Introduction

The mental health support gap in Ukraine is increasing due to many factors, including the ongoing war initiated by Russia, which escalated into a full-scale invasion in 2022 [1,2]. Children, one of the vulnerable groups, are among the most affected during such crises [3].

Due to their unique position in the communities, educational facilities play a crucial role in supporting children`s well-being, including mental health. The psychological support system has been integrated into the Ukrainian education system since 1993 (here and further, the meaning of “psychological support” includes a broad definition as support of “comprehensive development of individuals, protecting their mental and physical health, and assisting in forming a harmonious educational environment”; the meaning of “mental health support” includes all support and interventions provided specifically for mental health promotion, prevention, treatment and rehabilitation) [4]. The Law of Ukraine “On Education” (Law No. 2145-VIII), enacted on September 5, 2017, acknowledges the importance of psychological services within the educational context. According to Article 76, the psychological service in the education system is designed to promote the comprehensive development of individuals, protect their mental and physical health, and assist in forming a harmonious educational environment. The service aims to provide psychological and socio-pedagogical support to participants in the educational process, including students, educators, and parents [5].

While the law outlines the general purpose and significance of psychological services, practical psychologists’ specific tasks and responsibilities are detailed in subordinate regulations, such as the Regulation on the Psychological Service in the Education System of Ukraine [6]. This regulation outlines the key tasks of school psychologists as follows: Psychological Diagnostics, Correctional and Developmental Work, Counseling, Preventive Activities, Educational and Methodological Support, Research Activities, and Organizational and Methodological Work.

The recently available data (2022/2023 academic year) shows that the psychological service in the Ukrainian education system consists of 20,413 specialists, including 13,174 psychologists, 6,905 social pedagogues, and 82 methodologists [7]. These professionals work in various educational institutions, including preschools, general secondary schools, vocational institutions, and higher education establishments. Despite its essential role, the psychological service in Ukraine faces several challenges [7]:

• Staff Shortages: There is a deficit of specialists, especially in rural areas, due to unattractive working conditions, low salaries, and wartime emigration.
• Insufficient Funding: Many regions lack adequate financial support for psychological services, limiting resources for mental health initiatives.
• Overload of Specialists: The high number of students per psychologist or social pedagogue results in heavy workloads and limited individual support.
• Impact of War: The ongoing war has led to displacement, infrastructure damage, and increased demand for trauma-focused interventions.
• Lack of Institutional Support: Many schools lack dedicated positions for psychologists in their staffing structure, making service delivery inconsistent.
• Limited Professional Development: While training is required, many specialists lack opportunities for continuous professional development due to financial and logistical constraints.

However, the main challenge preventing the system from further development is rooted in the legislation discourse. This discourse positions the mental health and children`s well-being of school psychologists solely as the responsibility of school psychologists without imposing any obligation on other school administrations or teachers. Hence, there is an overload, a lack of support and funding, and other challenges.

Several approaches were explored to solve and overcome this discourse challenge: the whole-school approach to mental health in general [8,9] and trauma-sensitive schools in particular [10].

The whole-school approach to mental health integrates well-being into all aspects of school life through key principles such as leadership and management, embedding mental health into school policies, curriculum, and teaching to promote resilience. Students’ voices are heard, staff well-being and training ensure adequate support, and identifying needs and monitoring impact help assess and improve interventions [8].

A trauma-sensitive school is an educational environment that recognises the profound impact of trauma on students’ learning, behaviour, and emotional well-being. Children affected by trauma often experience difficulties with emotional regulation, concentration, relationships, and trust in authority figures, which can hinder their ability to engage in learning. Trauma-sensitive schools adopt a whole-school approach to creating a safe, supportive, and inclusive learning environment. Key principles of trauma-sensitive schools include fostering physical and emotional safety, building strong student-teacher relationships, using restorative and strengths-based approaches, and ensuring collaborative decision-making between educators, families, and mental health professionals [10].

Based on these approaches and following the WHO HAT Guideline [11] the idea for the Mental Health Sensitive School Concept (MHSS) evolved. The MHSS is a structured framework that fosters a school environment that actively promotes mental well-being and supports students, teachers, and school staff. Rooted in international best practices and evidence-based interventions, this concept promotes integrating mental health into the education system through promotion, prevention, early intervention, and referral mechanisms.

The primary objective of the MHSS is to create mentally healthy, inclusive, and supportive school environments where students and staff feel safe, valued, and empowered. To achieve this, the concept emphasises key goals, including promoting mental health awareness, preventing psychological disorders, providing early support, and systematically referring for specialised care when needed. Additionally, it advocates for integrating mental health considerations into school policies and governance to ensure a long-term, sustainable impact [12]. The detailed description of the MHSS in its current form is presented in the Discussion section and Fig 1.

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Fig 1. Mental Health Sensitive School Pyramid.

https://doi.org/10.1371/journal.pmen.0000368.g001

The study aims to develop and refine the Mental Health Sensitive School Concept as a structured framework that integrates mental health support into educational settings in Ukraine. By drawing on stakeholder perspectives through focus group discussions (FGDs), the research seeks to identify key principles, challenges, and practical implementation strategies for fostering mentally healthy, inclusive, and supportive school environments.

