of teachers promoting mental health. This is the case in Dey et al. [ 40 ], who reported that 91.5% of teachers acknowledge having identified children with mental health problems in their classrooms. Three-quarters of them were willing to offer them psychological support and referral to a qualified professional. In a study by Imran et al. [ 46 ], participants reported that in their teaching practices, they identified children with mental health problems. These included learning difficulties, aggression, disobedience, inattention, lying, and disrespect. Nalipay et al. [ 47 ], in a study on teachers’ experiences with pupils suffering from mental health problems, found that the participants’ current practices in this area were as follows: discussing and providing emotional support to pupils with problems, consulting with or referring pupils to the guidance counsellor, connecting to sources of support, and implementing teaching practices to support pupils’ mental health. Rojas-Andrade et al. [ 44 ], discussing the daily practices of teachers as school mental health professionals, revealed that teachers play an important role in identifying and addressing mental health issues in pupils, with 90% of them reporting that they have provided support to pupils with mental health issues. Teachers’ needs and expectations The needs and expectations perceived by participants were as follows: training, establishment of structures for caring for children in schools, the organisation of seminars, and integration of mental health into school curricula. These results are not dissimilar to those reported in other studies. In a study on supporting teachers’ mental health needs, Maclean & Law [ 42 ] reported that teachers believe they have a role to play in supporting children’s mental health. However, they acknowledge that they lack specific knowledge and skills to promote positive mental health. Lahti et al. [ 48 ] noted in a study on skills for promoting mental health in primary schools that the study participants felt that skills development was not sufficiently addressed in either initial or continuing teacher training. Digital tools, online resources, and online support are also lacking in the promotion of children’s mental health. Rojas-Andrade et al. [ 44 ] indicated that teachers feel the need to improve communication and collaboration with mental health professionals. Strengths and limitations To our knowledge, this study is the first in Kinshasa and perhaps in the DRC to explore teachers’ perceptions of MHPS and the factors that may explain their commitment. It provides an in-depth description of the experience of one of the key actors in MHPS, namely teachers. It fills gaps in the existing literature in resource-limited contexts, particularly in the DRC. The fact that the teachers who participated in the study came from different education networks within the Ministry of Education provided various perspectives. However, two limitations are worth mentioning. First, only teachers were included in this study. This did not allow us to understand the perceptions of other key education stakeholders on mental health promotion, namely pupils and school administrators. Second, this study used only individual interviews for data collection. The use of focus group discussions would have allowed us to obtain contrasting views from participants, leading to the co-construction of a common vision among key stakeholders. Implications for research and practice The study results suggest that mental health should be included in initial and continuing teacher training. Measuring teachers’ mental health literacy could determine their actual training needs in this area. Conclusions This study shows that mental health in schools is perceived by most teachers who responded to the interviews as a new concept, sometimes associated with mental health disorders, sometimes unknown. The factors promoting their commitment were mainly personal motivation and perceived institutional support. Despite their motivation, teachers identified several obstacles to their commitment, including a lack of training, a lack of resources, and a lack of sustained institutional support. The current practices related to mental health in schools perceived by the participants were the identification of psychological or behavioural issues in pupils, psychological assistance, and counselling. They feel the need for training in mental health and propose concrete solutions to improve the promotion of mental health, including the integration of mental health into school curricula. Taking the findings of this study into account would contribute, on the one hand, to promoting the mental health and well-being of primary school teachers and, on the other hand, to promoting mental health and learning among primary school pupils. This would enable progress towards Sustainable Development Goal (SDG) 3 (Good health and well-being, in particular target 3.4 on mental health and well-being) and SDG 4 (Quality Education) in the context of the DRC and other low- and middle-income countries. Abbreviations DRC Democratic Republic of Congo HPS health promotion in schools IDI in-depth interview MHPS mental health promotion in schools SDG Sustainable Development Goal Declarations Acknowledgements We sincerely thank Mr Pascal Atuba, Ms Ruth Bosebele and Mr Bonheur Matadi for their help in collecting data, and Dr Landry Egbende for his contribution to data analysis. We also thank the teachers who participated in this study for their availability. Author contributions JNM designed the study and the methodology, collected the data, drafted the main manuscript. DTK, JPJA, and DLEAO made substantial contributions to the methodology and supervision. SDNM, LBBM and EMM revised the methodology. All authors participated in reading and revising the main manuscript and approved the final version of the manuscript. EMM submitted the final manuscript. Funding This study, which is part of JNM’s PhD, received no specific funding. Data availability All data collected as part of this study have been published within this manuscript. They are also available upon request from the corresponding author. Ethics approval and consent to participate This study was approved by the Institutional Review Board of the Institut Supérieur des Techniques Médicales in Kinshasa (No. 0019/CBE/ISTM/KIN/RDC/PMBBL/2023). It adhered to ethical principles and the Declaration of Helsinki for research involving human subjects. All study participants signed themselves a free and informed consent form before participating in the study. All procedures were performed in accordance with the relevant guidelines and regulations of the research ethic committee. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Burns JR, Rapee RM. School‐based assessment of mental health risk in children: the preliminary development of the Child RADAR. 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Public school teachers’ perceptions about mental health. Rev Saúde Pública . 2014;48(6):940‑8. https://doi.org/10.1590/S0034-8910.2014048004696 Reinke WM, Stormont M, Herman KC, Puri R, Goel N. Supporting children’s mental health in schools: Teacher perceptions of needs, roles, and barriers. Sch Psychol Q . 2011;26(1):1‑13. https://doi.org/10.1037/a0022714 Aya M. Abd El Latif et al. Role of School Teachers in Pupils’ Mental Health Promotion. The Egypt. J. Comm. Med. 2018;36(1):117-129. Dey M, Marti L, Jorm AF. Teachers’ Experiences with and Helping Behaviour Towards Students with Mental Health Problems. Int Educ Stud . 26 2022;15(5):118. https://doi.org/10.5539/ies.v15n5p118 Flores III FJ. Perceptions des enseignants concernant l’auto-efficacité et le soutien à la santé mentale des élèves : une étude descriptive qualitative. Thèse de doctorat, Université Grand Canyon, 2025. Maclean L, Law JM. Supporting primary school students’ mental health needs: Teachers’ perceptions of roles, barriers, and abilities. Psychol Sch . 2022;59(11):2359‑77. https://doi.org/10.1002/pits.22648 O’Farrell P, Wilson C, Shiel G. Teachers’ perceptions of the barriers to assessment of mental health in schools with implications for educational policy: A systematic review. Br J Educ Psychol . 