Background

The World Health Organization (WHO) defines mental health as “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community”1. WHO has acknowledged the crucial link between health and education, recognizing the potential for schools to serve as primary hubs for safeguarding student health and well-being1.

In Saudi Arabia, children and adolescents make up about 67% of the population, according to the General Authority for Statistics (2020–2021)2. This demographic undergoes numerous physical, cognitive, emotional, and social developmental changes, with experimentation and risk behaviours often emerging during this period. Research shows that the rate of major depressive disorder rises from 1% in childhood to 25% during adolescence3.

Globally, 10–20% of teenagers experience mental health challenges, with violence risk, particularly bullying that serves as a significant contributing factor4. Salmon et al.5 define bullying as intentional aggressive behaviour involving a power imbalance, often occurring in high school settings. It is linked to low self-esteem, anxiety, depression, and academic struggles6. Further studies show that students who get bullied are more than twice as likely to show symptoms of anxiety, sadness, or mental disorders7,8. Such patterns of violence within schools can worsen psychological outcomes and lead to long-term emotional harm.

Saudi Arabia being one of the high GDP countries, provides a variety of growth opportunities that draw talent and ambition from every corner of the world. In 2014, the Saudi government’s Central Department of Statistics and Information reported that expatriates made up 33% of the total population, equating to 10.1 million individuals9. This number has grown steadily over the past decade due to rapid economic development and increased migration. Saudi Arabia’s education system includes two main streams of schools: national schools, which teach in Arabic and are primarily for Saudi citizens, and international schools, which offer instruction in English and entertain these 33% of expatriates of different nationalities10.

The international schools in Saudi Arabia host a highly diverse student body. Students often face unique social stressors such as language barriers, cultural differences, challenges in social integration, and difficulties forming friendships. These factors can indirectly increase academic pressure and lead to social loneliness. These conditions may increase the risk of mental health problems when compared to peers in national Saudi schools. The multicultural environment of international schools in Jeddah, while enriching, can also result in experiences of exclusion, bullying, or mental health issues that increase psychological vulnerability in high school students. Additionally, it can lead to students becoming more anti-social and overly attached to their gadgets, making them more susceptible to social loneliness and cyberbullying, another form of violence risk alongside school bullying. Therefore, the international schools are crucial for studying adolescent mental health due to concerns regarding social loneliness and risk of violence in this vulnerable population.

While earlier studies in Saudi Arabia have mainly focused on mental health among students in national schools, this study takes a broader view by including adolescents from both Saudi and non-Saudi backgrounds attending international schools in Jeddah.

To the best of our knowledge, this study is the first to explore mental health challenges and the risks of physical and cyber violence specifically among international high school students in Jeddah. Therefore, the study aims to explore the mental health challenges of these students and examine their relationship with both physical and cyber bullying.

Materials and methods

Study design and settings

A cross-sectional study was conducted between April 2023 and October 2023 to explore mental health concerns and their association with physical and cyber violence among international high school students in Jeddah, Saudi Arabia. Of the approximately 137 international schools listed in the Jeddah school directory11, only 20 offered a three-tier education system, including elementary, middle, and secondary levels. The remaining schools provided only elementary or primary education and did not meet our study’s inclusion criteria, which required secondary-level students as well. Ultimately, only 5 of the 20 eligible international schools agreed to participate in the study by providing formal consent.

Study participants

The included participants in this study were international high school students from grades 8 to 12, both male and female, who provided consent for participation, along with parental consent. Only schools with “international” in their official name were considered. These schools were identified through an online directory search for schools in Jeddah, and their current operational status was confirmed. The final selection of schools was based on the permission granted by the schools and the feasibility of data collection. The exclusion criteria included students outside of grades 8 to 12, students who did not receive parental consent for participation, and schools that did not grant permission to participate in the study.

Sampling tool

A pre-validated standardized questionnaire from the WHO Global School-Health Survey (GSHS) database was used as a survey tool. GSHS is a self-administered validated tool that aims to assess behavioural risk factors and protective factors in 10 domains amongst people aged 13–17 years old. The 10 domains comprising a total of sixty-four questions are categorized into modules about alcohol use, hygiene, dietary behaviours, drug use, mental health, physical activity, sexual behaviours that contribute to STIs and unintended pregnancy, tobacco use and violence, and unintentional injury.

For this study, only two modules from the GSHS, the Mental Health and Violence modules were selected. These modules were adapted into a Google Form. The first part of the survey collected socio-demographic data comprised of four questions, including participants’ age, nationality, grade level, and gender. The subsequent sections consisted of the selected GSHS modules.

