SWOT Analysis of Child and Adolescent Mental Health Services in the Rural Chris Hani District, Eastern Cape, South Africa

Abstract

Child and adolescent mental health (CAMH) is a global concern that is increasingly recognized and prioritized. Worldwide, mental health conditions affect a significant number of children and adolescents; however, access to CAMH services remains limited. This study sought to explore the implementation of child and adolescent mental health services in the rural Chris Hani District of the Eastern Cape province, South Africa, from the perspectives of health professionals and teachers, focusing on strengths, weaknesses, opportunities, and threats. Using a qualitative approach, a sample of 36 participants (12 health professionals and 24 teachers) was purposively recruited. Data were collected through face-to-face, semi-structured individual interviews and focus group discussions. Thematic analysis identified several strengths, including effective screening and identification of CAMH problems, training in psychiatry and psychology, teacher support, collaboration with stakeholders, and the availability of policy and guidelines. Key weaknesses included inadequate CAMH training, a limited CAMH workforce, personal barriers, guidelines primarily oriented toward physical health, and insufficient basic infrastructure. Opportunities for improvement include enhancing the skills of the existing workforce, increasing engagement in extramural activities, and empowering parents with knowledge of available CAMH services. Identified threats included the normalization of CAMH symptoms, challenges involving parents and feeder schools, stigma, poor stakeholder collaboration, and inadequate guidelines. Overall, the analysis of strengths, weaknesses, opportunities, and threats reflects the broader challenges present in low-resource settings that hinder the implementation of CAMH services. It also highlights the need for integrative approaches to implementing CAMH services in rural contexts, while identifying opportunities to improve service delivery.

1. Introduction

Child and adolescent mental health (CAMH) remains a global concern and public health priority [1,2,3]. Mental health conditions affect a substantial proportion of children and adolescents, with prevalence rates continuing to increase worldwide [4]. Recent global estimates indicate that one in seven adolescents experiences a mental health condition [5,6], while approximately 14% of children and adolescents aged 10–19 years in Sub-Saharan Africa are affected by a mental health condition [7]. Furthermore, up to half of all mental health disorders emerge during childhood or adolescence [6,7,8,9,10]. Despite the growing burden of mental health conditions among young people, access to CAMH services remains limited, inconsistent, and often of inadequate quality [11]. Although limited access to specialized CAMH services is a widespread concern [2], these challenges are particularly pronounced in low- and middle-income countries (LMICs). Roach et al. [12] estimate that fewer than 20% of children and adolescents experiencing mental health difficulties in LMICs receive the services they need. Although South Africa is classified by the World Bank [13] as an upper-middle-income country, many of the barriers experienced in LMICs remain evident within the country. Simelane and colleagues [14] reported that only one in ten South African children with a diagnosable and treatable mental disorder is able to access treatment.

In recent years, several models have been developed to guide, improve, and promote the implementation of CAMH services in LMICs [15]. In these contexts, mental health services are commonly delivered through a range of platforms and institutions, including primary healthcare (PHC) facilities, schools, child and youth care centers, non-governmental organizations (NGOs), and community-based volunteers [15]. In South Africa, the updated 2023–2030 National Mental Health Policy Framework and Strategic Plan (NMHPFSP) details the current state of CAMH service provision [16]. According to the NMHPFSP (2023–2030) [16], mental health services in South Africa remain significantly underfunded, with services for children and adolescents being particularly limited and underdeveloped. The implementation of mental health services in the country follows the World Health Organization’s (WHO) tiered model of care, which incorporates multiple levels and service settings, including PHC facilities, community-based services, general hospitals, and specialized psychiatric hospitals [14].

While there is no universally optimal model for implementing CAMH services, the WHO and the United Nations Children’s Fund (UNICEF) recommend a community-based approach to mental health care [11]. This model is more accessible and acceptable and leads to improved outcomes for individuals with mental health conditions [11]. PHC facilities and school environments are particularly well-suited for delivering these services at the community level. PHC clinics are integrated into diverse communities and provide daily health services to local residents [14]. Accessing mental health support within schools has also proven effective and is associated with a reduction in stigma [2].

The South African 2012 Integrated School Health Policy (ISHP) encourages collaboration between PHC facilities and schools in delivering health services, including mental health care [17]. The policy assigns PHC facilities a primary responsibility for comprehensive outreach to all schools and designates school-based support teams (SBSTs)—including Life Orientation (LO) teachers—as coordinators of ISHP activities within schools [14]. Kaku et al. [2] emphasize the importance of collaboration in CAMH service delivery at the community level, where community nurses, educators, and allied health professionals participate in screening, identifying, and managing CAMH disorders. Despite the intentions of the policy, the NMHPFSP (2023–2030) [16] notes that in South African schools, where CAMH services are urgently needed, only a limited number of scaled-up, evidence-based mental health promotion and prevention programs exist. Collaboration systems and implementation plans are insufficient at provincial and district levels throughout the country [14].

