The science of child and adolescent mental health in Mozambique: A systematic review of prevalence estimates, measurement tools, and interventions.

The science of child and adolescent mental health in Mozambique: A systematic review of prevalence estimates, measurement tools, and interventions Systematic review of child and adolescent mental health in Mozambique

Mozambique is home to 18 million children and adolescents largely underrepresented in mental health research. We conducted a systematic review of evidence-based resources (prevalence estimates, assessment instruments, and interventions) on mental health-related outcomes addressing individuals aged 0–19 years in Mozambique. We searched PubMed, Web of Science, PsycINFO, CINAHL, Google Scholar, African Index Medicus, and local catalogues. Extraction followed COSMIN and Cochrane manuals (PROSPERO registration: CRD420251016208). The search yielded 81 unique publications, including 61 reports presenting prevalence estimates from 25 studies, 29 reports providing data on 42 assessment instruments, and 9 intervention reports describing 8 intervention trials. The clinical prevalence of mental disorders were estimated in two surveys, conducted in Nampula (ADHD: 13·4%; N = 748, 6–18 years) and Maputo (any mental diagnosis: 23%, anxiety disorders: 17·5%; major depression episode: 8·5%; disruptive behavior disorder: 6·6%; substance use disorders: 4·5%; ADHD: 3·3%; PTSD: 1·2%; N = 486, 12–19 years). Most research focused on psychosocial adversities, with nationally representative adolescent surveys reporting significant exposure to violence (physical/emotional violence annually: 24·86%; girls suffering intimate partner violence: 21·11%; lifetime sexual abuse: 16·55%). National suicide rates were highest among 15–19-year-olds (1·53 per 100,000). Only four instruments were cross-culturally adapted and showed reliable psychometrics (MINI-KID, GAD-7, PHQ-A, and SDQ), whilst unadapted tools performed poorly. There was a single randomized clinical trial which reported a cost-effective intervention for neurodevelopment among high-poverty preschoolers. Children and adolescents in Mozambique face significant psychosocial adversity, and available evidence suggests a substantial burden of mental disorders according to limited clinical data. There are few available instruments assessing mental conditions, and culturally sensitive approaches are warranted for strengthening local research.

Introduction

The emerging field of global mental health requires strengthening resources in lower-middle income countries (LMIC), where approximately 90% of the world’s population under 19 lives but remain underrepresented in research data [1]. A recent global analysis shows the mental health data gap is especially pronounced across sub-Saharan African countries, with a near absence of nationally representative data on children and adolescents [2]. Mozambique, located in Southern Africa, is an illustrative case. The country is home to more than 18 millions of children and adolescents, representing over 55% of the total demographic composition [1]. It is estimated that the majority of these youth live below the poverty line, with socioeconomic vulnerabilities extending to climate-related disasters, exposure to violence and conflict, and the HIV/AIDS epidemic [3]. Their mental health and psychosocial development have gained increased attention from the national government and international agencies, with the Ministry of Health including children and adolescents as a priority in the Strategy and Action Plan for Mental Health 2016–2026 [4].

Mental health resources in Mozambique are critically strained. The country has fewer than 500 specialists (including psychiatrists, psychologists, and psychiatric technicians), with the first child and adolescent psychiatrist being trained in 2021 [5,6]. This shortage is reflected in the limited volume of research produced locally. A 2019 systematic review identified just 130 mental health–related publications from Mozambique, revealing substantial gaps in epidemiological data [7]. Despite these constraints, research output appears to be increasing: a PubMed search using the terms “mental health” AND “Mozambique” yields 189 records, 144 of which have been published since 2020. Some of this work explicitly focuses on bridging gaps in evidence-based resources for children and adolescents, including global and national surveys and work validating assessment instruments [8].

In non-Western contexts, synthesizing and appraising extant research is essential to enhance the reach and availability of evidence-based resources such as prevalence rates, assessment instruments, or intervention programs. National-level compilations on child and adolescent mental health have been conducted in countries such as Greece, Brazil, and South Africa, providing valuable tools to inform practice, policy, and research [9–12]. This study aims to synthesize the scientific literature on child and adolescent mental health in Mozambique. We conducted a systematic review of prevalence estimates, assessment instruments, and interventions addressing mental health–related outcomes in this population. Our goal is to present a comprehensive overview of evidence-based resources available in the country and to take practical insights for public health.

Materials and methods

We draw on national reviews conducted in Greece, Brazil, and South Africa, with a comprehensive search strategy followed by classification of studies into three independent arms (prevalence, assessment instruments, and interventions) [9–12]. The protocol has been published in PROSPERO [CRD420251016208]. All research conducted in Mozambique requires registration, and we obtained approval from the Ethics Committee of the Faculdade de Medicina da Universidade Eduardo Mondlane (UEM) and the Hospital Central de Maputo [CIBSFM&HCM/42/2025]. This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the PRISMA-COSMIN manual for reporting systematic reviews of measurement instruments (see checklist in Table A in S1 Appendix) [13,14].

Inclusion criteria

Our scope was the mental health of children and/or adolescents in Mozambique considering outcomes in a broad sense (e..g: mental disorders, substance use, suicidality, life adversities, childhood maltreatment and neglect, bullying, quality of life, wellness, neurodevelopment, learning difficulties, literacy, stigma). For eligibility, studies had to report specific data for samples in Mozambique with an average age up to 19-years-old (regardless of outliers), including data collected through self- or proxy-reported measures (for instance, caregiver- or teacher-rated scales measuring children’s symptoms). This scope builds upon comprehensive cataloguing efforts in Brazil, Greece, and South Africa [9–11]. It was initially designed to encompass all DSM-5 diagnostic domains and was subsequently expanded to incorporate additional areas identified through mapping of the national literature corpus.

Eligible studies were classified into one or more of three review arms based on the following criteria: (1) prevalence studies included community, school or clinical surveys using structured instruments, questionnaires, or epidemiological registries; (2) assessment instruments included studies that developed, translated or validated tools, further including studies that solely applied an instrument if that was the unique report of the tool in the country; (3) interventions studies with experimental (or quasi-experimental) designs, as well as translation, adaptation, or development of intervention programs.

We included peer-reviewed articles, academic letters, book chapters, theses and dissertations, and institutional reports, without restriction of language or date. For repeated datasets, we included the most recent and/or most comprehensive reports. We excluded multi-country studies that did not provide specific data for Mozambique, as well as general population studies without specific data for children or adolescents. Conference abstracts were not eligible.

Search strategy and screening

We searched multiple data sources from inception to August 6th 2026: (1) international databases, including PubMed, Web of Science, CINAHL, PsycINFO, and Google Scholar; (2) the African Index Medicus; (3) local university repositories from Universidade Lúrio (UniLúrio) and Universidade Eduardo Mondlane (UEM); (4) publications from the National Health Institute (Instituto Nacional de Saúde – INS); and (5) the local health journals, Revista Moçambicana de Ciência de Saúde (RMCS) and Revista Médica de Moçambique (RMM).

A comprehensive query combined terms associated with children/adolescents, Mozambique, and mental health-related outcomes, being adapted to the syntax and language (English and/or Portuguese) of each database (see Table B in S1 Appendix). First, records were retrieved from PubMed, Web of Science, CINAHL, and PsycINFO. Following deduplication, two independent authors conducted primary screening (based on titles and abstracts) and a single reviewer performed full-text screening. Second, we searched Google Scholar as a complementary source, adapting the query to its crawler-based engine using simplified terms in English and Portuguese. A single author screened results until 100 consecutive entries produced no new relevant studies.

Next, regional and local data sources were also screened by a single author. African Medicus Index was searched for records containing “Mozambique” or “Moçambique”; the UEM repository was searched with Portuguese terms related to children and adolescents; and the full catalogues of the remaining sources (INS, UniLúrio, RMCS, RMM) were manually verified.

The research team responsible for screening and data extraction (LEM, ACC, and JAV) was the same that had conducted these procedures in the national review in Brazil [10]. Prior to primary and secondary screening, a pilot calibration exercise was performed on 10% of the dataset to align inclusion decisions across reviewers. Regular meetings were held throughout screening and extraction to maintain consistency and shared understanding of criteria. When adopting single-reviewer screening procedures, 20% of the records were randomly verified by a second reviewer (LEM); this author also resolved discrepancies arising from two author independent screening. This strategy draws on prior national reviews which utilized a single-reviewer approach emphasizing sensitivity over specificity to maximize article inclusion (i.e., when in doubt, studies were included to make the review as comprehensive as possible) [9–12]. The rationale is fully detailed in the Brazilian systematic review [10]. In brief, this approach is particularly well-suited to compilation reviews and has demonstrated reliable performance in empirical evaluations informing Cochrane guidance [15–17].

The review was managed using Rayyan software. Potential duplicates were detected, automatically removing pairs with a 100% match in title/DOI or Overall Similarity Percentage above 95% (a metric calculated based on all characters and metadata associated with the reference); remaining candidates were manually verified. This threshold was informed by an assessment of the deduplication tool, which suggested that an initial 95% cut-off carries a negligible risk of false exclusions [18].

Data extraction

Data collection was conducted independently for each review arm, following specific methodological guidelines. A single reviewer performed the initial extraction and quality appraisal, and all datasheets were subsequently verified by LEM.

Prevalence studies followed procedures established in a widely cited systematic review on child and adolescent mental health disorders [19]. Risk of bias is assessed using a validated tool that evaluates external and internal validity, analytical bias, and population representativeness [20]. Table C in S1 Appendix presents extraction fields, with each estimate from each study representing a separate data entry.

For assessment instruments, we followed the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) for data extraction, quality assessment, and psychometric appraisal [21]. Table D in S1 Appendix shows extraction fields, collecting information for each instrument reported in a study on a separate line. Next, data is classified using psychometric criteria outlined in Table E in S1 Appendix.

Intervention studies were extracted following the Cochrane Manual for Systematic Reviews of Interventions [22]. Methodological quality was assessed with the revised Cochrane tool for randomized trials (RoB 2) and the Joanna Briggs Institute (JBI) checklist for non-randomized designs [23,24]. Extraction fields are detailed in Table F in S1 Appendix.

Data synthesis and presentation

We followed previous national compilation efforts to synthesize all available evidence in an accessible format, aiming at presenting a “catalogue of evidence” that was informative, comprehensive, and able to account for the substantial heterogeneity across populations, study methodologies, and outcomes [9–11].

Data were presented for each major area (prevalence, instruments, and interventions) and organized according to diagnostic domains. These domains included mental health disorders, mental health symptoms, and mental health-related outcomes (such as substance use, psychosocial adversities, and quality of life).

For prevalence, data was presented for each study (aggregating findings across multiple reports and secondary analyses referring to the same parent dataset). To align with the diagnostic domains, studies were initially grouped by methodological design: clinical estimates utilizing diagnostic interviews (reporting mental health disorders), estimates using mental health screening scores (reporting mental health symptoms), and findings from unstructured questionnaires and other surveys (reporting mental health-related outcomes). Within each of these categories, studies were sequentially sorted by sample size.