2023;93(1):262‑82. https://doi.org/10.1111/bjep.12553 Rojas-Andrade R, Aranguren Zurita S, Prosser Bravo G. Teachers as School Mental Health Professionals and their Daily Practices. School Ment Health . 2024;16(2):566‑76. https://doi.org/10.1007/s12310-024-09664-8 O’Toole C. The role of teachers in supporting students’ mental health. Teach Curric . 2023;23(1). https://doi.org/10.15663/tandc.v23i1.428 Imran N, Rahman A, Chaudhry N, Asif A. World Health Organization “School Mental Health Manual”-based training for school teachers in Urban Lahore, Pakistan: study protocol for a randomized controlled trial. 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They make it possible to reach not only schoolchildren but also those who are not in school and the entire community. Various evidence-based programmes can be implemented in schools, whether they focus on the school climate, the development of psychosocial skills, or the quality of teacher-pupil relationships [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These interventions contribute to the well-being of pupils, teachers, staff, and the community [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. They are particularly beneficial for children, promoting their academic success and development, including those exposed to risks such as poverty, family stress, learning difficulties or behavioural problems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The literature shows that mental health promotion and prevention interventions are particularly relevant during childhood and adolescence, two key periods for laying the foundations for healthy development [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Available data show that the scale of mental health problems in schools is a cause for concern worldwide, with an estimated prevalence of between 10% and over 20% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Zambia, a study revealed an overall prevalence of 37.7% among schoolchildren, including somatic complaints (29.6%), affective disorders (14.1%), and conduct disorders (12.5%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This situation contrasts sharply with the scarcity of MHPS interventions, particularly in sub-Saharan Africa, where such initiatives remain virtually non-existent [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe high prevalence of emotional and behavioural difficulties among schoolchildren highlights the importance of paying attention to pupils\u0026rsquo; mental health [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These unaddressed problems have major consequences: poor school achievement, exclusion, dropping out, juvenile delinquency, physical disorders, and an increased risk of substance abuse [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, it should be noted that behavioural issues among pupils may have a significant negative impact on teachers\u0026rsquo; mental health, as they are likely to increase their workload and exacerbate the job-stress related to their role as educators [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven that a correlation has been established between the mental health and wellbeing of teachers and those of pupils [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the development of mental health conditions in pupils would have repercussions on the mental health of teachers, and vice versa [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, implementing a mental health promotion programme in schools would be beneficial for both teachers and pupils.\u003c/p\u003e \u003cp\u003eThe promotion of mental health in schools (MHPS) should mobilise both health and education professionals, as it is an essential condition for effective pupil learning [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It involves all school and community stakeholders, with teachers playing a central role. Teachers are key stakeholders in MHPS: they can identify pupils with mental or psychosocial difficulties and help refer them to appropriate services [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. They also participate in the implementation of wellness promotion programmes and universal interventions while fostering an inclusive and welcoming school climate [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Their perception of MHPS is a determining factor in their commitment and participation in these interventions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch on the involvement of schools and teachers in supporting pupils\u0026rsquo; mental health is strongly recommended. Conducted using a qualitative approach, such research provides an in-depth and nuanced understanding of the experiences and perceptions of the actors involved [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTeachers\u0026rsquo; involvement and commitment to health promotion in schools have been extensively studied [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This research shows that the determinants of their participation fall into two categories: individual factors and organisational factors. Individual factors include a sense of competence, interest in the programme, a sense of personal effectiveness, and the programme\u0026rsquo;s alignment with the teacher\u0026rsquo;s values. Organisational factors refer to the existence of shared goals, effective leadership, and the local community. Furthermore, research indicates that most teachers recognise that promoting mental health is an integral part of their professional role [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the Congolese context, a study on teachers\u0026rsquo; perceptions of MHPS is part of the drive to relaunch or revitalise Health Promotion in Schools (HPS). The Democratic Republic of Congo (DRC) has a national school and university health programme, a national mental health programme, and a primary education programme that includes health-related content, such as personal hygiene, mental hygiene, environmental hygiene, domestic accidents, vaccination, and nutrition [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Despite this framework, services dedicated to MHPS remain virtually non-existent. In this context, the present study focused on teachers\u0026rsquo; perceptions of their role and commitment in MHPS. It aims to understand how primary school teachers perceive mental health promotion in schools and identify factors that may influence their commitment to promotional interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study adopted a qualitative phenomenological approach to gain an in-depth understanding of the meaning that teachers attribute to their experiences in MHPS. This approach was chosen because it is based on a hermeneutic perspective, according to which reality is composed of multiple mental constructs and subjective representations specific to the individuals involved in a given phenomenon [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, it does not seek to set aside assumptions, but rather recognises that interpretation is a necessary step towards understanding [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePhenomenology seeks to observe and describe the meaning that an individual attributes to an experience, based on their awareness of it. Applicable to various fields, particularly health, its objective is to capture human experience as it is lived, generally through in-depth interviews. In the context of this study, it allows us to explore teachers\u0026rsquo; subjective experiences regarding mental health promotion in schools [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We therefore believe that this methodological approach is the most appropriate for our study, as it has enabled us to capture the meanings and significance that teachers attribute to their commitment in MHPS through multiple interpretations linked to their professional experience, educational values, and institutional contexts.