At the provincial and district levels in South Africa, mental healthcare remains stagnant due to the continued low prioritization of financial investment and poor governance [18]. Unsurprisingly, findings from a 2019 CAMH policy analysis study conducted in the Western Cape province of South Africa revealed that, despite the existence of the CAMH policy at the national level, none of the country’s provinces had implementation plans in place to support CAMH policy implementation [19]. Although provinces received direct grants from the National Treasury to contract mental health professionals such as psychiatrists, psychologists, registered counsellors, social workers, and occupational therapists to complement existing staff in delivering mental healthcare services in PHCs, significant human resource shortages still persist [16].

In light of the growing global emphasis on prioritizing CAMH and the need for evidence-based knowledge to inform the effective implementation of CAMH services, further research is essential to strengthen and expand the existing knowledge base. In South Africa, data on the provision of CAMH services remain limited, with most studies conducted in urban settings across only three of the country’s nine provinces, namely the Western Cape, KwaZulu-Natal, and Gauteng [1]. By contrast, rural areas remain under-researched, and the literature emerging from these geographically isolated settings is sparse [20]. Accordingly, this qualitative study aimed to conduct a SWOT (strengths, weaknesses, opportunities, and threats) analysis of the implementation of CAMH services in the rural Chris Hani District, located in the Eastern Cape province of South Africa, from the perspectives of health professionals and teachers. The study sought to answer the following research questions: (i) What CAMH challenges have you identified among children and adolescents as a health professional in a PHC facility or as a teacher in your secondary school? (ii) What services do you provide as a PHC facility or school to address the identified challenges? (iii) What are the strengths, weaknesses, opportunities, and threats associated with the CAMH services provided?

SWOT analysis is a strategic approach used to identify internal and external strengths, weaknesses, opportunities, and threats within a given context [21,22]. This approach has been widely applied in health research to evaluate various aspects of healthcare policy and service implementation in order to inform future planning [21]. In the current study, the approach is used to provide insights about the existing conditions of CAMH service implementation, which will facilitate future strategic planning for the implementation of these services in the Chris Hani District. The results of this study are presented in this framework, focusing on four identified key elements of CAMH service implementation: (i) screening and identification; (ii) resources; (iii) collaboration; and (iv) policy, guidelines and legislation.

2. Methods

2.1. Research Design

Following an exploratory qualitative research design, this study used a combination of qualitative methods, including semi-structured interviews and focus group discussions, to conduct a SWOT analysis of the implementation of CAMH services in the rural Chris Hani District of the Eastern Cape province, South Africa. Exploratory design allows the collection of rich, nuanced data using interviews and focus group discussions, which this study used as methods of data collection. The study examined the perspectives of PHC professionals (nurses) and secondary school teachers regarding the strengths, weaknesses, opportunities, and threats (SWOT analysis) associated with CAMH service delivery. The study also employed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure compliance with recommended standards for qualitative research.

2.2. Recruitment and Participants

Purposive sampling was employed to recruit PHC nurses (hereafter referred to as healthcare professionals) and secondary school teachers who met the predefined inclusion criteria. Healthcare professionals were required to: (i) possess a minimum of 12 months’ work experience providing healthcare services to children and adolescents; or (ii) have at least three months of clinical training experience as healthcare professionals delivering services to children and adolescents; and (iii) demonstrate a willingness to voluntarily share their experiences and perspectives on the study topic.

Similarly, teachers were eligible to participate if they: (a) had a minimum of 12 months’ experience as qualified secondary school teachers; or (b) had at least three months of teaching experience if still in training; (c) taught Life Orientation (LO); and (d) expressed a willingness to voluntarily share their experiences and perspectives on the study topic.

A final sample of 36 participants, comprising healthcare professionals (n = 12) and secondary school teachers (n = 24), participated in this study. The healthcare professionals were recruited from six PHC facilities and were all professional nurses. The majority were female (n = 10), aged between 25 and 50 years, and had between nine months and 12 years of experience working at their respective facilities providing healthcare services to children and adolescents. Secondary school teachers were recruited from six secondary schools. Most were female (n = 14), aged between 20 and 55 years, with work experience ranging from one to 55 years. All participants, with the exception of one Afrikaans-speaking healthcare professional, identified isiXhosa as their home language and English as their second language. All teachers taught LO.

2.3. Procedure

Following receipt of all ethical approvals, the recruitment process at the PHC facilities began with obtaining permission from the sub-district manager of the Department of Health (DoH), who provided the researcher with a list of PHC operation managers (hereafter referred to as ‘nurses in charge’). The primary researcher met with the nurses in charge to present information about the study and requested their assistance in recruiting healthcare professionals. Those who expressed interest subsequently participated in the study. At the schools, the principals referred the researcher to the LO teachers, who then recruited colleagues to participate in the focus group discussions (FGDs).

The researcher obtained informed consent using a participant information sheet detailing the purpose of the study, which outlined the nature of participation and participants’ rights. Prior to the start of the individual interviews, participants were given the opportunity to ask questions. Interviews were conducted in isiXhosa and English, guided by semi-structured discussion schedule. The interviews took place in the consulting rooms of healthcare professionals. With the participants’ permission, all interviews were audio-recorded. Each interview lasted approximately 20 to 30 min and was intentionally kept brief, as they were scheduled during clinic operating hours.