For assessment instruments, data was presented by each tool. The psychometric classification per instrument was summarized by aggregating data across studies according to the codes presented in Table G in S1 Appendix (with all supporting data detailed in the footnotes).

For interventions, data were presented for each trial (encompassing findings reported across one or multiple publications). Due to the limited number of included studies, all data could be synthesized within a single table. We opted to order the studies by sample size rather than by diagnostic category.

Ethics statements

We obtained ethical approval from the Scientific Committee and Institutional Bioethics Committee for Health of the Faculty of Medicine at Eduardo Mondlane University and Maputo Central Hospital (Comité Científico e Comité Institucional de Bioética para Saúde da Faculdade de Medicina da Universidade Eduardo Mondlane e Hospital Central de Maputo) [Reference: CIBSFM&HCM/42/2025]. Although this study did not involve direct participation of human subjects, national regulations in Mozambique require local ethical approval for all review studies.

Results

Fig 1 presents a flowchart with search outcomes (see Fig A in S1 Appendix for PRISMA flowchart; see Table H in S1 Appendix for exclusion reasons; S1 Data provides full access to original search files and documents all screening decisions). Following the screening of 5,760 records, 81 unique publications were eligible for inclusion in one or more areas: 61 reports on prevalence estimates from 25 datasets, 29 reports containing data on 42 assessment instruments, and 9 reports detailing 8 intervention trials. S2 Data contains the full data sheets, which detail all included reports, extracted data, and risk of bias assessments.

Overview of scientific production

Fig 2 presents the extent of evidence-based resources, while Fig 3 shows temporal trends of publications. There were 75 peer-reviewed articles, 4 theses/dissertations, and 2 institutional research reports. Research output in Mozambique is relatively recent, with the vast majority of reports published in the past decade. The evidence base is skewed toward prevalence estimates, featuring very few intervention trials. Childhood adversity and trauma constitute a prominent line of inquiry, accounting for 28 of the included reports. Prevalence reports are also centered on substance use, and assessment instruments have a substantial concentration on neurodevelopment tests.

International authorship is predominant [25]. Among the 31 articles with a Mozambican affiliation, just 18 credited a local institution in first authorship and only 6 in senior authorship. Two PhD theses were associated with international universities (Arizona State University and Universidade do Porto) and two master dissertations were produced in a local postgraduate program (UEM) [26–29]. Institutional research reports were published by the World Bank and ActionAid [30,31].

International funding is also the primary source of support. There were several multinational surveys run by organizations such as the WHO [32–53], as well as national surveys sponsored by agencies like UNICEF [54] and the NIMH [55]. International development programs promoted 7 out of 8 intervention studies. Although more limited, national funding involves various public bodies. The National Demographic and Health Survey is a representative study which is implemented by the National Institute of Statistics, the Ministry of Health, and the National Institute for Health [56]. Other contributing agencies include the National Council for Combating AIDS (CNCS) and the National Research Fund under the Ministry of Science, Technology, and Higher Education [26].

Prevalence of mental health disorders

Table 1 presents estimates on the prevalence of mental health disorders. There were only 3 studies including clinical data according to manualized criteria. A study in Maputo recruited 486 adolescents, leading to three reports estimating the prevalence of any mental diagnosis (23%), any anxiety disorders (17·5%), major depression episode (8·5%), disruptive behavior disorder (6·6%), substance use disorders (4·5%), ADHD (3·3%), and PTSD (1·2%) [8,57,58]. Another survey in Nampula included 748 children and adolescents, with two reports on the prevalence of ADHD at 13·4% [59,60]. Additionally, a non-probabilistic study included 110 individuals aged 1–20, using clinical batteries to estimate the prevalence of neurodevelopmental impairment (mild: 18·2%; moderate-to-severe: 0·9%) [61].

10.1371/journal.pgph.0007513.t001Table 1Prevalence estimates on mental health disorders.

Prevalence estimates based on structured clinical interview and manualized criteria

Study Sample recruitment Sample (N)Description LocationYear Diagnostic criteria / clinical interview Findings RoB

Daniel et al. (2024) [59] [60], School-based, probabilistic sample
Two-step sample screening:1. Screening survey with SNAP-IV2. Clinical interview for high-risk N = 7486 to 18 years-old54·6% female Nampula2022 - 2023 DSM-5 criteriaKiddie Schedule for Affective Disorders and Schizophrenia for School-aged Children (K-SADS-PL) Current prevalenceADHD: 13·4% (95% CI 11·5%-19·2%)SNAP-IV positive screening (teacher- or caregiver-rate): 10·16% Low

Come et al. (2022) [57]Lovero et al. (2022) [8]King et al. (2026) [58] School-based, probabilistic sampleSingle-step sampling: all participants completed screening scores and diagnostic interviews N = 48612 - 19 years-old66·2% female Maputo2019 DSM-4 and ICD-10 criteriaMiniature International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) Current prevalence:Any MINI Diagnosis: 23%Anxiety disorders:* 17·5%Major Depressive Disorder Episode: 8·5%Disruptive Behavior Disorder:** 6·6%ADHD: 3·3%Alcohol Use Disorder: 2·7%Drug Use Disorder: 2·1%PTSD: 1·2%Suicidal thoughts (past month): 16·42%Suicidal behavior (past month): 6·16%Suicide attempt (lifetime): 8·89% Low

Paul et al. (2022) [61] Case-control on a cohort of survivors of invasive Group B Streptococcus infantControls identified via Health and Demographic Surveillance System N = 1101 - 20 years-old54·5% femaleControl group matched for survivors of invasive bacterial infection during early infancy Maputo2019 - 2021 WHO and Global Burden of Disease (GBD) criteria for neurodevelopmental impairmentBattery of neurodevelopmental tests:Malawi Developmental Assessment Tool (MDAT)Cambridge Neuropsychological Test Automated Battery (CANTAT) Neurodevelopmental impairment (moderate to severe): 0·9%Neurodevelopmental impairment (mild): 18·2%Cognitive impairment (moderate to severe): 4·8%Cognitive impairment (mild): 14·4%No clinical cases were identified through the Child Behavior Checklist (CBCL), which was attributed to a poor cultural fit of the instrument High

Prevalence estimates based on screening instruments

Study Sample recruitment Sample (N)Description LocationYear Assessment tools / cut-off scores Findings

2022-2023 Mozambique Demographic and Health Survey [56] [62], NationalProbabilisticCommunity-based N = 454815 - 19 years-old68·35% female Nationwide2022 -2023 Generalized Anxiety Disorder- 7 item (GAD-7) ≥ 5 & ≥ 7Patient Health Questionnaire – 9 item (PHQ-9) ≥ 8 & ≥ 10 Positive screening for:Generalized Anxiety Disorder (2 weeks): 6·3% - 18·51%Major Depressive Disorder (2 weeks): 6·6% - 10·25% Low

Di Gennaro et al. (2022) [54] RegionalClinical sample of youth accessing health services N = 2018 (HIV + : 1096 / HIV-: 201263% female10 - 24 years-old Sofala Province2019 - 2021 Cut-off scores:CAGE questionnaire ≥ 2Generalized Anxiety Disorder- 7 item (GAD-7) ≥ 10Patient Health Questionnaire – 9 item (PHQ-9) ≥ 11Post-Traumatic Stress Disorder – 5 item (PTSD-5)  ≥ 3 Positive screening (HIV+ group)Alcohol use disorder: 15·1%PTSD / Trauma: 14·7%Anxiety: 10·3%Depression: 7·1%Positive screening (HIV- group)Alcohol use disorder: 10%PTSD / Trauma: 9·4%Anxiety: 7·6%Depression: 7·6% High

Chimbutane et al. (2023) [63] RegionalProbabilisticSchool-based N = 138360% female13 - 16 years-old Rural areas in Nampula province (Nacaroa, Muecete, and Murrupula)2021 Generalized Anxiety Disorder- 7 item (GAD-7) > 10WHO-5 Wellbeing < 50 Anxiety symptoms (moderate to severe): 10%Low well-being: 31% High

Disrupting harm survey [64] Multi-country surveyProbabilisticOnline N = 99945% female12 - 17tears Nationwide2020-2021 Center for Epidemiologic Studies Depression Scale (CES-D)Paykel Suicide ScaleUNICEF’s Youth Empowerment Project scalePrevalence was based on response to single items instead of cut-offs Depression: 25.3%Self-harm: 11.1%Suicidal ideation/attempt: 27.2% High

Igreja et al. (2024) [25] RegionalNon-probabilisticConvenience sample in households and schools N = 7949 to 21 year-old45·8% female Gorongosa District in Sofala Province2013 Beck Depressive Inventory-II (BDI-II) Self-Report Questionnaire (SRQ-20)Nocturnal Intrusions after Traumatic Experiences (NITE) Depressive symptomsMild: 22·2%Moderate: 17·8%Severe: 14·2%Anxiety symptoms (high): 39·3%Sleep disturbances and anxiety dreams (severe): 37·3% High

Manafe et al· (2024) [65] RegionalNon-probabilisticConvenience community-based sample N = 75014 to 20 years-old66·2% female Cabo Delgado2023 Generalized Anxiety Disorder- 7 item (GAD-7)>= 10Primary Care Post-Traumatic Stress Disorder Checklist (PC-PTSD-5)>= 4Patient Health Questionnaire – 9 item (PHQ-9)>= 10 PTSD symptoms: 14·6%Depressive symptoms: 9·6%Anxiety symptoms: 8% High

Langa et al· (2022) [66] RegionalProbabilisticCommunity-based sample (household) N = 2772–14 years-old Mocuba district, Zambezia province2018 Clinical question on whether the participant presented inappropriate behavior, had auditory hallucination or delusions Psychotic symptoms: 10·5% (not based on a valid tool) High

CombinADO survey [55] RegionalNon-probabilisticClinical sample of adolescents living with HIV N = 21315 - 18 years-old74,87% female Nampulo2019 Generalized Anxiety Disorder- 7 item (GAD-7) > 10Patient Health Questionnaire – 9 item (PHQ-9) > 10 Anxiety symptoms: 12·2%Depression symptoms: 11·7% High

Thumbo (2025) [29] RegionalNon-probabilisticClinical sample from a service for vulnerable adolescents N = 4514 - 17 tears48,9% female Zimpeto2025 Generalized Anxiety Disorder- 7 item (PHQ-9)Generalized Anxiety Disorder- 7 item (GAD-7) Anxiety symptoms (mild): 71%Anxiety symptoms (moderate): 28,9%Depressive symptoms (mild): 73,3%Depressive symptoms (moderate): 26,7% High

Notes: *Anxiety Disorders groups Generalized Anxiety Disorder, Separation Anxiety, Social Phobia, Panic Disorder, and Agoraphobia. **Disruptive Behavior Disorder groups Conduct and Oppositional Defiant Disorder

National data points on mental health disorders were limited to screening cut-off scores reported at the 2022–2023 Mozambique Demographic and Health Survey [56] [62],. This study involved 4548 participants aged 15–19 years-old completing the Generalized Anxiety Disorder 7-item (GAD-7) and the Patient Health Questionnaire 9-item (PHQ-9). It was estimated that 6·3% to 18·51% presented significant symptoms of generalized anxiety disorders (GAD-7 ≥ 5 or ≥ 7), whilst 6,6% to 10,25% experienced significant major depressive disorder symptoms (PHQ-9 ≥ 8 or ≥ 10). Although the Disrupting Harm project utilized a nationally representative survey of Mozambican adolescents incorporating structured scales, prevalence estimates relied on single-item responses rather than validated cut-off scores [67].

