MENTAL HEALTH IN KENYAN SCHOOLS: TEACHERS’ PERSPECTIVES

Abstract

Introduction:

This qualitative study, conducted in public primary and secondary schools, sought teachers’ perceptions of mental health concerns that are relevant in school settings. Based on the phenomenological theory, the study aimed to understand the teachers experiences of mental health problems in the schools and how they handled them.

Method:

The schools sampled represented rural, suburban and urban sections of Kiambu County in Kenya. Data were collected through Focus Group Discussions (FGDs). The researcher made summary notes from both audio taped interviews and notes made by the research assistants and summarized the major themes.

Results:

Teachers reported that they were aware that students suffered from mental health problems. They recognized learning difficulties, externalizing problems, internalizing problems, bizarre behavior, and problem substance use among students. Teachers reported that lack of skills and time were challenges in dealing with student mental health problems.

Conclusion:

Teachers perceive presence of mental health problems among the students. There is need for in- service training for identification and referral and that school psychologists be employed to deal with student mental health problems.

Introduction

Globally, an estimated 10–20% of children and adolescents experience a mental health problem (Kieling et al., 2011; Belfer, 2008). In sub-Sahara Africa, 9.5% of children and adolescents are reported to have a psychiatric disorder (Cortina, Sodha, Fazel, & Ramchandani, 2012). In Kenya, the prevalence of the different mental health problems of children and adolescents in schools have been shown to vary between 10% and 50.5% (Ndetei et al., 2007; Ndetei et al., 2008; Khasakhala, Ndetei, Mutiso, Mbwayo, & Mathai, 2012; Karsberg & Elklit, 2012; Mbwayo & Mathai, 2016; Ndetei et al., 2016; Magai, Malik, & Koot, 2018).

Children and adolescents spend a considerable amount of time in school where mental health problems can interfere with learning and result in low academic achievement (Rothi & Leavey, 2006). While teachers strive to meet the academic needs of their students, they may not be trained to understand the impediments to learning caused by student mental health problems. Yet parents and others within a community often turn to teachers as experts when it comes to child and adolescent development and academic performance. Teachers are expected to rectify gaps between their expectations and students’ performance. Understanding teachers’ perceptions and knowledge regarding child and adolescent mental health is critical to the educational system addressing student performance gaps.

When parents have concerns about a child’s behavior, they consult the teacher (Dwyer, Nicholson, Battistutta, & Oldenburg, 2005), suggesting that they expect that teachers have expertise in identifying student mental health problems (Loades & Mastroyannopoulou, 2010). Studies show that teachers are aware that students they teach have mental health issues, but complain that they have insufficient insight and training to deal with these kinds of problems (Andrews, McCabe, & Wideman-Johnston, 2014; Ball et al., 2016; Ades et al, 2010; Osagiede et al., 2018). This lack of knowledge contributes to teachers feeling inadequate in identifying and addressing mental health problems of learners (Rothi, Leavey, Chamba, & Best, 2005; Rothì, Leavey, & Best, 2008). According to Nyutu and Bertel, (2012), teachers in Kenya increasingly find themselves acting in the role of mental health professionals as they strive to meet students’ developmental needs. The aim of the study was to explore Kenyan primary and secondary school teachers’ perceptions of student mental health. Using the phenomenological approach, teachers’ experiences of mental health among students in schools were sought. According to Giorgi and Giorgi, (2008) the aim of Phenomenological Research is to capture as closely as possible the way in which the phenomenon is experienced within the context in which the experience takes place, making this theory appropriate for this study.

Methods

Study setting.

The study was conducted in Kiambu County, in central Kenya,.bordering Nairobi, Muranga and Nakuru Counties. With conducive climate for farming, there are large scale farms producing tea, coffee and horticultural products as well as smaller subsistence farms. There are also several industries, both large and small scale. With proximity to the Kenyan capital city, Nairobi, Kiambu County has a multiethnic population, with the largest ethnic community being from the Gikuyu community.

Both primary and secondary schools in Kiambu County were selected by convenience. The schools were from rural, peri-urban and urban sections of the County. Participants were teachers from both public primary and secondary schools. The teachers taught the variety of subjects found in the primary and secondary school curricula. All the teachers had attended a teacher training college at either degree, diploma or Certificate level.