\u003c/p\u003e \u003cp\u003eThe data collection period was set considering the school calendar in force in the DRC. This study took place between October 2024 and January 2025, depending on the availability of teachers and schools. The research team responsible for the interviews consisted of the principal investigator assisted by two interviewers. The principal investigator holds a master\u0026rsquo;s degree in public health and a master\u0026rsquo;s degree in nursing and is trained in qualitative methods. The other two, a man and a woman, hold master\u0026rsquo;s degrees in nursing and are also trained in qualitative methods. The principal investigator and team members had no connection with the teachers participating in the study. The teachers were informed of the study\u0026rsquo;s objective, which helped establish a relationship of trust.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting and participants\u003c/h3\u003e\n\u003cp\u003ePrimary schools in the city of Kinshasa were our study setting. They met the following criteria: they are located in urban or semi-urban neighbourhoods, they may (or may not) be part of the healthy school\u0026rsquo;s network, and they are private, public, and faith-based schools.\u003c/p\u003e \u003cp\u003eThe study participants were primary school teachers. In accordance with the organisation of the Congolese education system, they belong to three levels of education: i) elementary level (1st and 2nd grades), ii) middle level (3rd and 4th grades), and iii) terminal level (5th and 6th grades). All of them applied the official curriculum, which includes certain subjects related to health promotion, such as health and environmental education, physical education, and sports. The teachers selected had proven teaching experience and regularly addressed topics related to health promotion in schools (HPS) in their teaching practices. This commitment was verified on the basis of their teaching documents (lesson plans, class journals, and subject forecasts), as well as through posters and other teaching aids present in the classroom. The evidence observed at these different levels demonstrates their commitment to HPS. The school administration also contributed to the selection process. After being informed of the study\u0026rsquo;s objectives, the researcher directed the researcher to the teachers considered most competent and likely to communicate their experience in promoting mental health at school in a detailed and relevant manner.\u003c/p\u003e \u003cp\u003eTeachers were recruited according to a principle of theoretical representativeness, considering the characteristics described above. To be selected, each teacher had to meet the following criteria: i) be a practising primary school teacher (standing teacher), ii) have at least two years of experience, have already mastered the teaching programme, and have already obtained at least two good grades in the evaluation, iii) be able to clearly express and develop their ideas and experience (ability confirmed during the joint selection process with the management), and iv) have agreed to participate in the study.\u003c/p\u003e\n\u003ch3\u003eSampling\u003c/h3\u003e\n\u003cp\u003eThis study used a purposive (or theoretical) sample, meaning that participants were selected based on the needs of the research. The researcher chooses informants who have in-depth knowledge of the subject or who have had a typical experience of the phenomenon under study and are able to describe it in a clear and thoughtful manner [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This strategy enriches the quality of data by encouraging expression, reflection, and sharing of authentic and detailed experiences. The value of the data depends on the richness, relevance, and depth of the narratives provided [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The sample size was gradually established as the interviews yielded the information sought. Recruitment continued until the data became repetitive and no longer provided any new information, indicating that saturation had been reached. The interviews were therefore analysed as they were collected.\u003c/p\u003e \u003cp\u003eIn this qualitative approach, the sample size is not fixed in advance. A small but carefully constructed sample is sufficient to achieve a comprehensive understanding of the phenomenon [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The final size depends on the principle of saturation, which is reached when the categories are described exhaustively and no new relevant information emerges. Saturation is widely recognised as a key methodological benchmark in qualitative research: beyond this point, continuing to collect or analyse data no longer adds value. Therefore, it is a reference criterion for determining the size of intentional samples in health science [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, it is important to distinguish between code saturation\u0026mdash;often achieved with about nine interviews\u0026mdash;and meaning saturation, which generally requires 16\u0026ndash;24 interviews [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In this study, 24 teachers from 12 private, public, and faith-based schools were recruited. This number corresponds to the sample size obtained when data saturation was reached.\u003c/p\u003e\n\u003ch3\u003eData collection method and tool\u003c/h3\u003e\n\u003cp\u003eThe data for this study were collected through semi-structured face-to-face in-depth interviews (IDI) with primary school teachers. This method was chosen for several reasons: i) it allows for direct interaction between the researcher and the participants; (ii) it provides access to the components of their personal frame of reference\u0026mdash;viewpoints, understandings, representations, experiences, and perceptions\u0026mdash;in relation to the phenomenon under study; (iii) it promotes an in-depth exploration of their perspective, providing access to their experiences and understanding of the subject [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], in a context of exchange where the teacher is recognised as the holder of specific knowledge [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe developed for this study the interview guide (in French), appended as a supplementary file (Text S1), which enabled us to explore primary school teachers\u0026rsquo; perceptions of MHPS and to highlight the factors explaining their commitment in HPS activities. Teachers\u0026rsquo; perceptions were explored using open-ended questions about their representation, understanding, and knowledge of mental health promotion in schools, the factors explaining their commitment, obstacles, needs, and expectations. A total of seven questions were asked of participants, encouraging them to comment more extensively on the various topics. Follow-up questions were asked when certain topics were not addressed or were only briefly touched upon by participants. This interview guide was tested on two teachers at a school with characteristics similar to those of the schools selected for the survey. This pre-test helped improve the quality of the instrument and assess the time and conditions required for its administration.\u003c/p\u003e \u003cp\u003e Each interview, lasting between 40 and 60 minutes, took place either in rooms reserved for teaching staff within the schools or, where more appropriate, in outdoor areas specially equipped to ensure the confidentiality and comfort of the participants. The interviews were recorded with the participants\u0026rsquo; permission. The observation notes supplemented them. The transcripts were submitted to the participants for verification and validation of their accounts. A reflective journal was kept at the end of each day of the survey during the researchers\u0026rsquo; meeting to improve the researcher\u0026rsquo;s posture and limit interpretation bias.