At regional level, a study involved a clinical sample of 2018 adolescents and young adults attending health services in Sofala found that 1096 HIV+ participants presented higher symptoms of mental disorders: 15·1% had positive screening for alcohol use disorder (CAGE ≥ 2); 14.7% for PTSD (PTSD-5  ≥ 3); 10,3% for anxiety disorders (GAD-7 ≥ 10), and 7·1% for major depressive disorder (PHQ-9 ≥ 1) [54]. Another study conducted in rural Nampula with a community based sample of 1,383 adolescents aged 13–16 years estimated that 10% presented moderate to severe (GAD-7 ≥ 10) [63]. Additional estimates came from convenience samples [25,29,65].

Prevalence of mental health-related outcomes

Table 2 provides findings from 17 surveys reporting on the use of substance, exposure to adversities, and psychosocial symptoms. Table I in S1 Appendix summarizes an additional 8 register-based articles describing clinical outcomes.

10.1371/journal.pgph.0007513.t002Table 2Prevalence surveys on mental-health related outcomes.

Study Population Sample Assessment Use of substance Exposure to adversities Other psychosocial symptoms

GYTS - Global Youth Tobacco Survey [68] NationalSchool-based2013-2018 N = 559913–17 years-old Questionnaire items Current smokers of cigarette: 11·7%Current use of smoke tobacco product other than cigarette: 4·2%Current use of smokeless tobacco: 4·3%Current use of any tobacco product: 20·7%

2022-2023 Mozambique Demographic and Health Survey [56] [62], NationalCommunity-based2022-2023 N = 454815 - 19 years-old68·35% female Generalized Anxiety Disorder- 7 item (GAD-7) ≥ 5 or GAD-7 ≥ 7Patient Health Questionnaire – 9 item (PHQ-9) ≥ 8 or PHQ-9 ≥ 10Items from questionnaire Current alcohol use (1 month): 6·33%Tobacco use (current, last month): 0·9% Suicidal attempt, ideation, or plan (12 months): 3·65%

2015 MozambiqueGlobal School-based Student Health Surveys (GSHS) [32–53] NationalSchool-based2015 N = 191813 - 17 years-old48·9% female Questionnaire items Substance useAlcohol use (current): 13·7%Drunkenness (lifetime): 10%Alcohol use problems (lifetime): 3·2%Tobacco use (current): 2·8% Exposure to violence (last year)Bullying (total): 45·4%Bullying (1–2 days/month): 31·1%Bullying (3–30 days/month): 13·4%Struck/hit by person: 3·6% Social isolation: 37·6%Psychosocial distress: 21·2%Suicidal ideation:17·7%Anxiety: 10·3%Loneliness: 9·8%

2011 Mozambique Demographic and Health Survey [69] NationalCommunity-based2011 N = 1483All female15 - 19 years-old Questionnaire items Physical partner violence: 21·11%Sexual partner violence: 6·34%Physical or sexual partner violence: 23·08%

2019 Violence Against Children and Youth Survey (VACS) [70] NationalCommunity-based 2019 N = 127513 - 19 years-old Questionnaire items Recent heavy alcohol use (15–19 years-old): 4·8%Early alcohol use (13–14 years-old): 1·4% History of pregnancy: 31·13%Out of school (current): 29%Orphanhood: 26·27%Physical or emotional violence (last year): 24·86%Sexual violence (lifetime): 16·55%Transactional sex (lifetime): 3·76%

2017 Global Youth Tobacco Survey (GYTS) [47] NationalSchool-based2017 N = 1211 Questionnaire items Tobacco use (current): 2·22%

Disrupting harm survey [64] Multi-country surveyProbabilisticOnline N = 99945% female12 - 17 years Questionnaire items Self-harm: 11%Loneliness: 35.3%

Family Migration and Early Life Outcomes (FAMELO) [71] Unclear regionsCommunity-based 2017–2018 N = 65111 - 17 years-old Questionnaire items Ever spank, slap, hit or beat the child (caregiver-rated): 44%

Mozambique child soldier life outcome study [72] NationalFormer child soldiers in rehabilitation1989 N = 5046 to 15 years-old50% female Questionnaire items Abducted from the family: 64%Experienced physical abuse: 51%Witnessed murder: 77%

Carneiro et al. (2019) [73] MaputoConvenience sample in Portuguese private schools
2017 N = 4383–13 years-old51% female Children’s Sleep Habits Questionnaire (cutoff: 52) Sleep problems: 28·4%

International Study of Pro/Antisocial Behavior in Young Adults [74] [75], NationalConvenience sample 2018–2019 N = 40018 - 20 years-old55·6% female Psychosocial and Family Vulnerability QuestionnaireAdverse Childhood ExperiencesQuestionnaire (ACE Questionnaire) Last year:• Drunkenness: 34·78%• Drug use: 13·4% Experienced in the first 18 years of life:• Child maltreatment: 70%Physical neglect: 41·82%• Sexual abuse: 36·16%• Domestic violence: 35·22%Emotional neglect: 22·01%Physical abuse: 13·94%• Emotional abuse: 13·21%

Maguele et al. (2020) [76] MaputoSchool-based2019 N = 36815 - 19 years-oldAll female Questionnaire adapted from the WHO Multi-country Survey of Women’s Health and Domestic Violence against Women Intimate partner violence (last year):• Any: 65%• Physical: 18·5%• Sexual: 22·3%• Psychological: 57·6%Intimate partner violence (lifetime):• Any: 57·9%• Physical: 20%• Sexual: 25%• Psychological: 53%

Stop Violence Against Girls in School [77] Rural areas in MaputoConvenience-sample2013 and 2019 N = 3638–17 years-oldAll female Questionnaire items 2009: • Any sexual violence: 29·3%• Peeping: 18·5%• Touching: 16·2%• Forced sex: 8·8%• Sex for goods: 1·8%2013:• Any sexual violence: 39·4%• Touching: 29·2%• Peeping: 23·7%• Forced sex: 8·8%• Sex for goods: 0%

Ribeiro et al. (2020) [78] MaputoSchool-based2010 N = 20812 - 18 years-old65·3% female Questionnaire items Any alcohol use (lifetime): 55%Any alcohol use (last month): 22%Drunkenness (lifetime): 18%Drunkenness (last month): 8%Tobacco (lifetime):9%Tobacco (last month): 4%

Gouveia et al. (2023) [79] MaputoCase-control study during crisis intervention in a school with cases of Emotional Contagion Behavior (ECB), including girls referred to treatment and convenience-sampled controls N = 154 (57 cases, 97 controls)16 - 24 years-oldAll female Questionnaire items Alcohol use (past two week)Case: 5·3%Control: 7·2%

Libombo et al. (2012) [80] Case-control study with community-based convenience sample of orphans and non-orphans in a district of Tete N = 150 (76 orphans and 74 non-orphans)10 - 14 years-old Questionnaire items OrphansRarely have time to play: 14%No trusted adult at home:35%Bullying: 58%Hunger at bedtime for two or more days in the last week: 57%Undeserved punishment 43%Child labor (work outside home) 61%Child labor (work outside home 6–7 days week 16%Currently not at school 20%Non-orphansRarely have time to play 4%No trusted adult at home 7%Bullying 32%Hunger at bedtime for two or more days in the last week 26%Undeserved punishment 45%Child labor (work outside home) 58%Child labor (work outside home 6–7 days week 3%Currently not at school 5% OrphansSuicidal ideation 37%Internalizing Disorders 6,1%Non-orphans Suicidal ideation 8%Internalizing Disorders 0,66%

Chaquisse et al. (2018) [81] NampulaPregnant women accessing antenatal care2013 - 2014 N = 148 < 18 years-oldAll female Conflict Tactics Scale 2 Physical abuse (lifetime): 34,5%Physical abuse (past year): 33,8%Sexual abuse (lifetime): 44,6%Sexual abuse (past year): 43,9%

At national level, there were 7 probabilistic surveys with adolescents, with sample sizes ranging from 999 to 5,599 participants [32–53,56,62,67–70]. These provided several data points on substance use (e.g.,: current tobacco use: 20·7%; current alcohol use: 13·7%), psychosocial symptoms (e.g.,: social isolation: 37·6%; suicidal ideation: 17·7%), socioeconomic vulnerabilities (e.g.,: out of school: 29%; orphanhood: 26·27%), and exposure to violence (e.g.,: physical/emotional - last year: 24·86%; intimate partner violence suffered by girls - last year: 23·08%; lifetime sexual violence: 16·55%; frequent bullying - past month: 13·4%).

Health registers provided further nationwide data points: a suicide rate of 0·65 per 100,000 people aged 5–19 was estimated based on a study collecting data from 2014 to 2019, with the highest rate of 1·53 among adolescents aged 15–19 [28]. All violent deaths are expected to be referred to forensic facilities, with three referral services operating in Mozambique at the time of the study. However, only absolute numbers were reported (70 suicides).

Instruments

Table 3 shows cross-cultural adaptation and psychometric properties of 22 tools, including 2 diagnostic interviews, 12 screening scales, and 6 neurodevelopment tests. Table J in S1 Appendix further lists 20 tools applied without formal adaptation or validation.

10.1371/journal.pgph.0007513.t003Table 3Instruments adapted or validated in Mozambique.