Recruitment.

The principal investigator (PI) met with head teachers in 6 selected schools (4 primary school heads and 2 secondary school heads). Once head teachers agreed that the school could be part of the study, the teacher invited the teachers to the staff room where the PI explained the purpose of the study. The only teachers who were excluded from participating in FGDs were head teachers and their deputies. In some primary schools, all the teachers apart from the two administrators participated. In the high schools where there were more teachers, teachers from the different departments were encouraged to join. The secondary schools had more teachers per school compared to the primary schools. The secondary schools had about 50 eligible teachers while the primary schools had about 60 eligible teachers. Teachers willing to participate underwent informed consent. On average the FGDs had 7–9 teachers. Study methods were approved by the Kenyatta National Hospital and University of Nairobi ethics review board (KNH/UON ERC), Protocol Number P8/01/2017.

Data collection.

The principal investigator explained the purpose of the study and gave out the consent document to teachers who volunteered to participate. Those who consented then completed a demographic questionnaire. Data about teachers’ understanding of student mental health problems were collected using Focus Group Discussions (FGDs). All the FGDs were conducted in English in a designated room in the school building. FGD proceedings were recorded, and research assistants took notes.

Researchers referred to an interview guide prepared by the PI and the researchers for focus group questions. Discussions took about one and half hours.

RESULTS

Results of social demographic characteristics are summarized in table 1

Table 1.

showing key demographic characteristics

Characteristic		Total	Primary	Secondary
Schools		6	4	2
Response rates	Number Invited	110	60	50
	Responded	51 (46%)	32 (53%)	19 (38%)
Teachers		51	32 (62.7%)	19 (37.3%)
Sex	Males	13 (25.5%)	6	7
	Females	38 (74.5%)	26	12
Level of Teacher Training	Primary Teacher 1 certificate	5	5	0
	Diploma	10	10	0
	Degree	33	15	18
	Master’s in Education	1	0	1
Teaching experience since employment by government	1–10	14	6	8
	11–20	9	6	3
	21–30	15	13	2
	31–40	4	3	1
Level of Training in Counselling	None	33 (71.7%)	17	16
	Less than 1 month	8	6	2
	Certificate	2	2	0
	Diploma	2	2	0
	Degree	0	0	0
	Master’s in counselling psychology	1	0	1

Table 1: Social Demographic characteristics

More primary schools and teachers participated compared to the secondary schools and teachers. In Kenya, there are more primary schools and teachers compared to the secondary schools and teachers. Most primary schools have fewer teachers than secondary schools. In primary schools, posting of teachers is per class and therefore if a school has 8 classes, there will be 8 teachers plus the head teacher and the deputy. This could account to almost all teachers in a primary school participating. On the other hand, though the teachers in secondary schools will be posted per the size of the school, they will also be dependent on the number of subjects taught and their frequency per week. This makes the secondary schools have more teachers than primary schools. All departments were in the schools were represented Humanities, sciences, mathematics and technical subjects. This means that the teachers who participated and those who did not are similar. The focus group discussions have participants of between 6 and 12 and therefore the numbers were met in the both groups. Several secondary school teachers are housed within the school compound and so the timing of the FGD, which was between 1 and 2 pm is the lunch hour could have made some teachers decid to go for lunch. Other unique factors of high schools include more academic and nonacademic activities which require the presence of the teacher. These activities are carried out during free time and so the teachers in charge take their lunch in less than the time provided to be able to join and supervise the students.

Teachers’ mental health knowledge: Teachers’ responses are organized for each question posed for discussion in the FDG. Question 1: “Have you had any experiences with mental health problems among students, and how did you conclude that the student has mental health problems?”

All the teachers said that they had experienced students whom they felt had mental health problems through the way the students behaved. From the behaviors that were described by the teachers, the following themes emerged: learning difficulties; internalizing problems; externalizing problems; bizarre behavior; and drug problems

1. Learning difficulties: Both primary and secondary school teachers pointed out that they experience children with learning difficulties as reflected by the following teachers:

• Primary Teacher (PTr) 1: We have some pupils who are slow learners and do not understand concepts.

• PTr.2: There are also pupils who are disciplined but cannot write anything.

• PTr 3: We also have pupils with mental retardation.