The principals of the participating schools referred the researcher to LO teachers, who in turn invited their colleagues to take part in the FGDs. An information sheet was distributed to all participants outlining the study’s purpose, the nature of their involvement, and their rights. Participants were afforded the opportunity to ask questions prior to providing written consent for participation in the study. The FGDs were held either in an empty classroom or a computer lab, and were conducted in both isiXhosa and English, guided by a semi-structured interview schedule to accommodate the participants’ language preferences. Each session was audio-recorded and lasted between 25 and 45 min.

2.4. Data Collection

Data for this study were collected by a primary researcher who was a black, female psychologist with a special interest in child and adolescent mental health at the time of the study. Although raised in the same setting as the study, the researcher had no conflicts of interest or familiarity with the participants, as she was no longer a resident of the same town and district. Data were collected using a demographic questionnaire and semi-structured interview schedules. For the questionnaire, participants were asked to provide demographic details such as professional qualifications, years of work experience, age, gender, and home language. For the interviews, the researcher designed two distinct semi-structured schedules: one for individual interviews with healthcare professionals and another for FGDs with school teachers.

In PHC facilities, individual interviews were conducted due to the limited number of health professionals, typically two to four nurses per facility. Additionally, data collection should not interfere with facility operations; hence, individual interviews were better suited to the PHC than FGDs. In school settings, FGDs were utilized to accommodate time constraints and to encourage broader participation among teachers, beyond just LO teachers, thereby facilitating the collection of a wider range of perspectives in a single session [23].

Both interview guides were developed to align with the study’s objectives. The following research questions were posed: (i) What CAMH challenges have you identified among children and adolescents as a health professional in a PHC facility or as a teacher in your secondary school? (ii) What services does your PHC facility or school provide to address these challenges? (iii) What are the strengths, weaknesses, opportunities, and threats associated with the CAMH services offered? In total, 12 individual interviews and six FGDs were conducted.

2.5. Ethical Considerations

Ethical approval for this study was granted by the Faculty of Humanities and the Faculty of Health Sciences at the University of Pretoria (reference: HUM081/0524). Additional approvals were obtained from the Eastern Cape DoH (reference: EC_202408_10), and the Eastern Cape Department of Education (DoE). To ensure participant confidentiality, codes were used in the presentation of the findings instead of participants’ names.

2.6. Data Analysis

Data analysis followed Braun and Clarke’s [24] six-step thematic analysis framework, which includes the following stages. (i) Familiarization with the data: Audio-recorded interviews were transcribed verbatim and translated by the primary researcher, who also conducted data collection and is fluent in both isiXhosa and English. This process enabled thorough immersion in, and familiarity with, the dataset. The transcripts were shared with the senior researcher, who also familiarized himself with the dataset. (ii) Generating initial codes: The primary researcher independently coded the data manually on hard-copy paper, as this was a small-scale study. The coding process was informed by Saldaña’s [25] coding manual for qualitative researchers. Meaningful features relevant to the research questions were systematically identified and coded across the dataset. These codes captured key patterns and provided insight into participants’ perspectives on the research topic. (iii) Searching for themes: Patterns and relationships among the initial codes were examined and organized into potential themes. (iv) Reviewing the themes: Preliminary themes were reviewed and refined and shared with the senior researcher who reviewed the themes against the dataset. This collaborative process ensured internal consistency and alignment of themes with the research questions. It also clarified the primary researcher’s interpretations and yielded additional insights to minimize the primary researcher’s biases [25]. (v) Defining and naming the themes: This stage involved further refinement of the themes, ensuring their alignment with the research question and the researchers reached a consensus about the final themes to be included in the report. (vi) Producing the report: The final stage involved synthesizing and interpreting the findings to present a comprehensive and coherent account of the data in relation to the study’s research questions.

2.7. Trustworthiness

From data collection through analysis, the principles of trustworthiness, specifically credibility, transferability, dependability, and confirmability [26], were maintained to ensure the quality of the study. (i) Credibility was established through environmental triangulation, in which two settings (PHC facilities and secondary schools) were examined to investigate the provision of CAMH services in rural communities within the Chris Hani District. (ii) Transferability was enhanced by providing detailed descriptions of the participants, study context, and data collection procedures, allowing readers to assess the relevance of the findings to similar contexts or settings [26]. (iii) Dependability was supported by reflexive analysis, which enabled the researcher to bracket personal interpretations of the data and foster transparency regarding potential bias. The primary researcher also engaged in ongoing discussions with the senior researcher during both data collection and analysis, increasing awareness of possible biases. Field notes were maintained throughout the data collection process. (iv) Confirmability was promoted through continuous consultation with the senior researcher, which encouraged impartiality and ensured that the findings were grounded in the data rather than influenced by researcher preferences.