Instrument Population Setting Rater Language Psychometrics REFERENCES

DIAGNOSTIC INTERVIEWS FOR MENTAL DISORDERS Cultural adaptation Other dialects CC CR CV IC IR ME R SV TR References

Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) ChildrenAdolescents School Health Professional Valid NA NA NA +a NA NA NA NA NA NA [8][57],

Kiddie Schedule for Affective Disorders and Schizophrenia for School-aged Children (KSADS-PL) - ADHD and Disruptive BehaviorDisorders modules ChildrenAdolescents School Health Professional Unadapted Brazilian version NA ?b NA NA NA NA NA NA NA [59][60],

SCREENING INSTRUMENTS FOR MENTAL DISORDERS Cultural adaptation Other dialects CC CR CV IC IR ME R SV TR References

General Anxiety Disorder (GAD-7) Adolescents School Self-report Valid NA NA +c +d +e NA NA NA NA +f [8,55,63]

Patient Health Questionnaire-Adolescent (PHQ-A) Adolescents ClinicalSchool Self-report Valid NA NA +g NA +h NA NA NA NA +i [8][55],

Strengths and Difficulties Questionnaire (SDQ) Adolescents Clinical Self-report Valid NA NA +j NA +k NA NA NA NA +l [8][57],

Children’s Sleep Habits Questionnaire (CSHQ) ChildrenAdolescents School Caregiver Unadapted Portuguese version NA NA ?m NA +n NA NA NA NA NA [73]

Swanson, Nolan, and Pelham scale(SNAP-IV) ChildrenAdolescents School CaregiverTeacher Unadapted Brazilian version NA ?o -p -q NA NA NA NA NA NA [59,60]

Child Behavior Checklist (CBCL) ChildrenAdolescents Community TeacherHealth professional Unadapted version NA -r NA NA NA NA NA NA NA NA [59,61,82]

Beck Depression Inventory (BDI-II) ChildrenAdolescents CommunitySchool Self-report Valid Chi-Gorongose NA NA NA +s NA NA NA NA NA [25]

Nocturnal Intrusions after Traumatic Experiences Questionnaire (NITE) ChildrenAdolescents CommunitySchool Self-report Valid* Chi-Gorongose NA NA NA +t NA NA NA NA NA [25]

Self Report Questionnaire (SRQ-20) ChildrenAdolescents CommunitySchool Self-report Valid* Chi-Gorongose NA NA NA +u NA NA NA NA NA [25]

Depression Anxiety and Stress Scale-21 Adolescents Community Self-report Valid NA NA NA NA NA NA NA NA NA NA [83]

Youth Psychopathic Traits Inventory - Short Version Adolescents Community Self-report Valid NA NA NA NA NA NA NA NA NA NA [83]

Deviant Behavior Variety Scale Adolescents Community Self-report Valid NA NA NA NA NA NA NA NA NA NA [83]

NEURODEVELOPMENTAL ASSESSMENT Cultural adaptation Other dialects CC CR CV IC IR ME R SV TR References

MacArthur-Bates Communicative Development Inventories (MBCDI) Short Form ChildrenAdolescents Community Caregiver Valid None NA NA NA NA NA NA NA NA NA [84][85],

Ages & Stages Questionnaire (ASQ) Children Community Caregiver Valid Changana NA NA NA NA NA NA NA NA NA [31][86],

Peabody Picture Vocabulary Test (PPVT) Children Community Self-report Valid Changana NA NA NA NA NA NA NA NA NA [31]

Early Development Instrument (EDI) Children Community Teacher Valid NA NA NA NA NA NA NA NA NA NA [31]

Cambridge Neuropsychological Test Automated Battery (CANTAB) Children ClinicalCommunity Health professional Unclear NA NA NA NA NA NA NA NA NA NA [61]

Malawi Developmental Assessment Tool (DMAT) Children ClinicalCommunity Health professional Unclear NA NA NA NA NA NA NA NA NA NA [61]

WELLBEING, POSITIVE HEALTH, AND LIFE OUTCOMES Cultural adaptation Other dialects CC CR CV IC IR ME R SV TR References

Family Migration and Early Life Outcomes (FAMELO) Questionnaire ChildrenAdolescents Community Caregiver Developed locally NA NA NA NA +v NA NA NA -w NA [27]

Rosenberg Self-Esteem Scale (RSES) Adolescents School Self-report Valid NA NA NA +x +y NA NA NA +z NA [87]

The World Health Organisation - Well-Being Index (WHO-5) ChildrenAdolescents School Self-report Unadapted Portuguese version NA NA NA +aa +bb NA NA NA NA NA [63]

Norwegian International Child Development Programme (ICDP) Evaluation Abridged Version [Children Community Caregiver Valid Changana NA NA NA NA NA NA +cc NA NA [31]

Adverse Childhood Experiences (ACE)Questionnaire Adolescents Community Self-report Valid NA NA NA NA NA NA NA NA NA NA [83]

Brief COPE Adolescents Community Self-report Valid NA NA NA NA NA NA NA NA NA NA [83]

The Altruistic Attitudes Scale Adolescents Community Self-report Valid NA NA NA NA NA NA NA NA NA NA [83]

Abbreviations: cross-cultural validity (CC), criterion validity (CR), construct validity (CV), internal consistency (IC), interrater reliability (IR), measurement error (ME), post-traumatic stress disorder (PTSD), responsiveness (R), structural validity (SV), test-retest reliability (TR). “+” stands for a property with positive evidence for validation, “+/-” for mixed evidence, “-” for negative evidence, “?” for available evidence that cannot be classified as positive or negative, “NA” for non-available evidence (see Table B in S1 Appendix).

Notes: [MINI-KID]aCorrelations with SDQ (Area Under the Curve: 0·7 - 0·9; Sensitivity: 0·72 - 0·83; Specificity: 0·67 - 0·74), with GAD-7 (AUC 0·85; Sensitivity 0·78; Specificity 0·72) and with PHQ-A (AUC: 0·84; Sensitivity: 0·81; Specificity: 0·72); [KSADS-PL]
bThere is no multigroup factorial analysis as per COSMIN criteria for cross-cultural validity, but authors debate a predictive performance and comorbidity pattern similar to the one found in studies worldwide; [GAD-7]
cCorrelation Mini-KID (AUC: 0·85; Sensitivity: 0·78; Specificity: 0·72); dCorrelation index > 0·83 with WHO-5 well-being; eCronbach Alpha: 0·69 - 0·84; fIntra-Class Correlation (ICC): 0·7 (one-week retest); [PHQ-A]
gCorrelation with Mini-KID (AUC: 0·84; Sensitivity: 0·81; Specificity: 0·72); hCronbach Alpha: 0·8; iICC: 0·74 (one-week retest); [SDQ]
jCorrelation with MINI-KID (AUC: 0·7 - 0·9; Sensitivity: 0·72 - 0·83; Specificity: 0·67 - 0·74); kCronbach Alpha: 0·73; lICC: 0·77 (one-week retest); [CSHQ]
mCorrelation with Parent`s Report Form (AUC: not reported; Sensitivity: 0·89; Specificity: 0·71); nCronbach Alpha: 0·75; [SNAP-IV]
oAuthors reported individual items were distributed differently than in other countries, as well as poor overall psychometric performance; pCorrelations with KSADS-PL clinical interview following DSM-5 criteria (AUCs  <  0·53); qCorrelations between individual symptoms rated by teachers and parents: kappa (k) scores < 0·35; [CBCL]
rThe scale was also applied in Argentina, India, Kenya, and South Africa, but only in Mozambique it was unable to detect clinical cases, which authors attributed to poor cultural fit; [BDI-II]
sCronbach alpha: 0·97; [NITE]
tCronbach alpha: 0·94; [SRQ-20]
uCronbach alpha: 0·93; [FAMELO]
vCronbach Alpha: 0·74 to 0·93; wRMSEA: 0·06 and CFI: 0·92; [RSES]
xΔR2: 0·39 (between self-esteem and a model involving relatedness, competence, and autonomy); yCronbach Alpha: 0·73; zConfirmatory Factor Analysis (CFA) for 2-factor model (CFI: 1; RMSEA: 0·000; TLI: 1; SRMR: 0·011); [WHO-5]
aaCorrelation with GAD-7 (0·83); bbCronbach Alpha: 0·79; [ICDP]
ccStatistically significant differences between pre- and post-intervention assessment.

The Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) was the only diagnostic interview that underwent cross-cultural adaptation, demonstrating positive evidence of construct validity according to correlation scores with SQD (Area Under the Curve: 0·7 - 0·9; Sensitivity: 0·72 - 0·83; Specificity: 0·67 - 0·74), GAD-7 (AUC 0·85; Sensitivity 0·78; Specificity 0·72) and PHQ-A (AUC: 0·84; Sensitivity: 0·81; Specificity: 0·72) [8,57].

There were nine cross-culturally adapted screening tools for mental health conditions, with psychometric assessment reported for six of them. The GAD-7, the PHQ-A, and the SDQ showed most favorable psychometric performance, with positive evidence for internal consistency (Cronbach’s alpha > 0·7), test-retest reliability (ICC ≥ 0·7 at one-week retest), and criterion validity (as per correlations with gold-standard MINI-KID) [8,55,63]. The other three tools were adapted to the local dialect Chi-Gorongose (Beck Depression Inventory - BDI-II; Self Report Questionnaire - SRQ-20; Nocturnal Intrusions after Traumatic Experiences Questionnaire - NITE), yet psychometric assessment was restricted to internal consistency [25].

Five instruments were used in non-adapted versions originally developed for Brazil or Portugal, which was associated with poor psychometric performance: The Child Behavior Checklist (CBCL) failed to detect clinical problems in the Mozambican sample, despite performing adequately in other national arms of the same study conducted in Argentina, India, Kenya, and South Africa [61,82]. The Swanson, Nolan, and Pelham scale (SNAP-IV) showed low predictive accuracy for ADHD diagnosis [59,60].

All neurodevelopment tests were cross-culturally adapted but lacked psychometric evaluation, with two tools translated to the local dialectic Changana (Ages & Stages Questionnaire - ASQ; Peabody Picture Vocabulary Test - PPVT) [31].

Intervention studies

Table 4 presents eight intervention studies, including one RCT, four controlled trials, and three uncontrolled pre-post designs. Reports indicated a high risk of bias across all study designs. Programs consisted of 4 psychosocial interventions targeting neurodevelopment, 2 focusing on gender equality, and 1 on mental health promotion.

10.1371/journal.pgph.0007513.t004Table 4Interventions.

