Perceived Barriers Related to School Mental

Health Program: A Study from Four High

Schools in West Java

Indri Y. Suryaputri1(B) , Rofingatul Mubasyiroh1 , and Bunga C. Rosha2

1 Research Center for Public Health and Nutrition, National Research and Innovation Agency,
Jakarta, Indonesia
indri.ysp@gmail.com
2 Center for Global Health Policy and Health Technology, Health Development Policy Agency,

Jakarta, Indonesia

Abstract. Mental health issues frequently appear in youth and persist throughout
adulthood. Interventions for adolescents’ mental health can be successfully carried
out in schools. There are currently educational initiatives in place in Indonesia that
emphasize mental health’s importance. Nevertheless, the actual implementation
in practice is not a simple process. The purpose of this study is to determine the
difficulties the school community faces due to the lack of a mental health policy.
Through a series of semi-structured interviews, this qualitative study gathered
information from 32 informants, including students, parents, school principals,
mental health workers, and school counselors. Between April and December 2019,
the research was conducted at four public schools in the Bogor City and Bogor
District areas of West Java. Schools “A” and “B” were there to represent the
schools in Bogor City, and Schools “C” and “D” were there to represent the schools
in Bogor District. According to the research findings, as many as 77 percent of
students (10 participants) were 16 years old, with the remaining 15 and 17 years old
(3 participants). Seven students with high mental health scores were selected, and
six of the informants were student committee members. The parents’ ages ranged
from 43 to 67, with a mean age of 51.8, and their levels of education went from
high school (one informant) to a master’s degree (one informant) to a bachelor’s
degree (one informant) (66 percent or six informants). In addition, two of the
informants were principals, four were school counselors, and one was involved
in school administration. Also interviewed were three primary care mental health
professionals. Several barriers continue to impede the implementation of mental
health programs in schools, according to the findings of this study. These include
a lack of understanding about mental health, a lack of specific human resources
capable of screening and treating students’ mental health problems, a lack of
money, and a high stigma associated with mental health conditions. The school’s
current curriculum and extracurricular activities, such as religious and literacy
activities, should be improved in the future. Adopting mental health initiatives in
schools requires strategic policy support, government endorsement, partnership
with the Ministries of Education and Health, and sufficient finance.

Keywords: mental health · school · stigma · barrier

© The Author(s) 2023

I. Nurlaila et al. (Eds.): ICHR 2022, AHSR 56, pp. 458–468, 2023.
https://doi.org/10.2991/978-94-6463-112-8_42
 Perceived Barriers Related to School Mental Health Program 459

1 Introduction

Mental health problems typically begin in adolescence and persist throughout adulthood.
In most studies, almost half of all mental problems start in the midteens and three-
quarters by the mid-twenties [1]. According to the Global Burden of Disease (GBD)
2019 report, mental health issues are a leading source of disability [2] and health burden
among individuals aged 15 to 19 years [3]. The poor educational outcomes [4] and future
unemployment may also be influenced by adolescents’ mental health [5].
In Indonesia, mental health problems in Indonesia at the age of 15–24 years are
6.2% [6]. Another study revealed that around 7.7% of Indonesian students experienced
mental-emotional issues [7]. Mental health problems such as anxiety, depression, and
psychosis have also started appearing at the young age group (15–24 years) [8].
Adolescent mental health issues must be addressed with a broad and appropriate
effect. Schools are a good place for teen mental health treatments, say several experts.
Indonesia has a mental health-focused educational policy. Implementation isn’t easy.
In 2019, the National Institute of Health Research and Development studied mental
health in schools with parents, students, school administrators, mental health providers,
and a school counselor. The study implements the Sekolah Sejahtera paradigm from
Gadjah Mada University and the Ministry of Health. The study ran for a year, and much
information was gathered, enriching the future directions of mental health in school
policy [9].
Previous research has demonstrated that school-based health promotion improves
mental health and well-being [10]. Additionally, a review of the literature of 29 inter-
vention studies revealed that school-based mental health promotion has a positive impact
on several aspects, including coping skills, help-seeking abilities, social skills, emotional
regulation, and the reduction of depression and anxiety symptoms [11].
Mental health programs in schools are the result of various collaborations between
parties ranging from national policies to schools and families and adolescents themselves.
One of the theories suggested for public mental health intervention and promotion is
Bronfenbrenner’s ecological theory, according to which individual and environmental
factors are related to health [12]. According to Bronfenbrenner’s theory, the mental
health of youth is best understood in the context of a context that ranges from the
level of the individual (personal issues) to the level of the environment (family, school,
friends, community) to the level of the most extensive system of norms, ideologies,
and values. According to research, educators still lack confidence in addressing student
mental health problems and need more training to improve their abilities [13]. Teachers
also highlighted the lack of expertise and training in addressing the mental health needs
of students and believe that mental health practitioners have a more significant role in
maintaining mental health lessons for the students [14]. From the student’s perspective,
the mental health in school should appreciate the young people’s experiences and good
relationships in the school community, reduce stigma and increase confidence so the
youth can take appropriate action [15].
The purpose of this study was to identify the enablers and barriers to implementing
mental programs in school settings, as well as to identify strategies for strengthening the
connection between research and practice in delivering interventions in schools.
460 I. Y. Suryaputri et al.