3. Results

The findings of this paper outline four key components of CAMH services implementation in the Eastern Cape province, South Africa: (i) screening and identification; (ii) resources; (iii) collaboration; and (iv) policy, guidelines, and legislation. Each component is discussed within the context of the SWOT analysis framework that guides this study. While this list does not represent all essential elements of CAMH service implementation, focusing on these areas is crucial for understanding the delivery of services in the Chris Hani District of the Eastern Cape province, South Africa.

3.1. Screening and Identification of CAMH

A summary of the themes related to screening and identification of CAMH services in the Chris Hani District is outlined in Table 1, according to the four domains of the SWOT analysis: strengths, weaknesses, opportunities, and threats. Each of these domains is described in more detail.

Table 1. SWOT in relation to screening and identification of CAMH.

SWOT Elements	Themes
Strengths	Screening and identification of mental health issues Identification by other personnel
Weaknesses	Unidentified cases of CAMH Lack of training in CAMH
Opportunities	Parents’ ability to recognize related symptoms Empowering parents with knowledge on CAMH conditions
Threats	Parents Feeder schools Normalization of symptoms Stigma associated with mental health conditions among children

3.1.1. Strengths

Screening and identification play a crucial role in the delivery of CAMH services in both PHC facilities and schools. Health professionals and teachers identified screening and identification (identification only for teachers) as strengths within their respective settings for implementing CAMH services. PHC facilities reported conducting screenings for CAMH concerns according to established health practice guidelines. These methods included clinical observation, mini-mental status examinations, and the developmental milestones section of the road to health booklet (children’s clinic card). Community healthcare workers also contributed significantly to the identification of CAMH cases during outreach programs. The following quotes illustrate participants’ perspectives on this aspect:

“We have developmental screening for children. So, that is where we are able to pick up those issues”. [Interview, Participant 10]

“For example, I recently received a complaint from the community health workers, they were complaining about children whose parent is abusing alcohol and neglecting children”. [Interview, Participant 07]

While schools were not necessarily performing screenings, they identified a wide range of mental health concerns among adolescents in secondary schools. These included mental health and psychosocial issues, personal difficulties, family-related issues, substance use, violence, relationship problems, and learning difficulties. One school reported having designated personnel, known as Learner Support Agents (LSAs), who were responsible for identifying and supporting students facing mental health challenges, among other issues.

“…we had an LSA who would identify such children, for example, she’d inform us that there is a particular child who is in need or a child that she sees that something is not okay with them”. [Interview, Participant 10]

The themes within this component demonstrate that PHC and schools were able to identify CAMH services, which is considered a central first step in the implementation of these services.

3.1.2. Weaknesses

A weakness was observed in the identification and screening processes within PHC facilities. Although health professionals reported screening and identification as strengths, they unexpectedly noted that cases of CAMH were rarely identified in these settings. In fact, they cited zero recorded cases of CAMH in PHC facilities.

“To be exact, our mental health services and the treatment we give are for the people who are 18 and above”. [Interview, Participant 07]

Insufficient training in CAMH was often identified by numerous health professionals as a significant barrier to recognizing and delivering appropriate services.

“So, sometimes you are not even able to pick up that particular thing because you are not trained…you would not stand confident and say you are competent in doing that particular thing even yourself. However, you do it anyway because it is part of the services”. [Interview, Participant 10]

The account above illustrates how insufficient training left health practitioners ill-equipped to identify and address CAMH issues. This challenge was compounded by the reported absence of screening tools. Consequently, mental health concerns were frequently neglected in the provision of health services to children, with primary attention given to physical health.

3.1.3. Opportunities

The health professionals identified an opportunity to improve the recognition of mental health concerns among children by strengthening parents’ ability to recognize symptoms and report them during consultations. This approach could facilitate the earlier identification of CAMH concerns, especially in young children.

“Some parents would let you know that the child is supposed to have started identifying objects, but they are unable to so. Maybe they cannot even talk, when they compare them with other children from the community, they see that the child is struggling, so the child does need an assessment” [Interview, Participant 10].

The schools, however, identified a need for parent-focused information sessions on CAMH, facilitated by mental health professionals from the district offices of the relevant governmental departments (Department of Social Development [DSD], DoH, and DoE). These sessions would be intended to address misconceptions that teachers single out specific children when notifying parents about issues, while also raising awareness of the mental health challenges faced by students.

“I wish the parents could be addressed but not by us teachers, we just come in as teachers, but primarily social development be the one who lays foundation with them so that it does not seem like to a parent I am treating their child a certain way because I know the child’s background. The social development people would be people that the parents are not familiar with compared to us as parents”. [Interview, Participant 01]

This component emphasizes the pivotal role of parents in facilitating the effective implementation of CAMH services. Their engagement can be further supported through awareness campaigns aimed at educating parents and caregivers about children’s mental health.

3.1.4. Threats

A prominent and commonly discussed challenge in the identification and implementation of CAMH services involves parental attitudes. At schools, teachers often characterized parents as being ‘a problem’ and in denial about their children’s mental health challenges, while health professionals expressed empathy regarding the difficulties parents face.