• Secondary Teacher (STr) 1: There were two boys in our school who put in a lot of effort in school work. They did a lot of reading. The boys were really disciplined and obedient. They sought academic help from teachers and though they would be helped, they still continued scoring D-. We sought help for one boy from the Kenya Institute of Special Education (KISE) and KISE diagnosed him with Dyslexia and the report was taken back to school.

• STr. 2. There is a girl in form 2. When she joined my class, I realized that she could not read English at all. I even went to an extent of going to her file and she had scored well in some subjects but had a problem with languages. I spoke to the head teacher and she was to call the parents but unfortunately the head teacher got transferred before she could call the parent.

• STr 3: I have a student who has a learning difficulty for sure. I have asked the principal to call the father. The father did not come to school as he said that he is aware of the son’s problem.

• STr. 4: You also know because you could be teaching a math’s concept and the student does not get anything.

2. Internalizing Problems: Both primary and secondary school teachers pointed out that there were learners who had problems that seemed to fit in the internalizing problems.

• P Tr 4: There are children who are withdrawn while in class.

• P Tr 5: Some pupils are withdrawn, have no interest in class, they are absent mindedness and perform poorly in class.

• P Tr 6: There is this student who tried to commit suicide twice and was truant in class.

• S Tr 5: One student was always untidy, withdrawn and looked traumatized. She was bed wetting. She was also not cleaning herself and at one point I had to supervise her to clean herself. The parents were called and told to take her for counselling.

• S Tr 6: I want to give an experience of a boy who was bereaved. I had a boy whose father had died in an accident. He was absent minded in class and even outside the class he was always alone. The mother said that the boy is always at the graveside of the father when he is not in school. He was doing poorly academically. It has been about 4 years since the father died and he is experiencing this.

3. Externalizing problems: Both primary and secondary school teachers identified more externalizing problems compared to internalizing problems. There were sub problems that emerged from the externalizing problems pointed out by teachers.

a) Hyperactivity

• P Tr 7: There are some pupils who though in class 6 cannot settle in class and keep moving up and down, sometimes take other pupils’ things or beat them.

• S Tr 6: There is a form three student who is always hyperactive. She is unkempt and tells the younger classes to call her princesses. She makes stories of her own.

• S Tr. 3: I had a student who was always moving up and down and did not want to listen.

b) Defiant and conduct problems

• S Tr. 7: There are students who do not take orders, they are defiant, and this is beyond adolescence defiance.

• S Tr. 8: A student claimed that the father was dead and was living with her uncle who was assaulting her. She could fake her voice and call the principal. She also faked she had a head surgery and came to school with the bandage on her head.

• P Tr 9: I have taught a student who was very brutal in class and he could not change even after being punished.

• S Tr.9: As head of scout, some members of the scout movement told me that one student had serious issues as the mother had gone to Saudi Arabia. We planned to help him with food and rent. One day he was being punished and when I tried to find out why, he explained that he had been sent school fees by the mother and he misused it and so did not pay the school fees. Later, the mother and father came to school, and they said that the mother had never left the country and they had been supporting him all along. So, the boy was cheating us.

2) Bizarre Behaviors

• S Tr.10: There was a time the principal called me that a boy wanted to see me. When I went to the Principals office and the boy saw me, he broke down crying and apologizing that he had wronged. I think he was hallucinating. He was taken to a mental hospital.

• S Tr. 11: There was a time we experienced a student who would say things out of the norm. He would even say he would kill somebody, one of these days. He had a lot of anger. He would even say he would want to kill his mother. I remember asking him what career he would want, and he said he will be a morgue attendant. Eventually he was taken to a mental facility.

• S Tr. 12: We had a student who would ask questions which were out of context and he was also exhibiting abnormal behavior, like having an urge to bite others or saying that he was being transported to other places, but nobody else could see the places.

3) Students with drug problems

• S Tr 13: We had a student who once came with a knife to school, he wanted to kill the principal. He said he had booked a plane to go to Columbia and it is the teachers who were preventing him. He was under the influence of bhangi. We involved the parent and he was helped.

Question 2: What challenges do teachers face in dealing with students with mental health problems? Six subthemes emerged.