2 Material and Methods

Design
The study was qualitative with semi-structured interviews. This study was part of mental
health in school research conducted by the National Institute of Health Research and
Development. The research was held between April and December 2019, the research
was conducted in two cities in West Java; there were Bogor City and Bogor District.
Ethical Approval obtained at 29 of March 2019 from the National Institute of Health
Research and Development with number LB.02.01/2/KE.106/2019.

Participants
Respondents were recruited based on the school selected, parents, students, school prin-
cipals or staff, mental health workers from primary health care, and school counselors.
The schools were selected with purposive sampling according to the number of stu-
dents, the sufficiency of facilities such as the school building and teacher condition,
overall learning outcomes in schools, not being the best high schools in town, and a
commitment to collaboration were the selection factors. The school principals, staff,
and counselors were the school coordinators. The students were selected based on the
chosen participants in mental health research who got the highest anxiety or depression
assessment score. The parents also choose based on the students selected. The mental
health workers were the coordinator responsible for the health issue in the school area.
All the informants were approved to join the study before interviewing.

Data Collection
In-depth interview questions were developed based on previous research and had been
tested in the pilot study. The questions involved policies and financing in schools and
primary health care level, school resources, existing policies that are in line with mental
health issues, school staff efficacy in handling the mental health treatment in school,
and perceived barriers from parents and also students to mental health treatment in
schools or primary health care. All answers were recorded, transcribed, and then selective
quotations were coded.

Data Analysis
The qualitative content analysis method was chosen because it allowed the study team
to analyze the interviews systematically, compare them, and abstract the material into
descriptive categories. After the transcriptions were finished, the researchers were read a
second time to acquire a greater comprehension and a feeling of the entire. Means units
were produced and compacted, and those aligned with the study’s goal were chosen.
The interviews were content encoded and linked together based on similarities and
differences. They were then classified into several content sections [16].
 Perceived Barriers Related to School Mental Health Program 461

3 Results

Informants Characteristics
The number of informants was 32, as much as 77% students (10 participants) were
16 years old and the rest were 15 and 17 years old (3 participants) The students charac-
terized as students with high scores of mental health problems were seven, and six were
from the students committee. The age of the parents was between 43 to 67 with average
51.8 years old, and the education range from primary high school (one informant), mas-
ter degree (one informant) and the rest graduated from bachelor degree as much as 66%
or six informants. The informants with criteria of school personnel, were ranging from
39 years old to 54 years old, with one was a principal, four were school counselor and
one was the school management staff. There were three informants representing mental
health workers from primary health care.