“Parents are in denial even though the parent knows that their children have this particular problem…” [Interview, Participant 02]

Health professionals observed that parents frequently normalize signs and symptoms of mental health issues in their children, potentially overlooking more significant challenges that the child may be experiencing. A lack of knowledge about mental health appeared to contribute to this normalization. Additionally, stigma associated with childhood mental health conditions further hindered the identification of these conditions. As a result, some parents of younger children did not report mental health problems their children were experiencing, and this stigma also contributed to the denial observed by teachers among parents of adolescents. The following participant’s account highlights the concerns related to normalization and stigma surrounding mental health.

“In most cases, such issues are regarded as a family issue and it is normal, that children from that family are slow because they are not aware. For some other people, it is due to the stigma, they do not want to bring their children because they fear that they will be labelled that they are not developing well, or they are not normal, or the child has previously attempted suicide or tried to overdose or something. So, they choose to avoid the clinic.” [Interview, Participant 10]

Feeder schools were also identified as a factor that delayed the recognition of mental health challenges, particularly among students with learning difficulties. This issue was compounded by parents who withheld information about the challenges their children experienced during the transition to secondary schools.

3.2. Resources

Table 2 provides an overview of the themes pertaining to CAMH service resources organized according to strengths, weaknesses, opportunities and threats. The findings within each domain are discussed below.

Table 2. SWOT in relation to resources.

SWOT Elements	Themes
Strengths	Training in psychiatry/psychology Providing support to children
Weaknesses	Lack of CAMH workforce Lack of training Gender differences
Opportunities	Recruitment of the specialized workforce Skilling of the existing workforce in PHC Involvement of children in extramural activities Keen interest of the workforce to assist Teacher characteristics Free land resource Proximity of schools and clinics
Threats	Lack of continuous professional development Lack of governmental support Lack of the basic infrastructure

3.2.1. Strengths

Although not exhaustive, training in psychiatry and psychology for health professionals and teachers during their formal education was regarded as a strength. This background benefited professionals in both fields by equipping them to deliver basic mental health services, such as lay counselling (primarily for teachers), and allowing health professionals to extend their roles beyond solely providing medical interventions.

“When we were training in college up to varsity when I was specializing, we briefly did social aspect of human although we did not get deeply into it, but we did it. We also did psych, as you may see from the bars here, this is psychiatry (pointing one of the bars), so it is part of the diploma in that 4 years. So, that is how we get equipped because it is included in the training we do. Then we would attend refresher courses in times they are made available training”. [Interview, Participant 07]

Teachers regarded their supportive role toward children as particularly important for the implementation of CAMH services. They viewed this role as a means of building rapport between children and teachers, which was expected to foster help-seeking behavior.

“Because I make it a point that I sit down with the child and speak to them. That causes a child, regardless of the state they are in, to see that you understand their circumstances and you do not judge. You do not judge them; you listen and also try by all means to show them that they need help”. [Focus group, Participant 03]

The highlighted strengths within the resource component emphasize the significance of mental health training, which is integrated into the professional education of nurses and teachers. Despite reporting limited competency in delivering services within their respective fields, this foundational training creates an opportunity for further skill development. Establishing close relationships and offering support to children serve as effective means of assisting students experiencing mental health challenges in schools.

3.2.2. Weaknesses

Without a specialized workforce, the implementation of CAMH services cannot be effective. PHC facilities and schools both recognized this as a significant challenge they faced.

“We are always complaining, we do not have resources here, especially for mental health…the psychologists, the social workers, we do not have those social services”. [Interview, participant 07]

This issue was exacerbated by insufficient training and limited investment in the existing workforce, which restricted their ability to deliver CAMH services. Providing targeted training could help address workforce shortages and facilitate the implementation of these services. The following quotes further illustrate this point:

“We are not trained to deal with these things. They shock us and we struggle to help, so we just do not have any strength in dealing with these things.” [Focus group, Participant 24]

Gender differences—specifically, whether a teacher is male or female—influenced interventions in schools. The gender of the teacher emerged as a barrier to identifying and providing interventions for children experiencing personal difficulties.

Male teachers expressed concern about being perceived as crossing boundaries or having conflicting interests when offering support to female learners. Similarly, female teachers experienced comparable apprehensions when working with male students.

3.2.3. Opportunities

A variety of opportunities to improve the implementation of CAMH services within the resource component were identified across settings. Participants frequently highlighted the importance of recruiting specialized personnel, such as social workers, to support service delivery at each facility (PHC facilities and schools). Additionally, training and upskilling the existing workforce emerged as a significant opportunity to enhance service implementation. Health professionals regarded community awareness campaigns, led by community healthcare workers, as a promising avenue for advancing these services. In schools, the involvement of children in extracurricular activities—such as sports, music, and school church organizations—as well as the presence of young and female teachers, were seen as beneficial. Young teachers, in particular, showed enthusiasm for facilitating service implementation; in one school, they established a support structure (social and welfare committee) dedicated to assisting children facing psychosocial challenges.