The Mental Health module included six close ended questions addressing topics such as number of close friends, feelings of loneliness, sleep disturbances (e.g., insomnia), and history of suicide attempts. The Violence module comprised nine close ended questions exploring experiences with serious injuries, school bullying, and cyberbullying. Both modules used Liker scale for scoring.

A full version of the administered questionnaire, including the scoring details is provided in Supplementary File 1.

Before data collection, a pilot study was conducted with twenty high school students to assess the clarity and reliability of the survey instrument. This was done to identify any issues with question comprehension, response options, and the overall survey structure. Based on the feedback from the pilot study, the only adjustments made were organizational, including the addition of sections and pages to divide the module, while the questions remained unchanged and were used exactly as they appeared in the standardized questionnaire.

Ethical approval

The study was approved by Batterjee Medical College, Jeddah, Saudi Arabia (RES-2023-0038). All methods were performed in accordance with the relevant local guidelines and regulations.

Sampling technique and data collection

A convenience sampling method was used to recruit participants, offering easy access to a broad range of willing respondents. International students were selected as they are more likely to face mental health and violence-related challenges due to the diverse nature of international school environments, aligning well with our study’s objectives. While this practical approach of convenience sampling, enabled quick data collection, its non-random nature limits the generalizability of the results. Therefore, the findings primarily reflect international students in grades 8 to grade 12 in Jeddah and may not totally represent all international high school students in Saudi Arabia.

For data collection, arrangements between the school administration and the data collectors were ensured so that students from 8th to 12th grade filled the online survey in a supervised manner. The minimum sample size was calculated to be 304 using Raosoft, considering a confidence level of 95%, a margin of error of ≤ 5% and expected prevalence of 50%. Informed verbal and written consents from the school, students and parents were taken prior to distributing the survey. The Google form and all data were stored in a secure and protected cloud and access to the data is only limited to the authors of this study.

Data analysis

The data was manually filtered to remove any data with anomalies in the demographics prior to analysis. Descriptive analysis was done including frequency, percentage and Chi-square (χ²) to test for association between the socio-demographic factors (age, academic year, gender, and nationality) and questions from the mental health and violence modules. Statistical analysis was conducted using IBM SPSS Statistics Version 26 and the p value of < 0.05 was considered significant for statistical test.

Results

General information of participants

A total of 586 responses from the students of grade 8–12 were collected through the survey. However, 48 responses were excluded from the study due to missing or abnormal data, resulting in a final sample size of 538 responses for analysis. The total number of students participated in this study was 538 with 252 males and 286 females. 85.3% (459 out of 538) of the students were non-Saudis and 14.7% (79 out of 538) were Saudi students. Out of all the male students: 85.3% (215) were non-Saudis and 14.7% (37) were Saudis. Similarly, amongst the female students: 85.3% (215 out of 286) were non-Saudis students and 14.7% (42 out of 286) were Saudi students. The mean age of students was 16.5 ± 9.04 years. The response rate was 100%. The demographic details of the participants are illustrated in Table 1.

Table 1 Demographics of Students.
Full size table

Mental health module

Saudi students exhibited higher rates of suicidal behaviour in the past 12 months (p = 0.014) and non-Saudi students, particularly females, reported higher prevalence of feelings of loneliness (p < 0.001), insomnia (p < 0.001), and suicide attempts (p = 0.001). Saudi Females were significantly (p = 0.001) more likely than males to have considered attempting suicide in the past 12 months, as indicated by the higher percentage of females reporting such thoughts (22.4% compared to 11.9% in males). Moreover, non-Saudi females were also more likely to have planned a suicide attempt in the past 12 months than male students (26.6% vs. 10.3%). The p-values reflect associations between mental health indicators with both nationality and gender. The detailed comparisons are presented in Table 2 below.

Table 2 Association between gender and nationality with mental health.
Full size table

Violence module

The analysis of violence-related experiences according to gender and nationality revealed several important patterns as given in the Table 3 in Supplementary File 2. Regarding unintentional injuries during the past 12 months, 61.8% of males and 70.1% of females reported no incidents. Concerning physical attacks, 17.9% of males and 9.8% of females reported being physically attacked at least once during the past year. This difference was statistically significant (p < 0.05), with males being more frequently attacked than females. Participation in physical fights was also significantly different between genders: 34.5% of males reported being involved in at least one physical fight compared to 11.5% of females. This difference was statistically significant (p < 0.05). Bullying on school property was reported by 27.8% of males and 26.2% of females. Cyberbullying was reported by 23.8% of males and 19.6% of females. This difference was statistically significant (p < 0.05), indicating that males experienced slightly higher rates of cyberbullying compared to females.