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe analysis was conducted using QDA Miner software, following Braun and Clarke\u0026rsquo;s approach to reflexive thematic analysis [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This approach is understood as an easily accessible and theoretically flexible interpretive approach to qualitative data analysis, which facilitates the identification and analysis of trends or themes in a data set. This approach is a six-step process: familiarising oneself with the data, generating preliminary codes, searching for themes, reviewing themes, defining and naming themes, and producing the report [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This reflexive thematic analysis was compared with the initial manual analysis tested by the principal investigator (JNM) using the phenomenological reduction method described by Colaizzi, following these steps: i) familiarisation, ii) identification of significant statements, iii) formulation of meanings, iv) grouping of themes, v) development of an exhaustive description, vi) production of the fundamental structure, and vii) verification of the fundamental structure with participants [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo ensure the rigour of the analysis, the themes were developed inductively. We verified consistency between coders by successively comparing the code matrices. The discrepancies observed between the codings were discussed among researchers, helping to reinforce the validity of the analysis. The credibility of the results was confirmed by validation with the participants. Analyses were also discussed among the researchers to improve their interpretative quality. The transferability of the results was ensured by a detailed description of the characteristics of the target population\u0026mdash;primary school teachers\u0026mdash;which guided recruitment and made it possible to construct a theoretical sample reflecting their experience in MHPS. Finally, fidelity was ensured by a sustained presence in the field, in-depth analysis of the narratives, and the use of participant feedback [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003eThis study is part of a large doctoral research protocol whose protocol was approved by the Institutional Review Board of the \u003cem\u003eInstitut Sup\u0026eacute;rieur des Techniques M\u0026eacute;dicales\u003c/em\u003e in Kinshasa (No. 0019/CBE/ISTM/KIN/RDC/PMBBL/2023). It was conducted according to the ethical principles of the Declaration of Helsinki. All study participants signed a free consent form.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSocio-professional characteristics of the participants\u003c/h2\u003e \u003cp\u003eThe study participants were aged between 20 and 80 years, with a mean age of 53.7 years. The majority were men (70%), 70% of whom were married. All were full-time teachers and held a secondary school diploma. In addition, 83% had received no training in mental health, and 96% had more than nine years of teaching experience.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePrimary school teachers\u0026rsquo; perceptions\u003c/h2\u003e \u003cp\u003eBy analysing primary school teachers\u0026rsquo; perceptions of mental health promotion, the following five main themes emerged: i) teachers\u0026rsquo; knowledge and understanding of mental health; ii) factors promoting their commitment in mental health promotion; iii) barriers to this commitment; iv) current practices related to mental health; and v) teachers\u0026rsquo; needs and expectations in relation to mental health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTeachers\u0026rsquo; knowledge and understanding of mental health\u003c/h2\u003e \u003cp\u003eMental health was described as a new concept by most participants. Some interpreted it as \u0026ldquo;madness\u0026rdquo;, while others perceived it as something unknown. Furthermore, a minority seemed to be familiar with the concept, albeit vaguely. Three categories were identified in relation to this theme.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMental health, a little-known (or unknown) concept, a new initiative for teachers\u003c/h2\u003e \u003cp\u003eMost teachers described mental health by as an intellectual disability or mental retardation. Given that apparently normal pupils are admitted to school, teachers thought that this problem would affect other people but not in a school setting. A participant expressed it in these terms:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In our school, we do not have children with these problems. Even when I was teaching lower grades, I never noticed any pupils with this problem, and now that I am teaching upper grades, I do not see any pupils with this problem. I think that mental health problems are for mentally retarded people who are not intelligent enough to understand a lesson or to understand something that I have understood.\u0026rdquo;\u003c/em\u003e (IDI, Participant 4)\u003c/p\u003e \u003cp\u003eFor some participants, mental health is a new concept in their practices about which they do not have sufficient information. One of them stated it in these terms:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In any case, it is a new concept. I remember that a year ago, a psychologist came to conduct a study on children with problems, but I do not have any information about that. It is already a superb initiative. As you know, children are really different in their daily lives. We manage them, and we already realise that not all children have the same intellectual or comprehension abilities, so your fieldwork is a very good thing, especially if we were to set up something related to children in this regard.\u0026rdquo;\u003c/em\u003e (IDI, Participant 2)\u003c/p\u003e \u003cp\u003eTeachers emphasise its importance in identifying and guiding pupils with specific needs. This is highlighted in the following statements from participants:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is already a superb initiative, as you know, children are really different daily.\u0026rdquo;\u003c/em\u003e (IDI, Participant 2)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Promoting mental health is like you coming here to promote mental health, to see if we have such children in our school.\u0026rdquo;\u003c/em\u003e (IDI, Participant 7)\u003c/p\u003e \u003cp\u003eAnother stated that\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think it is important that this be implemented in schools because some children have problems with maths, while others do not apply themselves well in school due to family problems.\u0026rdquo;\u003c/em\u003e (IDI, Participant 13)\u003c/p\u003e \u003cp\u003e \u003cem\u003eMental health is a problem linked to serious mental disorders, learning difficulties, and specific problems.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTeachers\u0026rsquo; understanding of mental health varies. Some perceive it as an issue related to serious mental disorders, while others associate it with learning difficulties or specific behaviours in pupils. Their statements are summarised as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;He is faced with a child who is not adapting to his teaching because he has no idea about the child\u0026rsquo;s mental health.\u0026rdquo;\u003c/em\u003e (IDI, Participant 1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Mental health is in the head, is not it? I can take the example of children with disabilities who are not normal and do not think like everyone else.\u0026rdquo;\u003c/em\u003e (IDI, Participant 6)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Mental health is when pupils do not really understand what we teach at school.\u0026rdquo;\u003c/em\u003e (IDI, Participant 10)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eA nearly good understanding of mental health\u003c/h2\u003e \u003cp\u003eWhile the concept of mental health has been confused with illness or intellectual disability, some teachers have a fairly good understanding of the concept, even if action still needs to be taken. For them, mental health is a matter for psychology and psychiatry. This dimension point to a psychological problem. Participants equate mental health with the brain, memory and reasoning. They put it this way:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;That is to say, the health of the mental faculties, brain, memory, etc. Regarding mental health, the child must be in a healthy psychological state and must have a good support system at home, where they live. They cannot be frustrated. All of this must be considered so that the child can do well in school.\u0026rdquo;\u003c/em\u003e (IDI, Participant 21)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is the child\u0026rsquo;s reasoning. I sometimes see that the child has difficulty reasoning and answering questions. They give you the wrong answer. The child has difficulty understanding what others understand easily. I might think that something is wrong with their mind, but since I cannot just say anything, we call the parents to explain their child\u0026rsquo;s condition.