“If there could be additional staff members and people who would specifically deal with mental health issues who could be able to run such programs while the clinic is running”. [Interview, Participant 01]

“If there could be continuous training and not only be limited to the training you receive while you were in school…mental health training is very scarce for us”. [Interview, Participant 03]

“Here at school, we are young people, be rest assured that we do work. We understand that we are not just limited to child going to class, even if those programs would be made available and we are asked to handle them as the staff members, we would really deliver”. [Focus group, Participant 06]

Furthermore, the proximity of some schools to PHC facilities was identified as a potential opportunity for collaborative efforts in implementing CAMH services.

Some schools had not yet been constructed and were utilizing temporary home structures. This was viewed as an opportunity to construct of consultation rooms for the delivery of CAMH services, as well as classrooms suitable for inclusive education programs once the schools are built. The availability of free land was also identified as an opportunity, as it would allow for the construction of such rooms.

3.2.4. Threats

Although previously identified as a weakness, the lack of training through continuous professional development was perceived as a threat to the effective implementation of services for both health professionals and teachers. The training received during their academic years was considered outdated and inadequate for addressing the challenges encountered in real-world settings, particularly in schools.

“…for example, you graduated 10 or 15 years ago, you only did psychology during your training. Do you think you are still able to recall? Not at all. So, I think there is a need for the workshops that are ongoing that will help the teachers”. [Focus group, Participant 03]

Government was perceived as being ignorant, failing to provide the necessary resources for the implementation of services, including unavailability of emergency transport service when needed for mental health cases in these remote, rural settings.

PHC facilities lacked basic infrastructure, including designated areas for the provision of child and adolescent services that are separate from the main facility used by community members. Health professionals noted that sharing spaces with the community members, particularly elders, contributed to feelings of stigma and discouragement among adolescents, ultimately deterring them from accessing care at the clinics.

3.3. Collaboration

Table 3 provides an overview of the main themes relating to collaboration in CAMH services within the Chris Hani District. A more detailed description of the strengths, weaknesses, opportunities and threats identified is provided in the sections that follow.

Table 3. SWOT in relation to collaboration.

SWOT Elements	Themes
Strengths	Collaboration with stakeholders
Weaknesses	Personal barriers
Opportunities	Empowering parents with knowledge
Threats	Lack of supervision Delayed or lack of attendance in referred cases

3.3.1. Strengths

The implementation of CAMH services involves a diverse group of stakeholders, including children and adolescents, parents and caregivers, health systems, service providers, government departments, and others. Children and parents remain central to the collaborative efforts, as they are the primary recipients of these services. Health professionals and teachers work alongside governmental stakeholders to deliver CAMH services. Key collaborators include the DSD, DoH, district hospitals, community organizations such as churches, and community leadership structures (chiefs), all working together to address mental health concerns and violent behaviors.

“We invite sister departments, all the relevant departments, to come here at the school to address the children and create awareness. All the relevant departments do try”. [Focus group, Participant 03]

Although there were no clearly defined referral pathways, both PHC facilities and schools initiated referrals to the next level of care from their respective sites. For instance, PHC facilities referred cases to the district hospital, while schools directed referrals to the district office of the DoE or the DSD.

3.3.2. Weaknesses

Personal barriers, such as resistance to seeking help, impeded the implementation of services for adolescents in schools, perpetuating the cycle of issues affecting individuals.

“Others sometimes refuse and flatly refuse if you plead with them, telling them that they are not fine nor coping with the situation, they refuse and say they will be okay, especially the boys. They would tell you that they will not go and talk to a stranger.” [Focus group, Participant 03]

One participant in PHC, reflecting on their general experience with mental health, highlighted personal barriers that hinder patients from recognizing and seeking help for mental health issues.

“Not everybody wants to know that they have this sort of mental health illness in them. So, first of all, there is this personal barrier, like you can tell a person you have this, but they are in denial”. [Interview, Participant 08]

Stigma related to mental health may contribute to the personal barriers individuals encounter.

3.3.3. Opportunities

Similar to the identification and screening component, opportunities in the collaboration component focused on empowering parents with knowledge through awareness campaigns and informational sessions on CAMH.

3.3.4. Threats

The lack of designated mental health specialists at the district hospital, remotely accessible to provide supervision to PHC professionals in managing cases relating to mental health was perceived as a threat to implementation of the services, further contributing to the lack of provision of these services at PHC.

“…there is no doctor that you can easily access, for example, a doctor that you can contact while helping a patient in front of you…” [Interview, Participant 10]

The absence of designated mental health specialists at the district hospital, who are accessible to provide supervision to PHC professionals managing mental health cases, was identified as a significant barrier to service implementation. This lack of support further hinders the provision of mental health services at PHC facilities.

“You know when you are always referring children, but the department is not doing anything, it really demotivates you, we end-up not referring at all. You end-up not even doing it because you know that there is no action that is going to be taken by the department. Even after you have referred, they never come or they take time or never even respond to your referral, so we tend up not doing anything as a school either”. [Interview, Participant 03]

3.4. Legislation, Policy and Guidelines

Themes concerning the legislative, policy and guideline context of CAMH services in the district are summarized in Table 4. The findings are structured according to the SWOT analysis domains.

Table 4. SWOT in relation to legislation, policy, and guidelines.