The primary objective of this study is to explore the perceptions, needs, and challenges of key stakeholders -including teachers, school administrators, psychologists, social pedagogues, and students - regarding integrating mental health support within schools. The study seeks to examine stakeholder perspectives on mental health-sensitive school environments, particularly regarding awareness, stigma reduction, and intervention feasibility; verify structural components for an MHSS framework, ensuring that it is addressing the specific challenges of the Ukrainian context; develop actionable recommendations for the implementation of MHSS, including policy integration, teacher training, student support initiatives, and crisis-adaptive mental health interventions.

This study report follows the Standards for Reporting Qualitative Research (SRQR guideline) [13].

Materials and methods

Results

Discussion

The focus group discussions findings provide valuable insights into integrating mental health-sensitive practices in schools. The high representation of teachers and school administrators highlights their central role in shaping school-based mental health interventions. The relatively low participation of students (18.5%) indicates that further efforts may be needed to increase student engagement in discussions on mental health-sensitive school policies. The involvement of school psychologists (12.7%) and social pedagogues (8.3%) underscores the importance of specialist mental health roles in implementing the MHSS. The underrepresentation of school nurses and teachers’ assistants suggests that these roles may be less involved in school mental health initiatives or that their participation was not actively sought.

Participants were not simply offering abstract reflections on mental health in schools; they were speaking from within a setting of displacement, grief, uncertainty, chronic stress, and rapidly shifting institutional demands. These conditions led to an increased urgency in demands for school-based mental health interventions and clearer referral pathways; greater emphasis on trauma-informed approaches, including psychological first aid and protective school climates; a heightened awareness of the emotional toll on educators, who are navigating dual responsibilities as caregivers and victims of conflict; calls for adaptability and resilience in MHSS design, with participants favouring flexible, scalable interventions over rigid programmatic models. This wartime context both sharpened stakeholders’ insights and added emotional weight to their contributions. It also affected feasibility assumptions, as participants often framed their input in terms of what could realistically be done now, given resource scarcities, rather than idealised future models.

While there was a broad consensus on the need to integrate mental health into school environments, stigma and lack of awareness remain barriers to student engagement. The hesitation of students to approach school psychologists due to concerns about confidentiality and perceived ineffectiveness suggests the need for awareness campaigns and peer-led mental health initiatives.

Existing interventions were acknowledged but often deemed insufficient. Teachers and psychologists expressed a need for structured, evidence-based programs that go beyond sporadic anti-bullying or stress management sessions. They strongly emphasised training teachers and psychologists to handle student disclosures sensitively and confidentially. Teachers and administrators also called for trauma-informed practices and the adaptation of international school mental health models to fit the Ukrainian educational system.

The burnout risk among teachers and school psychologists was a recurring theme. The findings indicate a pressing need for systematic mental health support for educators, including self-care programs and peer-support networks.

Regarding implementation, stakeholders stressed that mental health policies should be endorsed centrally rather than developed independently by schools. The request for ministerial-level guidance reflects a structural gap in mental health governance in schools.

The findings align with global studies on school-based mental health programs, emphasising the effectiveness of whole-school approaches [21,22]. The concerns about mental health accessibility and the need for mental health integration into education reflect broader trends in mental health research, particularly in post-conflict and trauma-affected societies [23,24]. The need for policy endorsement aligns with international frameworks, such as the World Health Organization’s (WHO) recommendations for promoting health in education systems [25].

However, while stakeholder perspectives informed the framework design, we acknowledge that these perspectives are embedded within broader discourses and may carry unexamined assumptions. For instance, the emphasis on mental health awareness and stigma reduction, while widely supported in global literature, has shown mixed outcomes depending on implementation context. Some studies suggest that awareness campaigns may unintentionally increase stigma by reinforcing illness-based framing, particularly when lacking complementary behaviour change strategies [26,27]. Therefore, future MHSS iterations should critically evaluate which forms of awareness-raising are most effective and culturally safe in specific Ukrainian school settings. Likewise, while participants advocated strongly for capacity-building, literature from conflict-affected settings cautions against over-reliance on non-specialist-delivered psychological support without adequate supervision or referral systems [28]. The MHSS addresses this by delineating roles and ensuring stepped-care alignment, but continuous monitoring will be required to ensure that role expansion does not lead to burden or mission drift.

Overall, integrating the participatory findings into the MHSS framework is a strength, but future implementation must retain space for critical reflection and adaptation as both evidence and context evolve.