1. Lack of skills: Teachers felt that they were not equipped to deal with several problems manifested by the students.

   • P Tr 12: We teachers are not trained on many mental health problems of students
   • P Tr 13: We only think more of stresses of students unless those teachers trained in special education.
   • S Tr 14: In colleges we were taught the problems we are likely to experience but were not taught how to handle them.
   • S Tr 15: Teachers are not trained for the problems.
   • S Tr 13: Most seminars given to teachers are on academics not on emotional or behavioral problems of children.
   • S Tr 8: Learning disorders need to be explained scientifically.
   • S Tr 1: I have confusion and ignorance as a teacher. I lack the know how to incorporate the psychological issues.
   • S Tr. 13: When we were going through college, there were no specific course that taught us how to deal with abnormal students, so we are not equipped.
   • S Tr. 16: There are some teachers who have been trained, especially those who have been trained in special needs. However, regular teaching courses don’t get into those details.
   • S Tr. 12: Before we realize that the student has a problem, we take it as indiscipline and deal with it from a discipline point of view.
2. Lack of time: Apart from lack of skills, the teachers pointed out that lack of time is a major problem as they have a full teaching load.

   • P Tr.14 The teachers have a full load of teaching/many lessons per week which leaves very little time to help pupils with problems especially as listening takes a long time.
   • S Tr 17: I have been training in counselling but there is a challenge of time. I can start with a student, but I don’t have time to follow up. We meet along the corridors as I move from one class to another.
   • S Tr. 18: Even the teachers who are trained are given as many lessons as the rest and so there is very little time.
   • S Tr. 19:There is a lot of burden on the teacher and for mental health issues, it needs to be handled by a different specific office.
3. Lack of support from the school administration. While some teachers said that they have had administrators who support them, others noted that some administrators don’t give appropriate support.

   • S Tr 6: When you take the cases to the administration, the administration has dealt with many cases, they (administration) just lets go the case.
   • S Tr 1: Administration sometimes looks at the problem as a student being defiant and therefore looks for ways of having the student leave the school.
   • S Tr 7: For obedient, tidy and hardworking students, the administration accommodates them even with a learning problem as they are not causing any trouble.
4. Problem with Guidance & Counselling (G&C) department: Some teachers pointed some problems with the department of guidance and counselling.

   • S Tr 7: The way the G&C handles the students is frustrating. They handle all cases sent to them in a similar manner. Most cases are treated like cases of defiance.
5. Problems with parents. Parents were identified as a challenge

   • S Tr 7: the parents are also a challenge because they are in denial.
   • S Tr 10: The parents fear being stigmatized by society, so they do not want their children to be known they have a mental health problem and so continue denying.
6. Systemic problems: this challenge touches on the whole education system

   • S Tr 3: The Kenya education system has been structured in ways that do not accommodate the students with mental health problems. They get transferred from one school to another. The system is too tight that we end up not helping students with mental health problems at all.

Question 3: Teachers were finally asked if there is any way of helping them deal with the mental health problems they encounter. Some teachers had the following remarks:

• P Tr 15: It would be good if we got a bit of information to help us deal with some cases and inform parents where there are problems and suspected problem confidentially.

• P Tr 16: Correct information will make us stop punishing pupils who need a different kind of help

• S Tr. 8: Those students whom we send to Kenyatta National Hospital are the ones we know are taking drugs. The ones with learning disorders are unaddressed. It would be good to have a way of identifying these learning difficulties to help the students.

• S Tr 17: There is need in the school for mental health programs. We at times rely on past experiences if one has handled a similar case before. It is important for teachers to get

• knowledge but only for first Aid. A department should be set apart purely for mental health. We have had many hostile cases. Please arrange a seminar to help us know what to do when we encounter such cases as they are many.

DISCUSSION

The results of the FGD with teachers on mental health in Kenyan schools’ sheds light on the teachers’ perceptions on mental health among students. Since teachers are with school children and adolescents for many hours in a school day and term, they are therefore the first to observe behaviors that indicate either the development or worsening of mental health problems (Whitley, Smith, & Vaillancourt, 2013).

The report by teachers of the kind of mental health problems they experience is a different approach from the results of research reported by Kenyan researchers about mental health problems in schools, which are results of screening instruments (Khasakhala et al., 2012; Ndetei et al., 2008; Ndetei et al., 2007; Musyimi et al., 2016; Mbwayo et al., 2016). The perception of the teachers that there are mental health problems among the students is a confirmation of what researchers’ have found. The results of the FGD go a bit further than what is captured by the researchers using screening instruments. The teachers report mental health problems which are described through bizarre behaviors of the students and conduct problems which are not captured using research instruments as such students have been sent away from schools or transferred to another school or have been sent for treatment in health facilities.