\u0026rdquo;\u003c/em\u003e (IDI, Participant 23)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eFactors that may explain teachers\u0026rsquo; commitment to mental health in schools\u003c/h2\u003e \u003cp\u003eAccording to the participants, the factors that facilitate their commitment to mental health in schools fall into two categories: on the one hand, personal motivation and, on the other hand, institutional support, establishing a comprehensive mechanism for promoting mental health in schools.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePersonal motivation\u003c/h2\u003e \u003cp\u003eFor most teachers, mental health is a really important issue these days. Many people experience these problems, and express the need to and desire for improved management of mental health issues. One of participants expressed it as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Personally, I can get involved because I agree with all of this. We may not have these children in our upper grades, but we may have them in other grades! We must come; it will help the school. There are pupils who are disruptive, maybe that is also a problem. Even if you correct them, they do not correct themselves. Some behave as if they were at home, when we are in an educational environment.\u0026rdquo;\u003c/em\u003e (IDI, Participant 4)\u003c/p\u003e \u003cp\u003eWhile another stated that\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;What motivates us to get involved are the lives and homes of the children we have to help, give advice to, guide in class, and not hit because they are problem children.\u0026rdquo;\u003c/em\u003e (IDI, Participant 3)\u003c/p\u003e \u003cp\u003eThey are also motivated by their passion for education and their desire to help \u003cem\u003epupils\u003c/em\u003e in difficulty and ensure that they are healthy in the school environment. Some pupils from turbulent backgrounds attend school, but so do bullies. This situation provides further motivation to learn about and receive training in mental health. This is what they said during their interviews:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The desire to help and mentor children drives us to get involved because for me, mentoring is a passion.\u0026rdquo;\u003c/em\u003e (IDI, Participant 2)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;What drives me personally with the children we have now, as this is a free school, is that we have taken in children from all over. The parents came to enrol them to benefit from this free education. Some of the pupils were Chegu\u0026eacute;s (i.e., street children in the DRC) or Kuluna (i.e., delinquent children in the DRC), but now we have taken them in. We need to do this because it can correct them, tell them that what they are doing on the streets is not right and that now they have to get involved in this! Naturally, what motivates me, especially since we are in an environment where there are many Kuluna, is that perhaps with this promotion of mental health, we can educate them and change them, starting with their little brothers, when they tell them that we had this at our school. It will be like advice to them.\u0026rdquo;\u003c/em\u003e (IDI, Participant 4)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eInstitutional support\u003c/h2\u003e \u003cp\u003eFor teachers, institutional support is essential for promoting mental health. They stated that it is important to organise training sessions but also to provide the resources to do so. Some participants stated the following:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;First of all, as a teacher and parent, I am very positive about this promotion, but we need to provide the resources. The problem here is that people have good ideas, but the resources are not there. Without resources, we cannot do anything good. Even just travelling requires resources, and caring for these children requires resources.\u0026rdquo;\u003c/em\u003e (IDI, Participant 1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I believe that once we have the training, we will commit to supporting this initiative, regardless of how the study is ultimately conducted.\u0026rdquo;\u003c/em\u003e (IDI, Participant 2)\u003c/p\u003e \u003cp\u003eA participant emphasised the need for a leader in this field:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In our community, we need a promoter, a leader, an agent who supports us; otherwise, there is no one here to help us promote mental health. Resources (financial and material) make our work in the area of mental health easier. What holds us back is training and an unsuitable environment.\u0026rdquo;\u003c/em\u003e (IDI, Participant 3)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to teachers\u0026rsquo; commitment to mental health in schools\u003c/h2\u003e \u003cp\u003eDespite their motivation, teachers identify several barriers to their commitment, including a lack of training, resources, and institutional support, as well as negative perceptions of mental health among some teachers. However, they place the greatest emphasis on financial resources.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eFinancial obstacles\u003c/h2\u003e \u003cp\u003eFinancial resources are a major obstacle to promoting mental health in schools. Teachers feel that resources are very necessary because any initiative would require financial resources, particularly for training, awareness-raising, curriculum programmes, and treatment centres. For example, the tools needed to promote mental health in schools require financial resources. This is what emerges from the following statements:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Even just your travel requires resources, caring for these children requires resources, the studies we have to do, how to guide these children requires resources, so the state must provide the resources if we want young people who can help this country tomorrow.\u0026rdquo;\u003c/em\u003e (IDI, Participant 1)\u003c/p\u003e \u003cp\u003eA participant highlighted the lack of tools for mental health screening:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We need the right tools to identify whether a child is sick or not because parents have to tell us about their child\u0026rsquo;s health, as some children do not like to say they are sick for fear of being insulted. Referrals are made at the centres, but we do not have a centre here.\u0026rdquo;\u003c/em\u003e (IDI, Participant 3)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eNegative perceptions of mental health\u003c/h2\u003e \u003cp\u003eThe belief that mental health is linked to insanity limits teachers\u0026rsquo; ability to promote it. As a result, this concept is seen as the preserve of those who can treat insanity and who do not see the importance of promoting mental health. A participant expressed it in these terms:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In our school, we do not have children with these problems. Even when I was teaching lower grades, I never noticed any pupils with this problem, and now that I am teaching upper grades, I do not see any pupils with this problem. I think mental health is for the mentally retarded.\u0026rdquo;\u003c/em\u003e (IDI, Participant 4)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCurrent practices related to mental health at school\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eIdentification of problem pupils\u003c/h2\u003e \u003cp\u003eThe identification of pupils with mental health problems is based mainly on observation of behaviour and interactions with parents. However, teachers often lack the tools and training to perform this screening systematically. The participants expressed themselves differently as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Normally here at school, pupils have to be really normal. If we see a pupil who is a little abnormal, we can send them to a school that treats abnormal pupils.\u0026rdquo;\u003c/em\u003e (IDI, Participant 12)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;For me, the components of health are: identifying children with mental health issues in each class.