Intervention Target Design Setting / Sample Sample sizeAge Results RoB* Funding

Preschool program following a structured daily routine with play and learning activities [31] Neurodevelopment RCT SchoolChildren from high-poverty rural areas N = 19073 -5 years Significant gains in developmental skills (cognitive, communication, motor, and socio-emotional) at a cost of $3 per child per month (no measure of clinical effects) HighCluster allocation; post-randomization reassignment of groups; differences in control group; voluntary participant; only 41% of eligible children enrolled; unblinded World Bank Group - Education Global Practice Group

Community-based program involving nutrition, sanitation, and hygiene (part of Transform Nutrition) [86] Neurodevelopment Quasi-experimental CommunityChildren from high-poverty areas enrolled in Transform Nutrition program N = 961 children0-23 months No impact on developmental scores or maternal mental health HighControl group was not comparable; lack of valid measurement; unblinded assessment USAID Advancing Nutrition Program

Adult–child communication (ACC) program developed by Go Girls! Initiative (GGI) with 11 sessions for caregivers [88] Girl’s vulnerability to HIV Controlled CommunityAdolescent girls in Zambezia and Nampula N = 603 (555 caregivers)11 - 18 years Girls reported improvement in relationship with parents, but hard outcomes were not assessed HighNo baseline assessment; lack of valid instrument;families participating in the intervention might be more prone to benefits; no distal outcome assessing direct effects President’s Emergency Plan for AIDS Relief (PEPFAR)US Agency for International Development (USAID)

School personnel training with 4-day workshops to promote gender-equitable teaching and safer environments for girls [89] Girl’s vulnerability to HIV Controlled SchoolTeachers working with adolescent girls in Zambezia and Nampula N = 525(67 teachers)11 - 18 years Distal outcomes not assessed,no significant differences in students perception of teachers’ gender bias attitudes nor perceived safety at school HighNo baseline assessment; lack of valid instrument; indirect intervention delivered with teachers to benefit girls; no distal outcome assessing direct effects President’s Emergency Plan for AIDS Relief (PEPFAR)US Agency for International Development (USAID)

Stop Violence Against Girls in School participatory program with multi-modal community activities [30] [77], Violence against girls Uncontrolled CommunityGirls in a rural area in Maputo N = 3638 - 7 years Increased percentage of girls reporting violence and showing gender-equitable attitudesIncreased the percentage of teachers with knowledge of laws, policies, and available support.No test of statistical significance. HighNo control group; lack of valid tool; no distal outcome assessing direct effects; convenience sample of girls participating in the project An ActionAid’s program supported by the UK’s Big Lottery Fund

International Child Development Programme (ICDP) with 10–12 weekly group sessions on parenting skills for caregivers [90] Neurodevelopment Controlled¹ CommunityCaregivers participating in the ICDP in Maputo N = 137²4·4 years (SD 2·2) Statistically significant decrease on child conduct problems scores and improvements on parents’ self-efficacy (no measures of effect size)Increased frequency of positive parenting practices HighNo baseline assessment; differences in control and intervention group;unblinded assessment; lack direct distal outcomes Part of the International Child Development Programme (ICDP), supported by multiple sources

Train community health workers to implement eight weekly psychodrama sessions [91] Mental health promotion Uncontrolled ClinicalAdolescents and young adults living with HIV attending supportive services in Beira N = 3515 - 24 years Statistically significant improvement in mental health knowledge and alexithymia (no measures of effect size) HighNo control group; researchers not blinded; lack of valid instrument; direct distal outcomes were not reported Part of Doctors with Africa CUAMM, supported by the Italian Agency for Development Cooperation (AICS) through the Global Fund project

Individual or pair activities for psychomotor and adaptive skills (twice-weekly 45-min sessions over 4 months) [92] Neurodevelopment Uncontrolled ClinicalChildren with developmental disorders institutionalized in a rehabilitation center in Maputo N = 66 - 13 years Significant improvement body awareness, gross motor skills, and adaptive skills (no measures of effect size) HighNo control group; limited sample size; unblinded; proxy-reported measures; multiple statistical tests without prior hypothesis or adjustments Not reported

Notes: *Methodological quality was assessed with the revised Cochrane tool for randomized trials (RoB 2) for the single RCT; the remaining assessments were based on the Joanna Briggs Institute (JBI) checklist for non-randomized designs [22,23].

1Post-hoc case-control design: 75 caregivers received the intervention, and 62 caregivers formed the control group. 2 The mean number of children per caregiver was 4·34, but analysis included only one child, focusing on the one closer to 4·4 years selecting

Abbreviations: RCT (Randomized Clinical Trial); RoB (Risk of Bias).

The RCT assessed a World Bank program among 1,907 preschool children in high-poverty areas [31]. It demonstrated significant developmental gains with an implementation cost of approximately $3 per child per month. However, it was judged to have a high risk of bias across all assessed domains, including selection bias, blinding of participants and outcome assessors, outcome measurement, and selective outcome reporting.

The single study focusing on mental health symptoms trained community health workers to deliver a psychodrama intervention for adolescents and young adults living with HIV+ [91]. Although lacking a control group, pre-post assessment with 35 participants showed statistically significant improvement in mental health knowledge and alexithymia.

Discussion

This systematic review synthesizes evidence on child and adolescent mental health in Mozambique, encompassing 61 reports from 25 prevalence studies, 29 reports describing 42 assessment instruments, and 8 intervention trials. The prevalence of mental disorders according to structured clinical criteria was only assessed at regional samples, including a survey with adolescents in Maputo (any mental health diagnosis: 23%) and another study with children and adolescents in Nampula (ADHD: 13·4%) [8,57–60]. Nationally representative surveys report mental health-related outcomes and risk factors, indicating that one in four adolescents experience physical or emotional violence annually, while 16·55% report lifetime sexual abuse, with particular concern regarding gender-based violence against girls [32–53,56,62,67–70]. National suicide rates per age group could be estimated via epidemiological registers (15–19 years: 1·53; 10–14 years: 0·59; 5–9 years: 0·05) [28]. Only one clinical interview (MINI-KID) and three screening instruments (GAD-7, PHQ-A, and SDQ) have undergone cross-cultural adaptation and positive psychometric evaluation across multiple properties, while tools lacking cultural adaptation showed poor performance [8,55,57,59–61,63,82]. Among interventions, only one RCT was identified, targeting neurodevelopment in high-poverty settings and showing positive outcomes and cost-effectiveness [31].

With significant data gaps, the current evidence in Mozambique is far from conclusive, warranting caution when drawing comparisons with international indicators. Clinical data is limited to two urban samples comprising a total of 1,234 participants, yet point to a higher prevalence of mental health disorders compared to global estimates assessed with similar manualized criteria [10,93]. Although suicide rates in Mozambique appear lower than then global averages (ages 15–19: 1.53; ages 10–14: 0.59 per 100,000), they are likely underestimated [94]. The single national study was based on three referral services responsible for all violent death autopsies in the country [28]. Moreover, the reliability of epidemiological and civil registration data in Mozambique is limited, with reports that nearly half of children under the age of five are not registered in official records [3]. Similarly, other register-based studies in Mozambique are scarce and rely primarily on service-level data from isolated facilities, limiting their generalizability. An integrated national health information system that includes mental health outcomes is needed to strengthen epidemiological data and monitoring across the country [95].

National-level data with adolescent samples indicate alarming rates of exposure to adversities and emotional and behavioral symptoms [32–53]. In particular, the high prevalence of physical, emotional, and sexual violence stands out as a clear public health priority. These experiences are not only key social determinants of psychological distress and mental disorders, but also undermine healthy development and long-term prospects, potentially perpetuating cycles of violence and trauma across future generations [96–99]. While current data in Mozambique is restricted to adolescents, it is likely that such exposures begin at younger age groups. Surveys including infants, preschoolers, and school-aged children are recommended to support data-driven action from the earliest possible stages of development [97]. It is worth noting that Mozambique has made progress in strengthening child protection mechanisms, with special consideration to gender-based violence and sexual exploitation [3,67]. The National Mental Health Strategy and Action Plan (2016–2026) also emphasizes interinstitutional cooperation with child protection bodies as a priority area [100].

We identified substantial gaps in the cross-cultural adaptation and psychometric validation of mental health instruments in Mozambique. While such gaps are common across non-English-speaking countries, they are particularly pronounced in Mozambique, where only 42 tools were identified (compared to 912 in Brazil and 261 in Greece) [9,10]. As a Portuguese-speaking country, Mozambique has often relied on instruments translated for use in Brazil or Portugal without further cultural adaptation, which was linked to poor psychometric performance in a few validation studies [59–61,82]. This highlights the need to adhere to culturally-sensitive practices in the country, including translating tools to local dialects; to this end, it is necessary to prioritize locally trained specialists over the current reliance on international experts [101].

The volume and scope of scientific literature on child and adolescent mental health in Mozambique remain limited, presenting a recent research body in which most output emerged in the last decade. Reflecting the country’s socioeconomic challenges, existing studies largely focus on adversities such as maltreatment and violence, with some research clustered around neurodevelopment in vulnerable populations [31–53,61,84,85]. While this underscores the elevated psychosocial burden and risk of mental disorders, few studies directly address mental health conditions. There are no nationally representative estimates of mental disorders based on standardized diagnostic criteria. Existing data are limited to a small number of disorders assessed in two localized samples from Maputo and Nampula, leaving other regions and rural areas unrepresented [8,57–60]. No prevalence estimates are reported for ASD or eating disorders, and no assessment tools are available for research or clinical practice on these conditions. This reflects the early stage of service development, with fewer than 5% of people experiencing mental health conditions receiving any form of care [101]. Future efforts should prioritize closing the data gap on estimates of both overall and specific mental disorders among children and adolescents, improving representation of national and regional samples.

The majority of scientific literature has been produced through international collaborations and funded by development agencies. Few local experts appear as first or lead authors, and only two dissertations have been published by a local university [28,29]. This reflects a scarcity of postgraduate programs and fragile academic infrastructure. Mozambique has only five medical schools, and no domestic capacity for postgraduate psychiatric training existed until 2018 (the first three Mozambican psychiatrists trained abroad graduated in 2004–2005) [101]. The need to strengthen national research capacity is acknowledged in the Strategy and Action Plan for Mental Health 2016–2026, which outlines an action front for developing research and human resources [4]. The Department of Mental Health has established partnerships with institutions in Portugal, Brazil, and the United States to support postgraduate training in mental health [102,103]. As a result, Mozambique now has 30 psychiatrists (10 PhDs, 6 Master’s), 693 psychologists (2 PhDs, 1 Master’s), and 41 occupational therapists (1 Master’s). Nevertheless, national universities remain weakly connected to medical specialization and offer few advanced training opportunities [104]. Eduardo Mondlane University has a Master’s in Mental Health, and some doctoral programs in Biosciences have recently integrated mental health [28,29,102]. Strengthening postgraduate training opportunities within the country is critical to building sustainable research capacity and a skilled mental health workforce.

This work builds on the methodological strengths of previous systematic reviews conducted in Greece, Brazil, and South Africa, employing a comprehensive search strategy and structured guidelines that provide best practices for appraising prevalence estimates, assessment instruments, and interventions [9–11]. We further increased reach by including studies involving clinical samples and screening institutional reports and local catalogues. Although screening was often conducted by a single reviewer, the emphasis on maximizing inclusion and identifying as many relevant studies as possible helped reduce the risk of missing important evidence, and no major discrepancies were identified during the independent verification of screening and data extraction (this likely reflects the reviewers’ prior experience with a similar review conducted in Brazil, as well as pilot calibration exercise and ongoing discussions throughout the review process).

However, this review does not capture the totality of mental health research on children and adolescents in Mozambique. Additional data may be scattered across uncaptured sources, including multinational assessments reporting only aggregate results, non-academic sources, and conference abstracts [105]. Given the limited scope of local research, these sources could represent a substantial body of evidence. Meta-analysis was not feasible due to the limited number and substantial heterogeneity of the included studies, which yielded few comparable data points. For instance, no single prevalence estimate or measurement property was evaluated across two or more studies with comparable samples (notably the two community-based studies using clinical interviews did not report on the same mental disorders, further relying on distinct diagnostic manuals and age ranges). This heterogeneity also precluded a formal certainty-of-evidence assessment (e.g., GRADE) given the lack of overlap across reports.