Community Barriers
Community plays an important role in mental health prevention. One existing policy
in primary healthcare is the school health unit or Upaya Kesehatan Sekolah (UKS).
For mental health programs carried out by the health sector in schools, in this case,
the Puskesmas located in the school area, the school admitted that a Puskesmas had
never visited them in terms of mental health. There are routine activities carried out by
the Puskesmas in schools, namely screening activities for class XI students but usually
related to physical examinations and the program of giving blood tablets. It is, as stated,
one of the following Puskesmas informants:

“Screening, for example, early detection screening, we do, then treatment, visits
to ODGJ patients, but at the community level, there are no activities at school,
only at the time of the screening, because I happen to be a mental health officer,
so I dug into the net. Other officers, I don’t know what it means to do it or not,
yesterday because there was a point there, I happened to understand, so I did it”
(AY, Mental Health Program Holder, Puskesmas D)

Budget
Budget is an important thing that must be provided in carrying out the program of
activities. Usually, the budgeting has started to be planned from the previous year the
program was run. For the budgeting of activity programs in mental health efforts in
schools, city and district control schools stated that they did not have a particular budget
for mental health programs. Still, there was a budget for activities in mental health efforts
such as staying overnight, motivational training, habituation, self-reflection, retreats,
Basic Training of Student Leadership or Latihan Dasar Kepemimpinan Siswa (LDKS),
and others. This is as explained by the following two informants:

“There is no special budget for holding mental health services in schools. So far,
the Informant said that it is possible to hold mental health services. So far, only a
direct approach to students. And if it is possible to provide mental health services,
462 I. Y. Suryaputri et al.

schools will follow orders if advised by the Education Office” (NR. Principal,
School D)

Puskesmas D admitted that they did not have a budget related to mental health in
schools because they did not know there was a mental health program. After all, so far,
there had been no instructions from the District Health Office to work on mental health
programs in schools. The Puskesmas is still focused on working on community-based
mental health programs. The following is the information provided by the informant:

“No, yes…because we didn’t have the budget, maybe because we didn’t know there
was a mental health program at school. If we knew, we would certainly budget it,
for repairs there…, if we apply, it’s easy to apply for a budget here” (AY, Holder
of Mental Health Program, Puskesmas D)

Human Resources or HR
Human Resources HR is also an essential element that must be available in mental health
activity programs. Aside from being seen from their availability in terms of quantity,
human resources must also pay attention to the quality or ability to carry out the program.
Moreover, the barrier came from the integrity from the school counselor, as mentioned
from one informant:

“The obstacle is more to commitment from us, because we like to forget that we
have an obligation to give mental health services” (AA, school counselor, School
C).

Another problem was the availability of schoolteachers who have the specific ability
to deal with mental health problems in schools. Some believes that the religious teacher
was sufficient to give counseling to the students. This is as stated by the following
informants:

“There are three school counselors in our civil servant or Pegawai Negri Sipil
(PNS) and two non-PNS. In terms of competence, because from mental health, we
feel it is the same as the school counselor, and the second one is with the religion
teacher too, that’s our religion teacher. If there is a school counselor training, we
have monthly meetings for teacher working groups or MGMP, there is an activity
abbreviated as MGMP and if there is an activity, we always send it. Like yesterday
from Marzoeki Mahdi, there was an activity about mental health seminars because
we were asked, we sent it from students and teachers, from students we usually go
to the adolescent red crescent or Palang Merah Remaja (PMR) who are related.
At the same time, there is an opportunity to increase the competence of educators
we always involve” (Da, School Management, School B).

The same thing was also expressed by school D, which stated that the human
resources for counseling guidance were reasonably competent. However, their com-
petence still had to be improved through training. Here’s an excerpt:
 Perceived Barriers Related to School Mental Health Program 463

“Only school counselors are competent in dealing with mental health problems in
children at school. But they still need the training to deal with children’s problems”
(NR, Principal, School D).