\u0026rdquo;\u003c/em\u003e (IDI, Participant 7)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We identify pupils with mental health issues, as I mentioned earlier, and we have been able to detect a few children.\u0026rdquo;\u003c/em\u003e (IDI, Participant 11)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003ePsychological support and guidance\u003c/h2\u003e \u003cp\u003eThe lack of resources and appropriate facilities limits access to psychological support and counselling for pupils with psychological issues. Teachers turn to parents or refer pupils to specialised schools. The participants expressed differently their support for pupils affected by psychological and behavioural issues in the following terms:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;For the guidance of children with problems, we deal with the parents, we give them advice to change schools, and we often send them to Bondeko Villages.\u0026rdquo;\u003c/em\u003e (IDI, Participant 6)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We want you to be able to provide us with assistance for these children.\u0026rdquo;\u003c/em\u003e (IDI Participant 20)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When a child is sick, we call the parents and tell them that the child is sick and that they need to take him or her to the hospital.\u0026rdquo;\u003c/em\u003e (IDI, Participant 18)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eTeachers\u0026rsquo; needs and expectations\u003c/h2\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eNeed for teacher training on mental health\u003c/h2\u003e \u003cp\u003eTeachers need to be trained on mental health so that they understand the concept and can apply mental health concepts in the school environment. Some teachers have never heard of this concept, and it is critical to improve their knowledge of it to help them detect certain signs even in a school setting. This is what three of the respondents stated in the following:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;First, I will tell you the truth: teachers who work with these children on a daily basis need to be trained in mental health because if we do not know anything about it, what can we teach the children? Those who work with children need to be given training in mental health, and then we can do something about it.\u0026rdquo;\u003c/em\u003e (IDI, Participant 1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;These situations are very rarely addressed in schools, which is why many teachers currently have difficulty monitoring children. They are faced with children who do not adapt to their teaching because they have no idea about children\u0026rsquo;s mental health. In our village, when we were still young, if you went into the principal\u0026rsquo;s office, you would see that each child had a medical file with information about everything related to the child\u0026rsquo;s health.\u0026rdquo;\u003c/em\u003e (IDI, Participant 1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;At our school, the truth is that we do not even talk about promoting mental health, and we do not even mention it.\u0026rdquo;\u003c/em\u003e (IDI, Participant 15)\u003c/p\u003e \u003cp\u003eIn addition, teachers expressed the need to set up mental health care institutions with all the necessary resources. A respondent put it this way:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Our needs, if you have the means to promote them, set up a centre here, bring us medicine, specialists who know how to deal with children with problems. Unless we have training in mental health, we will not know how to identify children who are ill. To promote health, we need lots of seminars and training on mental health, lots of dialogue between parents and pupils, between teachers and parents, teachers and pupils, and principals and parents.\u0026rdquo;\u003c/em\u003e (IDI, Participant 3)\u003c/p\u003e \u003cp\u003eWhile another stated that\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We need to ask the authorities to provide us with the necessary equipment to support children in case of illness, such as a school infirmary, because it is a large school. If we had a nurse who could treat children in serious cases, that is what we would like the state to help us with.\u0026rdquo;\u003c/em\u003e (IDI, Participant 5)\u003c/p\u003e \u003cp\u003eParticipants proposed concrete solutions to improve mental health promotion, including organising seminars and integrating mental health into school curricula. Three of them expressed this in turn as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Organise a seminar for each district or municipality, bringing together schools from a municipality in one place.\u0026rdquo;\u003c/em\u003e (IDI, Participant 13)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We want the government to include this course in the curriculum.\u0026rdquo;\u003c/em\u003e (IDI, Participant 9)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We expect the government to take full responsibility for this so that pupils and parents know that support is available.\u0026rdquo;\u003c/em\u003e (IDI, Participant 24)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study, which aimed to understand primary school teachers\u0026rsquo; perceptions towards MHPS and the factors that may explain their commitment to promoting it, suggest that the study participants still perceive mental health much more as mental disorders than as positive mental health, and that they are not very committed to promoting it in schools.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge and understanding of mental health\u003c/h2\u003e \u003cp\u003eThe knowledge and understanding of mental health among the teachers participating in the study indicate that the majority of them perceive it as a new concept that sometimes refers to insanity and sometimes as something unknown, a new initiative to identify and refer pupils with specific needs. However, a minority perceives it in terms of positive mental health. Our findings corroborate those of some studies published on this subject. This is the case, for example, in Ekornes\u0026rsquo; study [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], which indicates that mental health is an unfamiliar term in schools and often has negative connotations. This widely cited understanding remains somewhat diverse depending on the author. For Isaksson et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], the teachers participating in his study understand the promotion of mental health in schools as structured work involving monitoring and collaboration with parents and the creation of a pleasant atmosphere within the school that includes enjoyment, interaction through play, peace and tranquillity, and team spirit. In another study by Soares et al. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], mental health is understood as the balance between mind and body, as a requirement for happiness.\u003c/p\u003e \u003cp\u003eTeachers recognise the importance of developing mental health services in schools. They consider promoting mental health at school part of their professional identity [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. They identify with the role of first responders in mental health at school [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. They develop a school culture that considers schools to be in a unique position to encourage positive relationships between teachers and pupils and positively influence pupils\u0026rsquo; mental health [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Greater knowledge of mental health among teachers could increase their willingness to help pupils with specific problems [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eFactors promoting teachers\u0026rsquo; commitment to mental health promotion\u003c/h2\u003e \u003cp\u003eAccording to the participants, the factors facilitating their commitment to mental health in schools may stem from personal motivations on the one hand, but on the other hand from institutional support, putting in place a whole mechanism for the promotion of mental health in schools. This understanding is widely discussed in the literature.