The field of child and adolescent mental health is still emerging in Mozambique. While available data is scarce, it suggests a high burden of mental disorders, with public health priorities shaped by widespread socioeconomic adversity and alarming rates of gender-based violence. There are few available resources for screening mental health symptoms, and reliable assessment warrants cultural adaptation of instruments. Future research should target data gaps on prevalence rates of mental disorders across regional and national samples. There is an urgent need to strengthen local research capacity through investment in human resource development and the expansion of academic institutions.

Supporting information

References

1Census Bureau US . World population estimates and projections. International database. 2024 . Accessed 2025 July 30. https://www.census.gov/programs-surveys/international-programs/about/idb.html

2Casella CB , Kousoulis AA , Kohrt BA , Bantjes J , Kieling C , Cuijpers P , et al. Data gaps in prevalence rates of mental health conditions around the world: A retrospective analysis of nationally representative data . Lancet Glob Health . 2025 ;13 (5 ):e879–87 . doi: 10.1016/S2214-109X(24)00563-1
40288397

3UNICEF. The situation of children in Mozambique. UNICEF. 2021 . https://www.unicef.org/mozambique/media/4976/file/The%20Situation%20of%20Children%20in%20Mozambique%202021.pdf

4Ministry of Health. Estratégia e plano de acção para a saúde mental 2016 – 2026 . Ministry of Health; 2015 . https://zenodo.org/doi/10.5281/zenodo.16777478

5Dos Santos PF , Wainberg ML , Caldas-de-Almeida JM , Saraceno B , Mari J de J . Overview of the mental health system in Mozambique: Addressing the treatment gap with a task-shifting strategy in primary care . Int J Ment Health Syst . 2016 ;10 :1 . doi: 10.1186/s13033-015-0032-8 26734070 PMC4700645

6Daniel HMC. Certificado de especialidade de Helena Mutede Cutótua Daniel. 2021.

7Pires P , Belo A , Anube A , Santos D , Arroz J , Pereira J , et al. Mental health in Mozambique; A systematic review . Int J Fam Commun Med . 2019 ;3 (4 ). doi: 10.15406/ijfcm.2019.03.00146

8Lovero KL , Adam SE , Bila CE , Canda ED , Fernandes ME , Rodrigues TIB , et al. Validation of brief screening instruments for internalizing and externalizing disorders in Mozambican adolescents . BMC Psychiatry . 2022 ;22 (1 ):549 . doi: 10.1186/s12888-022-04189-3 35962378 PMC9373392

9Koumoula A , Marchionatti LE , Caye A , Karagiorga VE , Balikou P , Lontou K . The science of child and adolescent mental health in Greece: A nationwide systematic review . Eur Child Adolesc Psychiatry . 2023 .10.1007/s00787-023-02213-9 PMC11564383 37179505

10Marchionatti LE , Campello AC , Veronesi JA , Ziebold C , Tonon AC , Casella CB , et al. The science of child and adolescent mental health in Brazil: A nationwide systematic review and compendium of evidence-based resources . BMJ Glob Health . 2026 ;11 (7 ):e018542. doi: 10.1136/bmjgh-2024-018542 42431695 PMC13358285

11Bantjes J , Jenkins D , Brooke-Sumner C , Marchionatti LE , Mpisane N , Mosalisa M , et al. Systematic review and meta-analysis of child and adolescent mental health in South Africa . medRxiv . 2025 .

12Brooke-Sumner C , Marchionatti LE , Mneimneh Z , Harker N , Egbe CO , Jenkins D , et al. Systematic review and meta-analysis of the prevalence of substance use among adolescents in South Africa . Drug Alcohol Rev . 2026 ;45 (4 ):e70143. doi: 10.1111/dar.70143 41906279 PMC13033819

13Page MJ , McKenzie JE , Bossuyt PM , Boutron I , Hoffmann TC , Mulrow CD , et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews . BMJ . 2021 ;372 :n71.10.1136/bmj.n71 PMC8005924 33782057

14Elsman EBM , Mokkink LB , Terwee CB , Beaton D , Gagnier JJ , Tricco AC , et al. Guideline for reporting systematic reviews of outcome measurement instruments (OMIs): PRISMA-COSMIN for OMIs 2024 . J Patient Rep Outcomes . 2024 ;8 (1 ):64 . doi: 10.1186/s41687-024-00727-7 38977535 PMC11231111

15Li T , Higgins JP , Deeks JJ . Collecting data. Cochrane handbook for systematic reviews of interventions. Wiley ; 2019 . 109 –41 . doi: 10.1002/9781119536604.ch5

16Shemilt I , Simon A , Hollands GJ , Marteau TM , Ogilvie D , O’Mara-Eves A . Pinpointing needles in giant haystacks: use of text mining to reduce impractical screening workload in extremely large scoping reviews: text mining to reduce screening workload . Res Synthesis Methods . 2014 ;5 (1 ):31 –49 .10.1002/jrsm.1093 26054024

17Polanin JR , Pigott TD , Espelage DL , Grotpeter JK . Best practice guidelines for abstract screening large‐evidence systematic reviews and meta‐analyses . Res Synthesis Methods . 2019 ;10 (3 ):330 –42 . doi: 10.1002/jrsm.1354

18Kim MM , Shanaa AM , Hammady H , Aboelnour M , Ayan R . Enhancing transparency, auditability, and reproducibility of deduplication in systematic reviews: Tutorial for the rayyan method and systematic auto resolver . Interact J Med Res . 2026 ;15 :e94317. doi: 10.2196/94317 42447231 PMC13367408

19Polanczyk GV , Salum GA , Sugaya LS , Caye A , Rohde LA . Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents . J Child Psychol Psychiatry . 2015 ;56 (3 ):345 –65 . doi: 10.1111/jcpp.12381
25649325

20Hoy D , Brooks P , Woolf A , Blyth F , March L , Bain C , et al. Assessing risk of bias in prevalence studies: Modification of an existing tool and evidence of interrater agreement . J Clin Epidemiol . 2012 ;65 (9 ):934 –9 . doi: 10.1016/j.jclinepi.2011.11.014
22742910

21Prinsen CAC , Mokkink LB , Bouter LM , Alonso J , Patrick DL , de Vet HCW , et al. COSMIN guideline for systematic reviews of patient-reported outcome measures . Qual Life Res . 2018 ;27 (5 ):1147 –57 . doi: 10.1007/s11136-018-1798-3
29435801 PMC5891568

22Higgins JPT , Thomas J , Chandler J , Cumpston M , Li T , Page MJ . Cochrane handbook for systematic reviews of interventions version 6.5 (updated August 2024) . 6.5 ed. Chichester, UK: Cochrane; 2024 .

23Sterne JAC , Savović J , Page MJ , Elbers RG , Blencowe NS , Boutron I , et al. RoB 2: a revised tool for assessing risk of bias in randomised trials . BMJ . 2019 ;366 :l4898.10.1136/bmj.l4898 31462531

24Aromataris E , Stern C , Lockwood C , Barker TH , Klugar M , Jadotte Y , et al. JBI series paper 2: tailored evidence synthesis approaches are required to answer diverse questions: A pragmatic evidence synthesis toolkit from JBI . J Clin Epidemiol . 2022 ;150 :196 –202 . doi: 10.1016/j.jclinepi.2022.04.006
35429608

25Igreja V , Axelsen T , Brekelmans A . Exploring the mental health of young people in households and schools in Gorongosa District, Center of Mozambique . Sci Rep . 2024 ;14 (1 ):28057 . doi: 10.1038/s41598-024-79257-7 39543385 PMC11564890

26Chaquisse EE . Intimate partner violence HIV viral hepatitis and STI and knowledge about transmission modes among pregnant women in Nampula Mozambique: Results from a cross-sectional study. Porto, PT: Universidade do Porto; 2018 . https://repositorio-aberto.up.pt/handle/10216/116160

27Lee YL . Longitudinal relations among mothers’ perceived social support, parenting practices, and children’s social competence during middle childhood in Mozambique. US: Arizona State University; 2023 .

28Magaia-Jamela IPA . Perfil e tendência dos casos de suicídio admitidos nos serviços de medicina legal dos hospitais centrais de Maputo, Beira e Nampula no período de 2014 a 2018. Maputo: Universidade Eduardo Mondlane; 2023 . http://www.repositorio.uem.mz/jspui/handle/258/1193

29Thumbo MN . Influência do suporte social na ocorrência de transtornos mentais comuns em adolescentes acolhidos no Centro Arco-íris, Zimpeto. Mozambique: Universidade Eduardo Mondlane; 2025 . http://www.repositorio.uem.mz/handle/258/1564

30Parkes J , Heslop J . Stop violence against girls in school: A cross-country analysis of change in Ghana, Kenya and Mozambique . London: ActionAid International; 2013 . https://www.researchgate.net/publication/320242549

31Martinez S , Naudeau S , Pereira VA . Preschool and child development under extreme poverty: evidence from a randomized experiment in rural Mozambique . World Bank; 2017 . https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3092440

32Werneck AO , Araujo RHO , Oyeyemi AL , Silva DR . Social isolation is associated with higher leisure-time sedentary behavior and lower physical activity practice: A multi-country analysis of data from 79 countries from the Global School-Based Student Health Survey . Prev Med . 2023 ;175 :107677 . doi: 10.1016/j.ypmed.2023.107677 37607660

33Vancampfort D a v y , Firth J , Smith L , Stubbs B , Rosenbaum S , Van Damme T , et al. Cannabis use and leisure-time sedentary behavior among 94,035 adolescents aged 12–15 years from 24 low- and middle-income countries . Addictive Behav . 2019 ;99 .10.1016/j.addbeh.2019.106104 31470242

34Vancampfort D , Van Damme T , Stubbs B , Smith L , Firth J , Hallgren M , et al. Sedentary behavior and anxiety-induced sleep disturbance among 181,093 adolescents from 67 countries: a global perspective . Sleep Med . 2019 ;58 :19 –26 . doi: 10.1016/j.sleep.2019.01.048
31048258

35Vancampfort D a v y , Van Damme T , Firth J , Smith L , Stubbs B , Rosenbaum S . Correlates of physical activity among 142,118 adolescents aged 12–15 years from 48 low- and middle-income countries . Prevent Med An Int J Devoted to Pract Theory . 2019 ;127 .10.1016/j.ypmed.2019.105819 31445918

36Smith L , McDermott D , Jacob L , Barnett Y , Butler L , Shin JI , et al. Violence victimization and suicide attempts among adolescents aged 12–15 years from thirty-eight low- and middle-income countries. Vol. 66, General Hospital Psychiatry . Smith, Lee: Cambridge Centre for Sport and Exercise Science, Anglia Ruskin University, Cambridge, United Kingdom, CB1 1PT, lee.smith@anglia.ac.uk Netherlands: Elsevier Science; 2020 . 147 –53 .10.1016/j.genhosppsych.2020.08.005 32866883

37Smith L , Grabovac I , Jacob L , López-Sánchez GF , Yang L , Shin JI , et al. Bullying victimization and sexual behavior among adolescents aged 12–15 years from 53 countries: A global perspective . Smith, Lee: Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, United Kingdom, CB1 1PT, lee.smith@anglia.ac.uk Netherlands: Elsevier Science; 2020 . 2148 –55 .