In contrast to the opinion above, from the point of view of the parents of students
stating that the number of school counselors in the school B is significantly less to be
able to assist all students, the informants think that ideally, the school counselor is only
sufficient to handle tens of students, with the hope that all students can get widespread
attention. This is what the informant said:

“There are still very few school counselors so that all children get attention” (IK,
Parents, School B)

Ideally, handling mental health problems in students at school after being taken
by school counselor is to make referrals to health facilities such as health centers for
further observation by more competent health workers. Unfortunately, schools B and D
have not carried out the ideal treatment as above. This is because no policy from either
the Ministry of Health or the Ministry of Education regulates this. At the school and
health center levels, there is no Memorandum of Understanding (MOU) between the
two agencies in the referral system for handling mental health problems in schools. The
MOU built between the two agencies is still limited to the selection of students once a
year. This is as expressed by the following informants:

“If the school has issued a referral, we haven’t yet, but we have conveyed to the
parents that this child is different; please try to go to a psychiatrist. If the MOU
with the puskesmas is about mental health, we haven’t yet, but when it comes to
screening for children’s health, it is always there every year” (Da, Management
School, School B)

The above is in line with the recognition of Puskesmas D, which stated that there was
no referral system built yet and an MOU between schools and Puskesmas if students with
mental health problems were found. This is as expressed by the following informants:

“For counseling and treatment for school children, maybe no school children have
been detected... Because it takes a special time, I guess, the whole screening is for
physical health, not mental health... so there has been no referral for mental health
problems to the puskesmas” (RK, Person in Charge of UKS Program, Puskesmas
D).
“There is no MOU regarding referrals for mental health problems found in schools
to the Puskesmas” (AY, Holder of Mental Health Program, Puskesmas D).

Some of the obstacles encountered when referring students with mental health prob-
lems to health facilities are that there is still a stigma in the community that bringing
children to health facilities for further consultation and treatment means that the student
has a mental disorder. This is what the informant said:
464 I. Y. Suryaputri et al.

“There is still a stigma from schoolteachers regarding mental health in students.

The students who have mental health problems are “crazy” children” (H, Deputy
Headmaster, School D)

In addition, there is a feeling of discomfort and embarrassment if students are known

to have consulted on mental health problems at a health facility. This is as expressed by
the following student and school committee informants:

“Shame if you have to make a referral to a psychiatrist, health center or hospital”

(F, School Student D)
“I’d rather go to a psychologist or psychiatrist if I go to the puskesmas, I’m
embarrassed, ah, later people will know, right at the puskesmas there are more
queues when going to the psychologist, it is more private, and there is no need to
queue like in the puskesmas” (EW, Student Council, School B)
“Yes, it was up to the parents, if the parents want we can access the puskesmas
or psychological, if the parents don’t want us we can’t force them” (N, homeroom
teacher, School B)

According to one informant, the cost for further treatment at a health facility may be
an obstacle for parents to take their child to health facility or competent health personnel
regarding mental health issues. Here is what the informant said:

“Perhaps the problem of cost is an obstacle in referring to health services” (IK,

student’s parents, School B)
“For example, if the child has already been affected, it might also be an economic
problem, the distance to the place of treatment can also be an obstacle” (NR,
student’s parents, School B)

4 Discussion

This study found several barriers to maintaining mental health programs in school. Some
of the perceived obstacles, according to school personnel and mental health practitioners
from primary health care, were the supporting policy from the local government, the
availability of a budget to implement the program, teachers’ competence in screening
and handling the student’s mental health issue and the support and agreement from
parents and students itself to join the treatment. The barriers found in this study are
pretty similar to a study that concluded some of the obstacles like (a) school principal
and administrator support; (b) development of teacher involvement; (c) role of financial
resources to sustain practice; (d) availability of quality training and consultation strategy
to achieve fidelity to the model; (e) orientation of the intervention with school ethos,
goals, regulations, and programs; and (f) ensuring that program outcomes and effect are
visible to key stakeholders [17]. That barrier should be anticipated and resolved for the
following mental health intervention program in school.
 Perceived Barriers Related to School Mental Health Program 465

