Childhood Psychological Problems in School Settings in Rural Southern Africa

Background:Many children can be exposed to multiple adversities in low and middle-income countries (LMICs) placing them at potential risk of psychological problems. However, there is a paucity of research using large representative cohorts examining the psychological adjustment of children in school settings in these countries. Children’s psychological adjustment has been shown to affect educational progress which is critical for their future. This study, based in a rural, socio-economically disadvantaged area of South Africa, aimed to examine the prevalence of children’s psychological problems as well as possible risk and protective factors.Methods:Rates of psychological problems in 10-12 year olds were examined using teacher- and child-report questionnaires. Data on children from 10 rural primary schools, selected by stratified random sampling, were linked to individual and household data from the Agincourt health and socio-demographic surveillance system collected from households over 15 years.Results:A total of 1,025 children were assessed. Teachers identified high levels of behavioural and emotional problems (41%). Children reported lower, but substantial rates of anxiety/depression (14%), and significant post-traumatic stress symptoms (24%); almost a quarter felt unsafe in school. Risk factors included being a second-generation former refugee and being from a large household. Protective factors highlight the importance of maternal factors, such as being more educated and in a stable partnership.Conclusion:The high levels of psychological problems identified by teachers are a serious public health concern, as they are likely to impact negatively on children’s education, particularly given the large class sizes and limited resources in rural LMIC settings. Despite the high levels of risk, a proportion of children were managing well and research to understand resilience could inform interventions. © 2013 Cortina et al.