\u003c/p\u003e \u003cp\u003eFelipe Julian Flores II notes that the self-efficacy factors perceived by participants in his study were: administrative support to ensure practical application and integration in the classroom, confidence in supporting pupils, the establishment of a climate of trust and connection, a safe and stimulating environment, recognition of limitations, and the pursuit of improvement [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Mazzer \u0026amp; Rickwood [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] indicated that additional training in mental health and a clear definition of roles within the institution could motivate teachers to feel better prepared to effectively and adequately support pupils\u0026rsquo; mental health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to promoting mental health in schools\u003c/h2\u003e \u003cp\u003eDespite their motivation, teachers identify several barriers to their commitment, including a lack of training, resources, and institutional support, as well as negative perceptions of mental health among some teachers. However, they place the greatest emphasis on financial resources.\u003c/p\u003e \u003cp\u003eThese findings regarding barriers also corroborate those of other studies. This is the case for lack of training, identified as a major obstacle to the implementation of adequate support and screening, role conflict, lack of resources, time constraints [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], lack of time allocated to the programme, insufficient training, and inadequate inter-institutional support [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Teachers do not feel sufficiently prepared to adequately support pupils\u0026rsquo; mental health due to a lack of adequate training in this area [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Teachers feel they lack specific knowledge and skills to promote positive mental health [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In another study, participants identified the following barriers to promoting mental health in schools: feeling that they lack the experience or training necessary to help or that they are not in the best position to do so [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAya Abd El Latif et al. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] conducted a study on the role of teachers in promoting pupil mental health and identified the following obstacles: inadequate training in recognising the early signs of mental disorders in pupils, concerns about workload, and a lack of mental health services for teachers aimed at lightening their workload before expecting them to promote pupil mental health.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCurrent practices related to mental health in schools\u003c/h3\u003e\n\u003cp\u003eThe current practices carried out by the study participants in promoting mental health in schools mainly consisted of identifying mental health issues among pupils, providing them with psychological support and referring them to mental health professionals. These practices have also been reported in other studies and be part of the daily routine of teachers promoting mental health. This is the case in Dey et al. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], who reported that 91.5% of teachers acknowledge having identified children with mental health problems in their classrooms. Three-quarters of them were willing to offer them psychological support and referral to a qualified professional. In a study by Imran et al. [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], participants reported that in their teaching practices, they identified children with mental health problems. These included learning difficulties, aggression, disobedience, inattention, lying, and disrespect. Nalipay et al. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], in a study on teachers\u0026rsquo; experiences with pupils suffering from mental health problems, found that the participants\u0026rsquo; current practices in this area were as follows: discussing and providing emotional support to pupils with problems, consulting with or referring pupils to the guidance counsellor, connecting to sources of support, and implementing teaching practices to support pupils\u0026rsquo; mental health. Rojas-Andrade et al. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], discussing the daily practices of teachers as school mental health professionals, revealed that teachers play an important role in identifying and addressing mental health issues in pupils, with 90% of them reporting that they have provided support to pupils with mental health issues.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eTeachers\u0026rsquo; needs and expectations\u003c/h2\u003e \u003cp\u003eThe needs and expectations perceived by participants were as follows: training, establishment of structures for caring for children in schools, the organisation of seminars, and integration of mental health into school curricula. These results are not dissimilar to those reported in other studies.\u003c/p\u003e \u003cp\u003eIn a study on supporting teachers\u0026rsquo; mental health needs, Maclean \u0026amp; Law [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] reported that teachers believe they have a role to play in supporting children\u0026rsquo;s mental health. However, they acknowledge that they lack specific knowledge and skills to promote positive mental health.\u003c/p\u003e \u003cp\u003eLahti et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] noted in a study on skills for promoting mental health in primary schools that the study participants felt that skills development was not sufficiently addressed in either initial or continuing teacher training. Digital tools, online resources, and online support are also lacking in the promotion of children\u0026rsquo;s mental health. Rojas-Andrade et al. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] indicated that teachers feel the need to improve communication and collaboration with mental health professionals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eTo our knowledge, this study is the first in Kinshasa and perhaps in the DRC to explore teachers\u0026rsquo; perceptions of MHPS and the factors that may explain their commitment. It provides an in-depth description of the experience of one of the key actors in MHPS, namely teachers. It fills gaps in the existing literature in resource-limited contexts, particularly in the DRC. The fact that the teachers who participated in the study came from different education networks within the Ministry of Education provided various perspectives.\u003c/p\u003e \u003cp\u003eHowever, two limitations are worth mentioning. First, only teachers were included in this study. This did not allow us to understand the perceptions of other key education stakeholders on mental health promotion, namely pupils and school administrators. Second, this study used only individual interviews for data collection. The use of focus group discussions would have allowed us to obtain contrasting views from participants, leading to the co-construction of a common vision among key stakeholders.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eImplications for research and practice\u003c/h2\u003e \u003cp\u003eThe study results suggest that mental health should be included in initial and continuing teacher training. Measuring teachers\u0026rsquo; mental health literacy could determine their actual training needs in this area.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study shows that mental health in schools is perceived by most teachers who responded to the interviews as a new concept, sometimes associated with mental health disorders, sometimes unknown. The factors promoting their commitment were mainly personal motivation and perceived institutional support. Despite their motivation, teachers identified several obstacles to their commitment, including a lack of training, a lack of resources, and a lack of sustained institutional support. The current practices related to mental health in schools perceived by the participants were the identification of psychological or behavioural issues in pupils, psychological assistance, and counselling. They feel the need for training in mental health and propose concrete solutions to improve the promotion of mental health, including the integration of mental health into school curricula. Taking the findings of this study into account would contribute, on the one hand, to promoting the mental health and well-being of primary school teachers and, on the other hand, to promoting mental health and learning among primary school pupils. This would enable progress towards Sustainable Development Goal (SDG) 3 (Good health and well-being, in particular target 3.4 on mental health and well-being) and SDG 4 (Quality Education) in the context of the DRC and other low- and middle-income countries.