Teachers reported what they perceived to be learning disabilities. Though commonly reported by primary school teachers, they were also reported in secondary schools. Teachers reported children who could not do mathematics but could do English or do other subjects but not English. They voiced a lack of knowledge in identifying these problems. Studies of teachers teaching in regular classrooms have reported experiencing children they perceived have learning difficulties (Padhy et al., 2015; Shukla & Agrawal, 2015). Teachers in different studies have reported lack of knowledge on how to identify learning difficulties (Abo El-Gamelen Ebrahim Essa & Mohamed Ahmed El-Zeftawy, 2015; Shukla et al., 2015).

According to Shukla and Agrawal (2015), the invisible nature of these difficulties makes them unrecognized in the crowded schools and so teachers are not able to identify them. However, even in the case where the student was diagnosed with Dyslexia and the report was taken back to school there was nothing that was done to the student to help with learning.

The teachers seem to describe more of externalizing behaviors compared to problems related to internalizing behaviors. Studies have shown that internalizing behaviors for example depression, anxiety, social withdrawal and somatic complains, which are non-disruptive are easily overlooked by teachers (Gresham & Kern, 2004; Lane, Wehby, Robertson, & Rogers, 2007; Kerebih, Abrha, Frank, & Abera, 2016). Internalizing problems are also difficult to diagnose as the symptoms are directed towards self as opposed external objects (Papandrea & Winefield, 2011). Papandrea and Winefield, (2011) also noted a disparity in teachers’ referral of internalizing problems compared to externalizing problems, with more externalizing problems being referred.

The teachers outlined their perceived challenges related to school mental health. From the social demographic results 72% of teachers have had form of no training on any form of counselling. Their lack of skills to deal with mental health problems in schools is not unique to the Kenyan teachers as other researchers in other parts of the world have reported similar findings (Pavri, 2004; Whitley, Smith, & Vaillancourt, 2013; Koller & Bertel, 2006; Rothi et al., 2005; Rothì et al., 2008; Reinke, Stormont, Herman, Puri, & Goel, 2011; Hadlaczky, Hökby, Mkrtchian, Carli, & Wasserman 2014). This is attributed to the fact that the training of teachers does not involve training of mental health problems as also reported by the teachers. This has also been reported elsewhere (Loades et al., 2010). Teachers have also reported that they receive little in-service training relating to mental health identification among students (Repie, 2005; Koller & Bertel, 2006). This was identified as a major deficiency by teachers, with major emphasis in the in-service being academic performance oriented. A look at the curriculum of two universities training teachers at a degree level in Kenya found that none included mental health (http://education.ku.ac.ke/index.php/academic-programs/undergraduate; and http://education.uonbi.ac.ke/uon_degrees_details/1466#.course_anchor_1466_1722) in the regular curriculum of teachers training.

A study on opinions about mental illness among primary school teacher trainees in Kenya suggested that the Ministry of education in Kenya should include mental health training in the primary school training curriculum (Nyavanga & Barasa, 2016), suggesting that mental health of children and adolescents is not taught in these colleges as pointed out by teachers.

Teachers also felt that they lack the time to deal with mental health problems, even if they are trained due to the constraint presented by the teaching load which led to lack of time. Similar feelings have been reported in other studies (Williams, Horvath., Wei, Van Dorn, & Jonson-Reid, 2007; Nadeem et al., 2011). Some teachers felt that some parents were not supportive when informed about their child’s problem. Mixed findings have been found. In some studies parents of certain schools have been supportive of their children’s mental health problems while parents in other schools they are not (Williams et al., 2007; Reinke et al., 2011).