Primary health care in the study has had mental health programs, although not specif-
ically to handle the mental health issue in school. The relationship between the school
and primary care facilities will benefit the school’s mental health program. A study
indicated that schools with mental health agency partnerships looked to have a greater
likelihood of effective implementation [18].
From students’ points of view, some barriers persist in accessing mental health
services in a school or primary health care. The perceived stigma as well as ashamed
to get the assistance needed is in line with a systematic review that identified perceived
social stigma and embarrassment, including perceived confidentiality and the ability to
trust an unknown person, as well as the related to systemic and structural barriers and
facilitators, such as the financial costs associated with mental health services, logistical
barriers, and the availability of professional assistance, are the primary barriers identified
in this study [19]. Moreover, adolescents’ perception of the positive relation of mental
health staff in health care will improve their participation in the treatment [20].
In addition, parents believe that mental health access is expensive and time-
consuming. According to a qualitative survey, the obstacles cited by parents include
the difficulty of meeting mental health doctors, the time required for referral from one
health practitioner to another, and the amount of money they must spend [21]. Embarrass-
ment, the stigma associated with mental health difficulties, and the fear of being labeled
or receiving a diagnosis were other reasons why parents did not send their children to
mental health therapy [22]. Parental engagement could be established by (a) recogniz-
ing parents’ values and their competence about their children; (b) recognizing that they
desire to be good parents, and (d) providing them with alternatives for accomplishing
intervention objectives [23].
This study is the first stage in identifying factors that may hinder or assist the adoption
and sustainability of new school interventions. Conclusions are constrained by the study’s
small sample size and qualitative character. Another limitation was the limited number
of people who joined the interview and could be different results with another type of
study.
Globally, cooperation between schools and other youth-serving systems promotes
the development of school-based mental health services. The International Alliance for
Child and Adolescent Mental Health and Schools (INTERCAMHS) and the School Men-
tal Health International Leadership Exchange were two of the most prominent school
mental health programs (SMHILE). In a comparison of four nations, two have made sub-
stantial progress (the United States and Canada), one has made moderate progress (Nor-
way), and one has just begun work (Liberia). From these four countries, we could learn
that meaningful adolescent and family participation, implementation of evidence-based
methods, monitoring, and quality assurance contribute to the successful implementation
of school-based mental health programs in the United States; from Canada, we could
learn about mental health literacy and workforce development to prepare future teachers
to learn mental health modules; and from Norway and Liberia, the success point is cross-
sector collaboration [24]. Looking for more detail in Canada, there is also a model called
“School-based Pathway to Care” for secondary schools that connects schools to primary
care doctors, mental health services, and the larger community, enabling them to treat
juvenile mental health collaboratively. The paradigm emphasizes the need of mental
466 I. Y. Suryaputri et al.

health literacy, gatekeeper training, and education/health system integration in promot-

ing adolescent mental health, as well as boosting learning environments and academic
outcomes [25].

5 Conclusion
This study demonstrates that barriers for mental health in schools including a lack of
mental health awareness, a lack of human resources capable of screening and resolv-
ing students’ mental health problems, a lack of funding, and a high stigma associated
with mental health, continue to interrupt the implementation of mental health policies in
schools. From a parental standpoint, there are barriers to MH difficulties, such as stigma
and financial constraints. The students’ viewpoints also revealed that one of the chal-
lenges to mental health programs is the presence of stigma. In the future, it is necessary
to optimize the current curriculum and extracurricular activities such as religious and
literacy activities. School-based mental health solutions need tactical policy support,
government endorsement, partnership with the Ministries of Education and Health, and
an appropriate budget.

Acknowledgments. The researcher would like to express gratitude to the Head of the National
Institute of Health Research and Development, the Faculty of Psychology at the University of
Gadjah Mada, the scientists and informants who took part in this study as well because it was only
with their assistance that the study was able to be completed successfully.

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