SWOT Elements	Themes
Strengths	Availability of policy and guidelines
Weaknesses	Lack knowledge on legislation, policies and guidelines Physical health-oriented guidelines
Opportunities	–
Threats	Absence or inadequacy of guidelines

3.4.1. Strengths

Both PHC facilities and schools reported having policies, guidelines, and legislation in place to support the implementation of CAMH services. In schools, relevant policies included those related to inclusive education, which address the needs of children experiencing psychosocial and learning difficulties, as well as the policy regarding the presence of LSAs.

“The policies we use are the school policies; they will be known by management…There are some of the policies we use, for example, we have an LSA policy that we use. Also, there are other policies from the Department of Education that include the code of conduct…” [Focus group, Participant 24]

PHC facilities referenced a range of policies and guidelines, including developmental screening protocols in the Road to Health children’s clinic booklet, adolescent youth-friendly services guidelines, the Mental Health Act, and other policy documents.

3.4.2. Weaknesses

Although schools reported having policies and guidelines in place, teachers demonstrated limited familiarity with the documents governing the management and delivery of CAMH services in schools, such as the 2014 Screening, Identification, Assessment, and Support (SIAS) Policy, the 2012 ISHP, and relevant legislation related to CAMH.

At PHC facilities, the existing guidelines [27] for general service provision for children ages two to five focused on physical health.

“For children, we have integrated management of childhood illnesses…it covers physical health; it does not necessarily have mental health.” [Interview, Participant 03]

No guidelines addressed the needs of children aged six to twelve, while adolescents were included under Adult Primary Care [28], which incorporates mental health screening guidelines.

3.4.3. Opportunities

There were no identified opportunities.

3.4.4. Threats

Absence or inadequacy of guidelines compromised the provision of CAMH services at PHC facilities. In contrast, schools exhibited a lack of awareness regarding the policies and regulations that guide the implementation of CAMH services within educational settings.

4. Discussion

The implementation of CAMH services in South African provinces and districts remains underdeveloped, and faces challenges of low prioritisation in financial investment and poor governance [16,18]. Although policies that support the implementation of CAMH services exist, there is no evidence of their implementation across the country’s nine provinces [19]. The SWOT analysis in this study offers valuable insights into the strengths and opportunities that influence the implementation of CAMH services in the rural Chris Hani District. It also reveals the complex challenges that impact the effectiveness of service implementation.

From a strengths-based perspective, screening and identification were mutually perceived as fundamental components of CAMH service provision. While PHC health professionals indicated that they conduct screenings and identify cases, they reported encountering few cases of CAMH in their facilities.

In contrast, teachers primarily identified children in need through interactions with them in the classroom setting. A qualitative study by Skinner et al. [29] on teachers’ perceptions of learners’ mental health in South Africa reported similar findings, indicating that teachers recognize a broad spectrum of mental health issues among students. An international systematic review on teachers’ experiences in supporting children with mental health concerns [30] found that these issues are consistently increasing, emphasizing the necessity for services that address these needs. Although the identification process is not intended for diagnostic purposes, it facilitates the recognition of children’s challenges and informs decisions about the appropriate support required to address their difficulties [31]. Research by Luk [32] highlights teachers as highly effective observers of children’s behavior in the classroom, positioning them as well-suited to identify students facing social and emotional challenges.

Where concerns are identified, it becomes necessary to consult with the Special Needs Coordinator, an LSA in the South African school context, and the child’s parent to determine the appropriate next steps, which may include referral and formal intervention if required [31]. This process is typically guided by established protocols. In this study, however, significant challenges were observed. For example, teachers reported that parents often denied the existence of mental health conditions in their children, thereby withholding consent for intervention. These findings contrast with the results of Saade et al. [33], which indicate that parents play a significant role in supporting their children’s mental health, facilitating access to care, and ensuring adherence to treatment. Nevertheless, in PHC facilities, health professionals agreed with the arguments presented in this study, acknowledging that parents are usually the first to notice signs of mental health concerns in their children [33].

Antalek et al. [31] suggest that the identification of CAMH concerns is dependent on adequate training and ongoing professional development, which establishes a foundational understanding of the mental health and emotional needs of children and adolescents. Training in Mental Health First Aid, for instance, was shown to enhance mental health literacy among teachers [34], and could similarly benefit PHC health professionals. The lack of training and continuous professional development emerged as a significant weakness in this study, as reported by both health professionals and teachers. This deficiency was found to hinder the integration of CAMH services in South African PHC facilities [35]. Furthermore, the findings indicate that both PHC and school facilities in the Chris Hani District lacked sufficient human resources to implement these services. These results are consistent with a South African study conducted in the rural Amajuba District, which revealed that PHC facilities in rural communities were unable to provide specialized CAMH services due to a shortage of mental health specialists [3]. Similar conclusions were drawn in [35], indicating that PHC facilities in South Africa lack CAMH specialists to provide support and supervision to PHC practitioners.