38Smith L , Jacob L , López-Sánchez GF , Grabovac I , Yang L , Pizzol D , et al. A multicountry study of the violence-related risk factors for early sexual debut and risky sexual behavior in adolescents . J Interpers Violence . 2022 ;37 (3–4):NP1275–97 . doi: 10.1177/0886260520927502
32517565

39Shayo FK , Kalomo MH . Prevalence and correlates of sexual intercourse among sexually active in-school adolescents: An analysis of five sub-Sahara African countries for the adolescent’s sexual health policy implications . BMC Public Health . 2019 ;19 (1 ):1285 . doi: 10.1186/s12889-019-7632-1 31606038 PMC6790023

40Seidu AA , Amu H , Dadzie LK , Amoah A , Ahinkorah BO , Ameyaw EK . Suicidal behaviours among in-school adolescents in Mozambique: Cross-sectional evidence of the prevalence and predictors using the Global School-Based Health Survey data . PLoS One . 2020 ;15 (7 ):e0236448.10.1371/journal.pone.0236448 PMC7380623 32706805

41Seidu A-A . Prevalence and correlates of truancy among school-going adolescents in Mozambique: Evidence from the 2015 global school-based health survey . Scient World J . 2019 ;2019 :9863890 . doi: 10.1155/2019/9863890 31239835 PMC6556352

42Pengpid S , Peltzer K . Unintentional injuries and socio-psychological correlates among school-going adolescents in Mozambique . Vulnerable Children and Youth Stud . 2019 ;15 (1 ):32 –9 . doi: 10.1080/17450128.2019.1679936

43Pengpid S , Peltzer K . Suicide attempt and associated factors among in-school adolescents in Mozambique . J Psychol Afr . 2020 ;30 (2 ):130 –4 .

44Pengpid S , Peltzer K . Sexual risk behaviour and its correlates among adolescents in Mozambique: results from a national school survey in 2015 . SAHARA J . 2021 ;18 (1 ):26 –32 . doi: 10.1080/17290376.2020.1858947
33641602 PMC7919870

45Peltzer K , Pengpid S . Prevalence of bullying victimisation and associated factors among in-school adolescents in Mozambique . J Psychol Afr . 2020 ;30 (1 ):64 –8 .

46Li L , Zhao Y , Shi M , Wang Y . Relationship between the early initiation of substance use and attempted suicide among in-school adolescents in seven low- or middle-income african countries: An analysis of the global school-based student health survey data . Front Psychol . 2021 ;12 :753824 . doi: 10.3389/fpsyg.2021.753824 34858282 PMC8631758

47Li DX , Guindon GE . Income, income inequality and youth smoking in low- and middle-income countries . Addiction . 2013 ;108 (4 ):799 –808 . doi: 10.1111/add.12075
23216738

48Kugbey N . Prevalence and correlates of substance use among school-going adolescents (11-18 years) in eight Sub-Saharan Africa countries . Substance Abuse Treatment Prevent Policy . 2023 ;18 .10.1186/s13011-023-00542-1 PMC10329385 37420290

49Koyanagi A , Oh H , Carvalho AF , Smith L , Haro JM , Vancampfort D , et al. Bullying victimization and suicide attempt among adolescents aged 12-15 years from 48 countries . J Am Acad Child Adolesc Psychiatry . 2019 ;58 (9 ):907-918.e4. doi: 10.1016/j.jaac.2018.10.018 30926574

50Felez-Nobrega M , Haro JM , Vancampfort D , Koyanagi A . Sex difference in the association between physical activity and suicide attempts among adolescents from 48 countries: A global perspective . J Affect Disord . 2020 ;266 :311 –8 . doi: 10.1016/j.jad.2020.01.147
32056893

51Darteh EKM . Alcohol use among school-going adolescents in Mozambique: Prevalence and correlates . Journal of Substance Use . 2021 ;27 (2 ):156 –61 . doi: 10.1080/14659891.2021.1916843

52Carvalho AF , Stubbs B , Vancampfort D , Kloiber S , Maes M , Firth J , et al. Cannabis use and suicide attempts among 86,254 adolescents aged 12-15 years from 21 low- and middle-income countries . Eur Psychiatry . 2019 ;56 :8 –13 . doi: 10.1016/j.eurpsy.2018.10.006
30447436

53Amu H , Seidu A-A , Agbemavi W , Afriyie BO , Ahinkorah BO , Ameyaw EK , et al. Psychosocial distress among in-school adolescents in Mozambique: A cross-sectional study using the Global School-Based Health Survey data . Child Adolesc Psychiatry Ment Health . 2020 ;14 :38 . doi: 10.1186/s13034-020-00344-4 32999685 PMC7520017

54Di Gennaro F , Marotta C , Ramirez L , Cardoso H , Alamo C , Cinturao V , et al. High prevalence of mental health disorders in adolescents and youth living with HIV: An observational study from eight health services in Sofala Province, Mozambique . AIDS Patient Care STDS . 2022 ;36 (4 ):123 –9 . doi: 10.1089/apc.2022.0007
35438520

55Nguyen N , Lovero KL , Falcao J , Brittain K , Zerbe A , Wilson IB , et al. Mental health and ART adherence among adolescents living with HIV in Mozambique . AIDS Care . 2023 ;35 (2 ):182 –90 . doi: 10.1080/09540121.2022.2032574
35277102 PMC10243515

56Pengpid S , Peltzer K , Efraime BJ . Suicidal behaviour, depression and generalized anxiety and associated factors among female and male adolescents in Mozambique in 2022-23 . Child Adolesc Psychiatry Ment Health . 2024 ;18 (1 ):142 .10.1186/s13034-024-00835-8 PMC11545947 39511572

57Come AX , Polanco-Roman L , Dos Santos PF , Fumo W , Mutemba R , Pathare S , et al. Social and psychiatric factors of suicidal thoughts and behaviors in Mozambican adolescents . J Am Acad Child Adolesc Psychiatry . 2022 ;61(7 ):841 –4 .e1.10.1016/j.jaac.2022.03.032 PMC11013564 35452784

58King A , Adam S , Bila C , Fernandes ME , Rodrigues T , Dos Santos PF , et al. Prevalence of mental disorders and healthcare seeking among Mozambican adolescents in school . Transcult Psych . 2026 ;13634615251409683:13634615251409683.10.1177/13634615251409683 42283102

59Daniel HMC , Duarte I , Caye A , Suleman A , Fumo W , Rohde LA . Attention-deficit/hyperactivity disorder in Mozambique: An epidemiological investigation in a primary school sample . Rev Bras Psiquiatr . 2024 ;46 :e20233343.10.47626/1516-4446-2023-3343 PMC11189130 38243805

60Daniel HMC , Duarte I , Caye A , Rohde LA . Exploring diagnostic performance of a screening instrument for ADHD and DSM-5 number of symptoms criterion in primary school students from Mozambique . J Atten Disord . 2024 ;28 (5 ):583 –8 . doi: 10.1177/10870547231215290
38084065

61P aul P , Chandna J , Procter SR , Dangor Z , Leahy S , Santhanam S . Neurodevelopmental and growth outcomes after invasive group B streptococcus in early infancy: A multi-country matched cohort study in South Africa, Mozambique, India, Kenya, and Argentina . EClinicalMedicine . 2022 ;47 (101358 ):101358 . doi: 10.1016/j.eclinm.2022.101358 PMC9142788 35747160

62Dadras O . Mental health and help-seeking behaviors among Mozambican youth: Insights from a post-pandemic National Survey Amidst Internal Conflict . Soc Psychiatry Psychiatr Epidemiol . 2025 ;60 (7 ):1681 –93 . doi: 10.1007/s00127-025-02817-3
39849198 PMC12238195

63Chimbutane F , Herrera-Almanza C , Karachiwalla N , Lauchande C , Leight J . COVID-19 school closures and mental health of adolescent students: Evidence from rural Mozambique . SSM Ment Health . 2023 ;3 :100203 . doi: 10.1016/j.ssmmh.2023.100203 36987504 PMC10010050

64Albajara Sáenz A , Kurten S , Saxton J , Kardefelt-Winther D , Ford T , Orben A . Mental health measures among adolescents in 12 low- and middle-income countries: Measurement invariance and cross-sectional analyses of Disrupting Harm survey data . JCPP Adv . 2025 ;e70087:e70087.10.1002/jcv2.70087 PMC13338989 42416615

65Manafe N , Ismael-Mulungo H , Ponda F , Dos Santos PF , Mandlate F , Cumbe VFJ , et al. Prevalence and associated factors of common mental disorders among internally displaced people by armed conflict in Cabo Delgado, Mozambique: a cross-sectional community-based study . Front Public Health . 2024 ;12 :1371598 . doi: 10.3389/fpubh.2024.1371598 38689772 PMC11058794

66Langa I , Padama F , Nhancupe N , Pondja A , Hlashwayo D , Gouveia L , et al. The burden of T. solium cysticercosis and selected neuropsychiatric disorders in Mocuba district, Zambézia province, Mozambique . PLoS Negl Trop Dis . 2022 ;16 (7 ):e0010606. doi: 10.1371/journal.pntd.0010606 35834558 PMC9321429

67UNICEF, ECPAT, End Violence Partnership. Disrupting Harm in Mozambique - Evidence on online child sexual exploitation and abuse . UNICEF; 2022 . https://www.unicef.org/innocenti/media/4116/file/DH-Mozambique-Report-2022.pdf

68James PB , Bah AJ , Kabba JA , Kassim SA , Dalinjong PA . Prevalence and correlates of current tobacco use and non-user susceptibility to using tobacco products among school-going adolescents in 22 African countries: A secondary analysis of the 2013-2018 global youth tobacco surveys . Arch Public Health . 2022 ;80 (1 ):121 .10.1186/s13690-022-00881-8 PMC9009031 35422011

69Decker MR , Latimore AD , Yasutake S , Haviland M , Ahmed S , Blum RW , et al. Gender-based violence against adolescent and young adult women in low- and middle-income countries . J Adolesc Health . 2015 ;56 (2 ):188 –96 . doi: 10.1016/j.jadohealth.2014.09.003
25620301

70Howard AL , Chiang L , Picchetti V , Zhu L , Hegle J , Patel P , et al. Population estimates of HIV risk factors to inform HIV prevention programming for adolescent girls and young women . AIDS Educ Prev . 2023 ;35 :20 –38 . doi: 10.1521/aeap.2023.35.suppA.20
37406147 PMC11249023