Based on the results of FGDs, which provided crucial insights, the MHSS Concept was finalised. Mental Health Awareness and Stigma Reduction theme informed the integration of universal mental health promotion activities in Component 3: Intervention Areas and supported the need for student-led campaigns and inclusive school environments in Component 4: Key Interventions. School-Based Mental Health Interventions theme shaped the tiered approach outlined in Component 2: Target Groups, which distinguishes between universal, at-risk, and referral-level students, and informed intervention selection within Component 3. Policy Development and Institutional Support theme provided the rationale for Component 1: Policy, embedding mental health strategies into official school development plans and guiding the formation of Mental Health Task Forces. Target Groups and Accessibility of Services theme strengthened stratification logic in Component 2, including mechanisms for identifying and supporting students with varying levels of need, and ensuring accessibility regardless of socioeconomic or geographic background. Teacher and Staff Capacity-Building theme Directly shaped Component 5: Key Actors, which outlines training and support structures tailored to the roles of teachers, administrators, psychologists, and other school staff. Adaptation to Crisis Contexts, Models, and Best Practices theme influenced the inclusion of trauma-informed, context-responsive strategies across all components, and ensured alignment with global frameworks such as WHO’s Helping Adolescents Thrive [11] and IASC’s MHPSS [29].

Five key principles guide the current MHSS framework. First, it follows a systemic approach, embedding mental health considerations into school policies and daily practices. Second, it adopts a needs-centered focus, ensuring interventions are tailored to different groups’ specific mental health requirements. Third, it incorporates a tiered support model, offering a range of interventions from universal awareness campaigns to targeted mental health support and specialised care referrals. Fourth, the concept prioritises evidence-based practices, ensuring that all implemented programs are supported by scientific research. Finally, the framework is competency-driven, meaning that school staff, including teachers and psychologists, must be adequately trained to address mental health issues effectively.

Structurally, the MHSS consists of five core components, forming a mental health support pyramid (Fig 1). The first component focuses on developing school mental health policies that integrate mental health awareness and interventions into school governance. The second component identifies and categorises target groups within the school community, ensuring tailored support for students and staff based on their mental health needs. These groups include individuals who require general well-being promotion, those at risk of psychological distress, those in need of active mental health support, and those requiring specialised professional intervention.

The third component outlines the areas of intervention, covering mental health promotion, preventive measures, early mental health support, and structured referral mechanisms. The fourth component describes the key interventions, which include teacher training, student support programs, structured psychological interventions, and the development of safe school environments that promote emotional regulation and mental well-being. The final component defines the key actors responsible for implementing the MHSS, including school administrators, teachers, psychologists, social workers, parents, and community partners. Each group plays a crucial role in fostering a mentally healthy school environment through collaboration and active engagement.

The MHSS provides a step-by-step roadmap for schools to follow to support implementation. The process begins with establishing a Mental Health Task Force and developing a school-wide mental health policy that aligns with national education strategies. Schools then conduct an assessment to identify the mental health needs of students and staff, which informs the selection and implementation of tiered interventions, ranging from mental health promotion to targeted mental health support and specialist referrals. Finally, regular monitoring and evaluation ensure that interventions remain effective and responsive to the evolving needs of the school community.

The Mental Health Sensitive School Concept represents a proactive and holistic approach to integrating mental health into educational settings. Its structured yet adaptable nature ensures that mental health is recognised not as a separate issue but as a fundamental pillar of holistic education, reinforcing the idea that there is no health without mental health.

The study reinforces the need for a nationally endorsed MHSS policy integrated into Ukraine’s broader education reform. Teacher training should include mental health literacy, psychological first aid, and self-care strategies to address stress and burnout. Schools should move from reactive interventions (addressing mental health issues once they arise) to preventive models, incorporating mental well-being into daily school activities. Given the current war context, interventions should incorporate mental health support mechanisms for both students and educators, including specialised trauma-focused programs.

While the MHSS framework was designed in response to the current mental health needs that existed before the war and were exacerbated during it, it can also serve as a foundation for post-conflict recovery and resilience. The psychological consequences of war, such as chronic stress, unresolved grief, disrupted attachment, and intergenerational trauma, will likely reverberate for many years. In this context, the MHSS cannot treat the war merely as a temporary disruption but must institutionalise long-term capacity for trauma-informed education and restoration. Embedding the war’s ongoing legacy into the MHSS pyramid explicitly could ensure that schools are not only sites of immediate protection but also engines of societal healing.

Conclusions

The FGDs highlighted a strong demand for integrating mental health-sensitive approaches into schools while identifying critical barriers that must be addressed. Participants widely supported the concept but stressed the need for concrete steps, systemic changes, and active involvement of all stakeholders. The six thematic areas identified provide a structured roadmap for developing and refining the Mental Health Sensitive School Concept. The findings indicate that the successful implementation of the MHSSC will require policy backing, resource allocation, and structured capacity-building programs at all levels of the education system. A psychologist from the FGD summarised: “The reality is that our society will need this - whether within this framework or another - it has to be implemented.”

Limitations of the study

This study has several limitations. While Rivne oblast had the highest participation, other regions had lower engagement, which may limit the generalizability of findings across Ukraine (as well as sampling constraints). Given the focus group methodology, responses may have been influenced by social desirability bias, particularly among teachers and school administrators. Also, we recognise research biases (intervention-optimist and cultural embeddedness biases). The study does not assess the long-term impact of implementing the MHSS, highlighting the need for future implementation studies on the Mental Health Sensitive School Concept.