Research Ethics Approval was obtained from the Witwatersrand University Committee for Research on Human Subjects (Medical; M070221) and the Oxford Tropical Research Ethics Committee (008–07), the local Department of Education and each school’s Governing Body. Extensive discussions with local health, education and social welfare governmental organizations were undertaken during the development of this research to address questions and concerns about the study and obtain consent. Informed, written parental consent and written child assent were obtained. The research was conducted within the Agincourt health and socio-demographic surveillance site (Agincourt HDSS) in the sub-district of Mpumalanga Province in north-eastern South Africa bordering Mozambique [22]. Since 1992, some 16,000 households, in 27 contiguous villages, are interviewed on an annual basis to update key health, social and demographic variables. In the study site, only 57% of children and adolescents aged 6–15 live in a household with both parents present, with many fathers absent either permanently or temporarily for work [23]. A third of all deaths in the site are attributed to HIV [24]. This area has a considerable in-migrant population from Mozambique following its civil war from 1977–1992. One third of households in the site are self-settled refugees, their children are therefore second-generation former refugees. In 2010, schools in the local district were declared amongst the lowest performing in the country [25]. The placement of this study within the Agincourt HDSS provided access to a range of prospectively collected individual and household demographic and SES information on the children, their mothers, and their families. The data used in this study therefore come from two sources: selected individual and household-level data collected by the Agincourt HDSS from 1992–2007 and a large cross-sectional study conducted in 2007 of all the children in grades four and six at 10 of the 28 primary schools in the area chosen by random stratification. Stratification was based on the Provincial Department of Education school performance ratings. Teachers reported on children’s behavioural and emotional difficulties in English. Children provided self-report measures on their emotional problems (anxiety and depression), symptoms of post-traumatic stress, and perceptions of the school environment. Children’s questionnaires were translated into Shangaan (the local language) and back-translated. A separate pilot study was undertaken prior to data collection on approximately 200 grade 4 and 6 children to facilitate this work. Assessments were conducted in the classrooms by two researchers (MC and TH) who were available to provide any necessary clarification. Demographic and personal information were collected on each child to enable matching of cross-sectional data to household Agincourt HDSS results. Our principal area of interest was children’s behavioural and emotional adjustment; these were the latent variables that we aimed to assess. Emotional adjustment (internalising state) is best assessed by the child’s own self report while behaviour (externalising state) is best assessed by an external observer such as caregiver or teacher report. While there are no measures specifically validated with cut-off points for this population sample, a number of widely used relevant and validated measures have been used in other parts of Africa. These were the basis of the instruments that were identified for this study. The psychometric properties of these scales were examined in detail to ensure their suitability for use in the population. Only scales with good psychometric properties were included in the final analysis (Figure 1). We chose the Strengths and Difficulties Questionnaire (SDQ) because of its wide use internationally and its acceptability to teachers in our pilot work. While the SDQ covers both emotional and behavioural adjustment, the child reports needed to focus more specifically on emotional (internalizing) problems, which is well- addressed by the Youth Self Report (YSR). Behavioural and emotional problems were assessed with the 25-item child- and teacher-reported SDQ [26]. The SDQ has been shown to be a good screening tool to assess a broad range of symptoms in a population, has been widely used in socioeconomically deprived contexts, and has been validated in several languages [27]–[29]. It has established validity and reliability [26] and assesses a breadth of symptoms in five subscales (conduct problems; emotional symptoms; hyperactivity; peer problems and prosocial behaviour) as well as giving a total difficulties score. The self-report version [30] is generally suitable for children aged around 11–16, depending on their level of literacy and comprehension. More recent studies have shown that it is possible to use this self-report reliably in those 10-years and older [31], [32]. Anxiety and depression were assessed with the 13-item Youth Self Report (YSR) anxious/depressed scale [33]. The YSR is widely used and targets 11–18 year olds. Although it is normed on a mixed-ethnicity US population, the YSR has been used in many different contexts, including Southern Africa [34]. It has good reliability and validity even when the subscales are used separately [35]. Post-traumatic stress symptoms were assessed with the 44-item Trauma Symptom Checklist for Children –Alternate form (TSCC-A) [36]. The TSCC was selected because it has been shown to be a useful tool for assessing symptoms of chronic trauma and distress and because it evaluates children’s responses to unspecified traumatic events in a number of different symptom domains. It has been standardized on a large sample of racially and economically diverse children from a variety of urban and suburban environments providing norms according to age and sex [36]. Furthermore, dissociative symptoms are measured which have been reported to be common in some sub-Saharan societies [37]. Perception of the school environment was assessed with six questions adapted from a questionnaire assessing social literacy in schools [38]. Items were chosen and adapted from the Peace Zone questionnaire, a US inner-city programme developed to teach social literacy in schools [38]. The questions were administered on a four-point likert-type scale (all of the time, most of the time, sometimes, never), with the instructions: ‘Answer the items for what you are thinking RIGHT NOW’. Identification of signs of psychopathology in children in South Africa can be challenging, and assessment can be complex. [39] It was therefore important to assess a range of potential difficulties. The SDQ and YSR have been previously found to be highly correlated [40], however as both had not been previous used in the population, we deemed it important for validity to include two similar measures. In line with Parry’s [41] recommendations, this research followed a specific process of translation, back-translation and adjustment to assure linguistic equivalence. Two members of the research team, one of whom has a Master’s degree in mental health and the other a research officer, translated the questionnaires into Shangaan. Both were native to the research area and fluent in Shangaan. Each item was discussed in detail to determine an appropriate translation. A third member of the team who was also fluent in Shangaan back-translated the items. In order to obtain some index of the relative levels of psychological difficulties experienced by children in this study, we looked for published studies from samples of children with characteristics as similar as possible to the current sample. The comparative group chosen for the SDQ teacher-reported total difficulties score was from a study in the Democratic Republic of Congo [42]. The normative values in the YSR Multicultural supplement classifies cultures into three groups [43]. The closest culture to South Africa included in their multi-cultural norm list was Ethiopia, therefore values specified for Group 2 of the YSR anxious/depressed and somatic scales were used as comparison to this Agincourt sample. The YSR data comes from a regional school-based sample of 681 Ethiopian children aged 11–18 [44]. There are no published norms from a sample similar to Agincourt for the TSCC-A, therefore the normative values from the professional manual were used [36]. The normative sample comes from several studies in the United States, resulting in an ethnically diverse sample of 3,008 children aged 8–16 years. Although the norms are not from the same context, there are similarities. A number of variables considered relevant to this context were extracted from the Agincourt HDSS database: age and sex of household head; household socioeconomic status (SES); household size; the number of childcare grants a household receives (another poverty indicator); whether the child’s mother is alive or deceased and whether the mother resides in the household; period mother has been resident (months); maternal education level; mother’s partnership status; refugee status; whether and duration of child’s breastfeeding; period child has been resident in household (months); exposure of household to death in the previous year; and whether the child has work obligations outside of the home. Prevalence rates were examined to identify the level of psychological problems displayed by the children (emotional and behavioural problems, anxiety, and depression) and impressions of the school environment. Statistical analyses were performed using SPSS (Version 17.0.0). We used the expectation-maximization (EM) algorithm [45], [46] to deal with missing values exceeding the prescribed maximum allowable, using simple imputation techniques with 25 iterations. As described above, cut-off scores from the relevant test manuals were applied to determine primary prevalence rates for each outcome measure for the entire sample and by gender. Classification for the SDQ scales were based on standard norms [47]. Classification for the YSR scales were based on the group 2, YSR Multicultural supplement norms [43]. Classification of the TSCC-A scale was based on the norms specified in the TSCC manual [36]. Univariable and multivariable analyses were conducted to examine the main effects of gender and grade along with any potential interaction effects (gender and grade were entered as fixed factors). One-sample t-tests were used to compare means from this sample to those published elsewhere. Where possible, means from similar samples were applied, otherwise published norms were used. The variables that were significantly correlated with each scale were used as predictor variables in a multiple regression. A separate regression analysis was conducted for each of the core psychological outcomes. The following selection strategy was used: 1) All variables which were significantly correlated (p<0.05) were entered into forward stepwise regressions to identify an optimum model. For each regression model, the psychological domain of interest was entered as the dependent variable; 2) Model diagnostics were examined to check for potential violations of the assumptions of multiple regression; 3) F values were examined to determine the model significance; 4) Nested models were compared using F-tests (F change) to determine whether the nested models showed a significant improvement. The coefficient of determination (R 2) was examined to determine explanatory strength for each model. Standardized residual plots, histograms, and matrix plots were also examined as model diagnostics [46]. Cronbach’s α was used to assess the reliability of scores [48]. The Agincourt website (http://www.agincourt.co.za/index.php/data/) contains information on accessing the HDSS data, including questionnaires, data dictionaries and metadata associated with the Agincourt HDSS. Survey data, such as those used in these analyses, are archived by the MRC/Wits-Agincourt Unit. Tailored data requests can be made, with data extraction and access dependent on appropriate ethical approvals.

N/A

• Dima Health