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDemocratic Republic of Congo\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehealth promotion in schools\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ein-depth interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMHPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emental health promotion in schools\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustainable Development Goal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank Mr Pascal Atuba, Ms Ruth Bosebele and Mr Bonheur Matadi for their help in collecting data, and Dr Landry Egbende for his contribution to data analysis. We also thank the teachers who participated in this study for their availability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJNM designed the study and the methodology, collected the data, drafted the main manuscript. DTK, JPJA, and DLEAO made substantial contributions to the methodology and supervision. SDNM, LBBM and EMM revised the methodology. All authors participated in reading and revising the main manuscript and approved the final version of the manuscript. EMM submitted the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study, which is part of JNM\u0026rsquo;s PhD, received no specific funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data collected as part of this study have been published within this manuscript. They are also available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the \u003cem\u003eInstitut Sup\u0026eacute;rieur des Techniques M\u0026eacute;dicales\u003c/em\u003e in Kinshasa (No. 0019/CBE/ISTM/KIN/RDC/PMBBL/2023). It adhered to ethical principles and the Declaration of Helsinki for research involving human subjects. All study participants signed themselves a free and informed consent form before participating in the study. All procedures were performed in accordance with the relevant guidelines and regulations of the research ethic committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBurns JR, Rapee RM. School‐based assessment of mental health risk in children: the preliminary development of the Child RADAR. \u003cem\u003eChild Adolesc Ment Health\u003c/em\u003e. 2019;24(1):66‑75. https://doi.org/10.1111/camh.12258\u003c/li\u003e\n\u003cli\u003eLamboy B, Cl\u0026eacute;ment J, Sa\u0026iuml;as T, Guillemont J. 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Competences for promoting mental health in primary school. \u003cem\u003eHealth Educ J\u003c/em\u003e. 2023;82(5):529‑41. https://doi.org/10.1177/00178969231173270\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"mental health promotion, perceptions, teacher commitment, primary school, qualitative study, Democratic Republic of Congo","lastPublishedDoi":"10.21203/rs.3.rs-8497600/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8497600/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground.\u003c/h2\u003e \u003cp\u003eIn low- and middle-income countries, most primary school teachers still have negative perceptions of mental health, which may limit their key role in promoting mental health in schools. This study aimed to understand primary school teachers\u0026rsquo; perceptions of mental health promotion in schools (MHPS) and the factors that are likely to explain their commitment to MHPS interventions.\u003c/p\u003e\u003ch2\u003eMethod.\u003c/h2\u003e \u003cp\u003eThis qualitative study, inspired by phenomenology and hermeneutics, was conducted in the megacity of Kinshasa, in the Democratic Republic of Congo. We collected data by conducting in-depth individual interviews with 24 primary school teachers from 12 schools (private, public and faith-based). We analysed the data according to Braun and Clarke\u0026rsquo;s reflexive thematic analysis approach, informed by a phenomenological perspective. The results were organised around the following themes: teachers\u0026rsquo; understanding of mental health, factors explaining teachers\u0026rsquo; commitment to MHPS, perceived obstacles, current practices, and mental health needs and expectations.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003eMost participants perceived mental health in school as a concept associated with \u0026ldquo;madness\u0026rdquo; or simply misinterpreted it. Participants stated that they perform mental health promotion activities based on their knowledge, including identifying pupils with mental health conditions, providing psychological first aid, and referring them to specialist services. Their commitment to promoting mental health in schools depended on their personal motivations and perceived institutional support. However, several factors, such as lack of training, lack of resources, and lack of sustained institutional support, were cited as perceived obstacles to their commitment. Participants highlighted the need for specific training in mental health promotion and advocated integrating mental health into school curricula to strengthen its promotion.\u003c/p\u003e\u003ch2\u003eConclusion.\u003c/h2\u003e \u003cp\u003eThe findings reveal that primary school teachers in Kinshasa still perceive mental health more as the presence of mental disorders than as positive mental health. Mental health promotion is not being implemented optimally in primary schools, as several perceived obstacles affect teachers\u0026rsquo; commitment. These findings point to the need to revitalise mental health promotion in primary schools, particularly by establishing psychological support structures in schools and training teachers in mental health promotion.\u003c/p\u003e","manuscriptTitle":"Primary school teachers’ perceptions of mental health promotion in schools and factors explaining their commitment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-29 09:23:02","doi":"10.21203/rs.3.rs-8497600/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-09T08:09:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T15:15:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-03T17:36:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202174602781685403610452719283033454978","date":"2026-01-29T16:58:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"65567760441235510144821218910778093520","date":"2026-01-29T08:53:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-28T01:04:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284870050475184929144191789961649292994","date":"2026-01-27T21:51:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309627203465518942428946240642012560092","date":"2026-01-27T19:13:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-27T08:36:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-21T12:41:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-08T05:39:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-08T00:25:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-08T00:19:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bca22d09-bb62-4fff-8875-649333272f14","owner":[],"postedDate":"January 29th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:00:32+00:00","versionOfRecord":{"articleIdentity":"rs-8497600","link":"https://doi.org/10.1186/s12889-026-27374-5","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-04-14 15:56:52","publishedOnDateReadable":"April 14th, 2026"},"versionCreatedAt":"2026-01-29 09:23:02","video":"","vorDoi":"10.1186/s12889-026-27374-5","vorDoiUrl":"https://doi.org/10.1186/s12889-026-27374-5","workflowStages":[]},"version":"v1","identity":"rs-8497600","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8497600","identity":"rs-8497600","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}