Discussion

The study delves into the complex landscape of mental health challenges and violence risks among International high school students in Jeddah, Kingdom of Saudi Arabia (KSA). Through examining various factors such as suicide, loneliness, insomnia, and violence, our study highlights significant insights.

Mental health module

This module highlights the prevalence of suicidal behaviours among Saudi students, despite Saudi Arabia being a Muslim-majority country where suicide rates are generally lower than in many other nations12. This apparent contradiction may be explained by the cultural sensitivity and taboo surrounding the topic of suicide. In Saudi society, strong family bonds are culturally valued and often act as a protective factor for youth13. However, even with comparatively low national suicide rates14, our findings suggest that suicide remains a significant public health concern.

Notably, a greater proportion of Saudi female students reported experiencing suicidal thoughts in the past year compared to their non-Saudi counterparts. Females, both Saudi and non-Saudi, also appeared more likely to have considered suicide within the previous 12 months. Results from the Chi-Square test indicated that the differences between males and females in reported suicide attempts statistically significant, suggesting gender a contributing factor in the likelihood of such behaviour.

Our findings are consistent with a retrospective study that highlighted repeated suicide attempts among Saudi adolescents15. A similar study not only observed gender-related disparities in suicidal behaviour similar to our study but also hypothesized that this disparity may stem from a combination of hormonal changes, evolving social roles contributing to depressive symptoms, and increased vulnerability to depression following menarche. It reported that females were 1.5 to 2 times more likely than males to exhibit suicidal behaviour and the hormonal factors, taken together, may explain the twofold increase in depression prevalence among adolescent girls compared to boys by mid-adolescence16,17. Additionally, other studies reporting lower rates of suicidal behaviour among males suggest that such behaviour is often only disclosed when symptoms become severe18,19. This pattern may be linked to gender-specific coping mechanisms, with males more likely to internalize or suppress emotional distress, whereas females tend to express it at earlier stages20. Further analysis of associated risk factors across studies also reveals that experiences such as bullying, lack of close friends, involvement in physical fights, feelings of loneliness, and insomnia are linked to a higher risk of suicidal behaviour21.

In terms of social connections, 68.7% of male students and 63.6% of female students reported having three or more close friends, while fewer than 5% of both groups reported having no close friends. Nevertheless, loneliness was reported more frequently by female students, with 40.6% indicating they felt lonely, compared to 32.5% of male students. This exceeds the findings of a study conducted in Riyadh, which reported only 10% of students as socially isolated22.

Loneliness is defined as a negative emotional state resulting from unmet social needs or the perception of being a burden to others13. It is closely associated with psychological conditions such as anxiety and depression23. Limited social interaction and experiences such as bullying have been shown to significantly contribute to loneliness among adolescents, highlighting the importance of addressing these issues24. The higher rate of loneliness reported by female students in our study may reflect their greater tendency to internalise negative social experiences, which in turn can lead to increased anxiety and feelings of isolation25. Conversely, an international study found that males exhibited higher levels of loneliness than females, which may be attributed to differences in cultural norms and living conditions23.

When comparing students by nationality, non-Saudi females reported higher levels of loneliness than their Saudi counterparts. This may be due to several types of loneliness: personal loneliness resulting from separation from family and friends in their home country; social loneliness caused by the disruption of social networks due to language barriers, cultural differences, or financial limitations; and cultural loneliness stemming from the absence of familiar customs, language, and social environments26.

Regarding insomnia, approximately 32% of both male and female students reported occasional difficulty sleeping due to persistent worry during the past 12 months. However, 12.9% of females experienced this constantly, more than twice the rate reported by male students. This trend is consistent with national data on insomnia in the Saudi population27. Interestingly, a greater proportion of non-Saudi students reported frequent difficulty sleeping compared to Saudi students, particularly when asked if they experienced this problem “most of the time.” However, fewer non-Saudi students reported that they “always” had trouble sleeping. The high rate of persistent sleep disturbance among non-Saudi students has not yet been widely documented in the existing literature.