Although there were numerous challenges associated with implementing CAMH services in PHC facilities and secondary schools within the rural Chris Hani District, there were also opportunities to enhance service delivery. These included utilizing existing staff and providing training for screening, diagnosis, and treatment of CAMH, applying specifically to PHC settings. In this context, Shisana et al. [36] recommend empowering professional nurses in PHCs to prescribe mental health medication and employing registered counselors in these facilities. Consistent with the findings of this study, Liang et al. [30] reported that the teacher-child relationship plays a significant role in supporting children’s mental health. While utilization of a supportive relationship and open-door policy may encourage help-seeking behavior and allow children to share their experiences, concerns arise regarding the potential for blurred boundaries between teachers and children in the school setting. In this study, male teachers expressed particular apprehension about providing support to female students, which limited their involvement compared to female teachers. As such, training teachers beyond identification would not be ideal.

Several threats to accessing mental health services for children in Africa, as reported by Saade et al. [33], were also identified in the current study. These included parents’ lack of knowledge or familiarity with mental health conditions, refusal to seek help, parental denial, living in rural areas, delayed parental concern regarding a child’s mental health status, and the older age of caregivers. Challenges related to policy implementation, absence of clear guidelines, infrastructural shortcomings, and insufficient collaboration highlighted prominent obstacles faced by PHC facilities and schools in the Chris Hani District. For instance, intersectoral collaboration was limited, facilities lacked adequate space for service delivery, and existing policies and guidelines were not being enforced.

Conclusively, the implementation of CAMH services primarily depends on governmental support through allocation of necessary resources, which include human resources, skilling of the existing workforce, ensuring effective intersectoral collaboration and supporting the implementation of CAMH-related policies in PHCs and the schools [22]. Several strategies that support the implementation of these services, such as community awareness programmes, parental involvement, and involvement of other stakeholders would facilitate the implementation of the CAMH services [22].

This study has several limitations. Primarily, the use of a purposive sampling approach, resulting in self-selection of PHC facilities and schools for participation, introduces potential researcher bias, which may affect the interpretation of the findings. The sample included only health professionals and teachers, who are key stakeholders in the implementation of CAMH services. The perspectives of adolescents, parents, and caregivers of younger children, who are also important stakeholders as recipients of these services, were not explored.

Additionally, the study simultaneously examined the implementation of services in two distinct settings: PHC and the school environment. These settings are heterogeneous by nature, and this broad focus introduces analytical complexities when considering multiple perspectives across different contexts. Such factors may affect the transferability of the findings to other settings.

In addition, the study was conducted in a single rural district, where findings should be considered within the specific social, cultural and health system context of the study setting. Even though generalisability cannot be achieved in qualitative research, the findings may be transferable to other rural South African or low-and-middle-income settings experiencing similar challenges.

Furthermore, this study was based on participants’ perceptions rather than direct assessments of the factors influencing service implementation, which could have been obtained through methods such as closed-ended questionnaires. This reliance on perceptions may further impact the transferability of the study’s results.

Implications for Policy, Research, Practice, and Society

Policy: Policies and legislation addressing CAMH are already established in South Africa. However, effective implementation remains a significant challenge. Engagement from the national government is essential to provide clear guidance on policy execution, as well as to ensure proper monitoring and evaluation of these efforts.

Research: Future research should include adolescents, parents, and caregivers as primary stakeholders in the implementation of CAMH services. Qualitative studies exploring their lived experiences with accessing—or lacking access to—mental health services in various settings are necessary.

Practice: The effective delivery of CAMH services depends on adequate workforce, financial, and infrastructural resources. Recruiting site-based mental health professionals such as social workers and registered counselors, and providing additional training for PHC professionals, would strengthen the implementation of CAMH services. Furthermore, the development of innovative structures within PHCs, including dedicated pediatric and adolescent units that integrate CAMH services, is needed for these facilities.

Society: This study identified a substantial knowledge gap regarding CAMH issues in rural communities, further complicated by stigma surrounding mental health conditions in children and adolescents. Community-based mental health awareness programs are required to educate the public about CAMH, including signs, symptoms, and the consequences of untreated disorders. These programs should also challenge stereotypes and negative attitudes and encourage individuals to seek help.

5. Conclusions

This study conducted a SWOT analysis of CAMH services in the Chris Hani District of the Eastern Cape province, South Africa. The findings revealed notable strengths, such as the identification of mental health symptoms and the existence of guiding policies, which supported the implementation of these services. However, the study also identified significant challenges, including weaknesses and threats, that must be addressed to advance service delivery. Several strategies could help overcome these challenges. These include creating vacancies and recruiting mental health professionals, such as registered counselors, social workers, and auxiliary social workers for both PHC and schools. Optimizing the existing workforce in PHC facilities, particularly by training healthcare professionals (nurses) to diagnose and treat common mental health conditions among children and adolescents, can further enhance service provision. Task shifting, by empowering community healthcare workers to facilitate parent-focused CAMH awareness campaigns in communities and schools (in line with the ISHP), represents another viable approach. Taking advantage of available resources, such as free land, child- and adolescent-friendly consultation areas could be constructed in PHC facilities. Additionally, training interested teachers to provide these services in schools and equipping parents with knowledge about CAMH may contribute to improved outcomes.