Teachers felt that mental health problems are with them in schools and they suggested ways in which they can help the students. They suggested that they get trained to be able to recognize the problems. It has been shown that training teachers on mental health knowledge increases mental health knowledge among the teachers (Anderson et al., 2018). However, they felt that the time constraints and heavy workload could prevent them from handling the problems, but the knowledge could help them identify and refer such cases appropriately. Similar findings have been found where teachers felt that the training to carry out mental health interventions increases the burden of teachers (Eustache et al., 2017). This is in line with the fact that a teacher’s role is not for making a diagnosis of students with mental health problems but to rather identify the students then refer them for assessment and treatment and support them in the classroom (Nadeem et al., 2011). However, the teachers would welcome training about mental health problems and how to handle such problems in a classroom setting even when a student is under medical treatment. Such findings have been found in other studies where teachers would welcome such training to manage classroom situations (Walter, Gouze, & Lim, 2006; Loades et al., 2010). Recommendation of training teachers in mental health has been reported (Schulte-Körne, 2016).

The schools in Kenya have a department of Guidance &Counselling (G&C). In the secondary schools, a head of G&C Department is posted into the school by the teacher employer and is supposed to form a team to work in that department. All the members of the department including its head are ordinary teachers and have a full teaching load. Unless the members have taken initiatives to attend training on counselling, in most cases they are not trained or have done short courses. Where there is lack of skills, then they handle cases just like other teachers and they will lack the time to deal with cases due to their full timetable. This would then make the other teachers feel that the G&C members are not dealing with cases as they should. Elsewhere, there has been concerns that the quality of mental health support (particularly school counselling) is inconsistent (Thorley, 2016).

The current public system of education comprising 8 years in primary schools, 4 years in secondary schools and 4 years at the university, and followed by many private schools in Kenya, has laid emphasis on academic performance. Until recently, children would be forced to go to schools on Saturdays and many weeks during the holidays, giving the students only a very short period of rest. This is because the schools and parents wanted the children and so the school to perform well academically. As pointed out by the teachers, the system was not friendly to children who had any mental health problems as they kept being transferred from school to school. The government has changed the education system, with a curriculum which is competency based and therefore children who are not gifted academically can utilize the different talents that they have. This is a positive move as children can excel in their areas of strength and reduce stress related to academic performance. The first batch of students on this curriculum is in grade 3.

In conclusion, different types mental health problems are experienced by some students in schools. While teachers express the willingness to identify these problems, they are faced by different challenges. Lack of skills and time were the major challenges pointed out by the teachers. The teachers would like to identify the mental health problems to offer first aid and then refer appropriately as teaching load does not give them time to deal with the cases.

Though the study was carried out in one county in the country, including both primary and secondary schools around the county helped to gather helpful information. It pointed to the fact that more externalizing problems were reported by high school teachers for example drug and bizarre behavior. We know that drug taking starts in primary schools. The study results point to the need of all teacher training colleges to include a module on mental health problems of children and adolescents. Similar suggestion has been made elsewhere (Thorley, 2016). This would give teachers the basic knowledge on mental health and what to do when confronted with a child with behavior suggesting a mental health problem.

For the current teachers, an in-service training should be held for them. Easy and acceptable modes of training can be explored, one which does not interfere with teaching time. This training would increase teacher’s mental health literacy knowledge, attitude and practice and not just the knowledge. An emphasis on teaching of life skills to the students would act as a way of increasing the students’ knowledge on internalizing and externalizing behaviors. Such knowledge can make students offer support to fellow students through reporting to the teachers’ students they think have problems or students can individually approach the teachers for any support.

Teachers need help to deal with mental health problems of students for the development of the full potential of the students. The Kenya Institute of Special Education (KISE) should find ways of ensuring it can easily assess children thought to be having learning difficulties for appropriate intervention. This can be through KISE or their representatives being easily accessible by parents.

Implication on policy and practice:

The teacher training curriculum in the Colleges and Universities need to include mental health of children and adolescents and how to deal with such problems in the school setting. This will help the teachers get information on how to identify and appropriately refer the affected students. Within the schools, the teachers need to realize that a negative change in a student’s behavior is not always due to indiscipline. By the teacher carrying out more inquiry of the student including consultation with the care giver, early identification of any mental health problem can be done, and help sought early enough. The head teachers can improve the school community’s knowledge on mental health by organizing talks for them on emotional and behavioral problems experienced by children and adolescents and what can be done. This can be done in collaboration with the stakeholders.

Limitation:

the study was carried out in few schools in one county in Kenya. It would be important for such a study to be replicated in some other counties in Kenya to compare results.