Head Teachers' Perspectives on the Acceptability of an Evidence-Based Mental Health Intervention in Ugandan Schools.

Emotional and behavioral difficulties affect up to 41% of adolescents in sub-Saharan Africa, yet few mental health services are accessible to this population. This service gap is especially concerning given that adolescents aged 10-19 comprise approximately 23% of the region's population. While schools are often the primary access point for psychosocial support, there is limited evidence on the effective implementation of school-based interventions in low-income countries. This study presents a qualitative analysis of the acceptability of the evidence-based multiple family group (MFG) intervention in schools, focusing on the implementation experiences of school head teachers in Uganda. As part of the SMART Africa-Uganda randomized clinical trial, eight head teachers were selected using stratified purposive sampling and interviewed about their experiences hosting the intervention. Interviews explored staff perceptions, implementation facilitators and barriers, and sustainability considerations. Thematic analysis combined a priori and inductive coding approaches. Findings revealed both individual and organizational-level factors influencing implementation. Head teachers viewed the MFG intervention as highly acceptable, citing its relevance to students and broader school communities. Reported benefits included improved student behavior, enhanced caregiver-child communication, and stronger teacher-student relationships. The intervention was seen to foster greater caregiver-school collaboration, contributing to a more supportive school climate. Key facilitators included the structured intervention format, trained facilitators, and logistical supports (e.g., lunch and school fee coverage) that reduced participation barriers. Head teachers played a critical role in adapting school schedules, aligning the intervention with school priorities, and promoting staff buy-in. Despite limited resources, many head teachers expressed strong commitment to sustaining the program by embedding it into existing school activities. Macro-level considerations such as policy integration, sustainable funding, and parental engagement were also identified as essential to long-term scalability. These findings contribute to the limited but growing evidence base on school-based mental health implementation in sub-Saharan Africa and support policy-oriented approaches to integrating mental health services into education systems in low- and middle-income countries.