Violence module

Violence ranks as the fifth leading cause of death among adolescents accounting for over 12% of male deaths globally24. In the Middle East, Saudi Arabia is among the top countries affected by cyber violence, with 62% of internet users reporting exposure to cybercrimes as per 201428. There are various reasons for children to be bullied including countries of origin, appearance, speech, mental and psychiatric disorders, and even negative attitudes towards school which can result in negative consequences leading to further aggression and bullying29,30.

In our study. males reported to be seriously injured compared to females and the most frequent known cause were fractures, dislocated joints and knocked out tooth due to this demographic being more involved in violence at school. On the other hand, females reported most injuries due to cut and stab wound and other unlisted causes. Additionally, Saudi students were recorded to be significantly involved in violence which could be due to various reasons such as: (1) exposure to violence in its numerous forms (media, games, internet)28, (2) lower socio-economic status and low education can also be one of the factors for increased violence31.

Moreover, our findings show Saudi students (32.9%), particularly males reported being bullied on school premises and 24.1% reported having been cyberbullied. This doesn’t align with previous research, which documented a lower rate of around 26% of adolescents experiencing bullying in the last 30 days, and one in three adolescents encountering physical violence at school in the past year. Notably, akin to our findings, higher males than females and older adolescents across studies were more exposed to bullying32.

A comprehensive epidemiological study offering national prevalence estimates for bullying revealed significant insights. Jeeluna, a study focusing on adolescent health needs in Saudi Arabia, reported that 25% of students had experienced bullying in the month prior to the study, a figure lower than our findings. Moreover, males (27.1%) were more inclined to engage in bullying compared to females (22.7%)33.

Lastly, Saudi Arabia has a noted prevalence of cyberviolence, as indicated by a study in Riyadh28. Factors contributing to this include discrimination in various forms, school environment, exposure to violent media, and societal influences like emotional frustration. These elements collectively fuel both on-school and cyberbullying30. Despite some awareness campaigns, there’s still a need for a dedicated national policy for bullying prevention. While the Ministry of Education has expressed interest in initiating a nationwide bullying prevention program, its current policy manual lacks clear protocols for addressing such incidents. Developing a dedicated national policy for bullying, accompanied by comprehensive awareness and training initiatives, is imperative. Countries like Sweden, with successful low bullying rates, offer valuable lessons through their early implementation of national policies and interventions32,34.

Overall, our study offers alarming insightful information on mental health risks and the prevalence of violence in high school population. These findings can aid the ministry, and the school authorities to prioritize and create effective prevention and management plans in high schools in KSA. In addition, more importance should be placed in raising awareness of the rates and harms of bullying, especially cyberbullying due to the increased internet consumption through social media and gaming. Most importantly, governing authorities should establish robust channels for facilities to aid mental health and ensure that every school has access to an on-campus or virtual mental health counsellor. To the best of our knowledge, this is the first study highlighting the mental health and violence risks in Jeddah’s international high school population in both Saudis and non-Saudi students.

Limitations

Our study has several limitations which should be disclosed. We focused on international schools which resulted in a difference in the population of Saudis and non-Saudis. This could have led to a difference in the actual numbers of representation and may not have accurately reflected the consensus of the current Saudi high school student population. In addition to this, due to the sensitive nature of the survey questions several schools refused to provide consent in collecting data from their students therefore we were limited in the number of schools from which we were able to collect data. It’s important to note that since we only used closed ended questions from the WHO Global School Health Survey modules on mental health and violence, we could not explore the reasons behind the students’ responses in more detail. The absence of qualitative data limited the understanding of contextual or cultural factors influencing student mental health and exposure to violence. Lastly, we recognize that the use of convenience sampling may introduce selection bias. However, given the logistical constraints and the need for school consent, this method allowed for efficient data collection from a diverse group of students across multiple international schools. Further research can be conducted to address the aforementioned limitations and dive deeper into other familial, socioeconomic and cultural factors that may contribute to rising rates of mental health and violence risks.

Conclusion

In conclusion, this study provides crucial insights into the mental health landscape and violence risks among high school students. Saudi students are disproportionately affected by violence, with males showing significant involvement in bullying. Additionally, Saudis exhibit higher rates of suicidal behaviour, while non-Saudi females report increased loneliness, insomnia, and suicide attempts respectively indicating a concerning trend that demands immediate attention. To effectively address these concerns, schools should prioritize student mental health through targeted screenings, regular counselling by qualified psychological professionals, and the implementation of evidence-based interventions. Furthermore, understanding the prevalence of bullying and suicidal thoughts in the Saudi population alarms educators, policymakers, and healthcare professionals to proactively address these issues, and aim to foster a safe and supportive environment that enhances student well-being.