71Alcaraz M , Pierce H , Eggum ND , Nuño-Gutiérrez BL , Ghimire D . A cross-cultural examination of adverse childhood experiences in low-and middle-income countries and their relation with adolescent educational aspirations. Child Abuse and Neglect . Alcaraz, Melissa: Department of Sociology, 2037 JFSB, Provo, UT, US, 84602, melissa.alcaraz@byu.edu Netherlands: Elsevier Science; 2024 . 1 –13 .10.1016/j.chiabu.2024.106756 PMC11175623 38531287

72Boothby N , Crawford J , Halperin J . Mozambique child soldier life outcome study: lessons learned in rehabilitation and reintegration efforts . Glob Public Health . 2006 ;1 (1 ):87 –107 . doi: 10.1080/17441690500324347
19153896

73Carneiro IM , Fonseca P , Ferreira R . Children’s sleep habits questionnaire in two subpopulations from cape verde and Mozambique: Exploratory and regression analysis . Acta Med Port . 2019 ;32 (10 ):628 –34 . doi: 10.20344/amp.11841
31625874

74Villanueva L , Maciel L , Gomis-Pomares A , Gouveia-Pereira M , Adrián JE , Costa MSA , et al. The global impact of multisystemic vulnerabilities on criminal variety: A cross-continental study in young adults . J Interpers Violence . 2025 ;40 (11–12):2467 –93 . doi: 10.1177/08862605241270016
39135482

75Basto-Pereira M , Gouveia-Pereira M , Pereira CR , Barrett EL , Lawler S , Newton N , et al. The global impact of adverse childhood experiences on criminal behavior: A cross-continental study . Child Abuse Negl . 2022 ;124 :105459 . doi: 10.1016/j.chiabu.2021.105459 35007971

76Maguele MS , Tlou B , Taylor M , Khuzwayo N . Risk factors associated with high prevalence of intimate partner violence amongst school-going young women (aged 15-24 years) in Maputo, Mozambique . PLoS One . 2020 ;15 (12 ):e0243304.10.1371/journal.pone.0243304 PMC7725391 33296426

77Heslop J , Parkes J , Januario F , Sabaa S . Making meaning from data on school-related gender-based violence by examining discourse and practice: Insights from a mixed methodology study in Ghana and Mozambique . Compare: A J Comp Int Edu . 2017 ;49 (1 ):64 –80 . doi: 10.1080/03057925.2017.1385388

78Ribeiro A , Willhelm AR , De Lemos VDO , Vilanova F , De Freitas CPP , Dede E . A network analysis of substance consumption patterns among students of public schools in Mozambique . Univ Psychol . 2020 ;19 .

79Gouveia L , Mandlate F , Ziebold C , Fumo W , Mabunda D , Lovero KL , et al. Emotional contagion behavior in a group of young girls in a secondary school in Maputo, Mozambique . Int J Soc Psychiatry . 2023 ;69 (2 ):447 –53 . doi: 10.1177/00207640221111265
35841157 PMC11023688

80Libombo P , Baker-Henningham H , Grantham-McGregor S . Factors associated with internalising problems in orphans and their caregivers in rural Mozambique . East Afr Med J . 2012 ;89 (1 ):3 –10 . 26845805

81Chaquisse E , Fraga S , Meireles P , Macassa G , Soares J , Mbofana F , et al. Sexual and physical intimate partner violence among women using antenatal care in Nampula, Mozambique . J Public Health Afr . 2018 ;9 (1 ):744 . doi: 10.4081/jphia.2018.744 30079164 PMC6057723

82S35Chandna J , Liu WH , Dangor Z , Leahy S , Sridhar S , John HB , et al. Emotional and behavioral outcomes in childhood for survivors of invasive group B Streptococcus disease in infancy: Findings from 5 low- and middle-income countries . Clin Infect Dis . 2022 ;74 (Suppl_1):S35-43.10.1093/cid/ciab821 PMC8776308 34725686

83Basto-Pereira M , Queiroz-Garcia I , Maciel L , Leal I , Gouveia-Pereira M . An international study of pro/antisocial behavior in young adults . Cross-Cultural Res . 2019 ;54 (1 ):92 –105 . doi: 10.1177/1069397119850741

84Vogt P , Mastin JD , Aussems S . Early vocabulary development in rural and urban mozambique . Child Develop Res . 2015 ;2015 :1 –15 . doi: 10.1155/2015/189195

85Mastin JD , Vogt P . Infant engagement and early vocabulary development: A naturalistic observation study of Mozambican infants from 1;1 to 2;1 . J Child Lang . 2016 ;43 (2 ):235 –64 . doi: 10.1017/S0305000915000148
26087953

86de Castro F , Momade K , Yourkavitch J , Arnold CD , Manhiça A , Zano F . The impact of an integrated nurturing care intervention to improve early childhood development outcomes in Nampula Province, Mozambique . Public Health Nutr . 2025 ;29 (1 ):e93.10.1017/S1368980025100554 PMC13398206 40506265

87van Egmond MC , Hanke K , Omarshah TT , Navarrete Berges A , Zango V , Sieu C . Self-esteem, motivation and school attendance among sub-Saharan African girls: A self-determination theory perspective . Int J Psychol . 2020 ;55 (5 ):842 –50 . doi: 10.1002/ijop.12651
31912496

88Schwandt HM , Underwood C . Making a difference in adult-child relationships: Evidence from an adult-child communication intervention in Botswana, Malawi, and Mozambique . J Adolesc . 2013 ;36 (6 ):1177 –86 . doi: 10.1016/j.adolescence.2013.09.005
24215964

89Schwandt HM , Underwood C . Engaging school personnel in making schools safe for girls in Botswana, Malawi, and Mozambique . Int J Edu Develop . 2016 ;46 :53 –8 . doi: 10.1016/j.ijedudev.2015.10.008

90Skar A-MS , Sherr L , Clucas C , von Tetzchner S . Evaluation of follow-up effects of the international child development programme on caregivers in Mozambique . Infants & Young Children . 2014 ;27 (2 ):120 –35 . doi: 10.1097/iyc.0000000000000006

91Benoni R , Malesani C , Sartorello A , Cardoso H , Chaguruca I , Alamo C , et al. Assessing the impact of a community-based psychodrama intervention on mental health promotion of adolescents and young adults in Mozambique: A mixed-methods study . J Glob Health . 2024 ;14 (04182 ):04182 .10.7189/jogh.14.04182 PMC11271167 39051689

92Silva AF , Santos S . As competências psicomotoras e adaptativas na qualidade de vida de crianças e jovens moçambicanos com perturbações do desenvolvimento: o contributo da intervenção psicomotora . Motricidade . 2021 ;17 (2 ):1 –24 .

93Kieling C , Buchweitz C , Caye A , Silvani J , Ameis SH , Brunoni AR , et al. Worldwide prevalence and disability from mental disorders across childhood and adolescence: Evidence from the global burden of disease study . JAMA Psychiatry . 2024 .10.1001/jamapsychiatry.2023.5051 PMC10831630 38294785

94Glenn CR , Kleiman EM , Kellerman J , Pollak O , Cha CB , Esposito EC , et al. Annual research review: A meta-analytic review of worldwide suicide rates in adolescents . J Child Psychol Psychiatry . 2020 ;61 (3 ):294 –308 . doi: 10.1111/jcpp.13106 31373003

95Fabian KE , Muanido A , Cumbe VFJ , Manaca N , Hicks L , Weiner BJ , et al. Optimizing treatment cascades for mental healthcare in Mozambique: Preliminary effectiveness of the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) . Health Policy Plan . 2021 ;35 (10 ):1354 –63 . doi: 10.1093/heapol/czaa114
33221835 PMC8600015

96Merrick MT , Ports KA , Ford DC , Afifi TO , Gershoff ET , Grogan-Kaylor A . Unpacking the impact of adverse childhood experiences on adult mental health . Child Abuse Negl . 2017 ;69 :10 –9 . doi: 10.1016/j.chiabu.2017.03.016
28419887 PMC6007802

97Lui CK , Witbrodt J , Li L , Tam CC , Williams E , Guo Z , et al. Associations between early childhood adversity and behavioral, substance use, and academic outcomes in childhood through adolescence in a U.S. longitudinal cohort . Drug Alcohol Depend . 2023 ;244 :109795 . doi: 10.1016/j.drugalcdep.2023.109795 36774809 PMC10089259

98Sharratt K , Mason SJ , Kirkman G , Willmott D , McDermott D , Timmins S , et al. Childhood abuse and neglect, exposure to domestic violence and sibling violence: Profiles and associations with sociodemographic variables and mental health indicators . J Interpers Violence . 2023 ;38 (1–2):NP1141–62 . doi: 10.1177/08862605221090562
35445607 PMC9709533

99Badenes-Ribera L , Fabris MA , Prino LE , Gastaldi FGM , Longobardi C . Physical, emotional, and sexual victimization across three generations: A cross-sectional study . J Child Adolesc Trauma . 2019 ;13 (4 ):409 –17 . doi: 10.1007/s40653-019-00273-1
33269041 PMC7683646

100Ministério da Saúde. Estratégia e Plano de Acção para a Saúde Mental 2016 - 2026 . Maputo: Governo de Moçambique; 2015 .

101Daniel HMC , Marchionatti LE , Veronesi JA , Campello AC , Casella CB , Rohde LA , et al. The mental health care system for children and adolescents in Mozambique: A systematic review and health system analysis . PsyArXiv . 2026 .

102Noormahomed EV , Mandane A , Cuambe A , Rodrigues MA , Noormahomed S , Carrilho C . Design and implementation of postgraduate programs in health in a resource-limited setting in Mozambique (the Lúrio University) . Adv Med Educ Pract . 2021 ;12 :399 –412 .10.2147/AMEP.S291364 PMC8075734 33911914

103Sweetland AC , Oquendo MA , Sidat M , Santos PF , Vermund SH , Duarte CS , et al. Closing the mental health gap in low-income settings by building research capacity: Perspectives from Mozambique . Ann Glob Health . 2014 ;80 (2 ):126 –33 . doi: 10.1016/j.aogh.2014.04.014
24976551 PMC4109687

104Noormahomed EV , Noormahomed S , Cossa M , Joyce N , Miambo RD , Sousa IM . Transforming the health research workforce in Mozambique: Achievements of the Mozambique Institute for Health Education and research (MIHER) over a 13‑year journey . Ann Glob Health . 2024 ;90 (1 ):78 .10.5334/aogh.4528 PMC11639690 39678200

105Chhabra D , Lovero KL , Adam S , Bila C , Eduarda F , Rodrigues T , et al. Mental disorders and health care seeking among Mozambican adolescents. J Am Acad Child Adolesc Psych . 2020 ;59 (10 ):S143.