- Need to incorporate novel audio-visual, digital resources’ based education methods into school health prog.
The life skills based programme which is incorporated into the school health programme of Sri Lanka could, according to health experts, be utilised to improve the mental health of school-going adolescents.
This observation was made in an original research article on "Are life skills’ based interventions effective to reduce peer related problems among school going adolescents in a conflict affected rural area in Sri Lanka?" which was authored by S. Nadeeka (attached to the Health Ministry's National Programme for Tuberculosis Control and Chest Diseases) and K. Wijewardena (attached to the Sri Jayewardenepura University's Medical Faculty's Community Medicine Department) and published in the Journal of the College of Community Physicians of Sri Lanka's 28th Volume's Third Issue in November 2022.
With the onset of puberty, many biological, social and cognitive changes take place during adolescence. A vital component of social cognition in the transition from adolescence to adulthood is the process of understanding oneself, others and relationships. The World Health Organisation's (WHO) "Skills for health: Skills based health education including life skills: An important component of child-friendly health promoting schools" mentions that the complexity of social interactions increases during adolescence and that adolescents spend more time with their peers and spend less time at home with their family members. A study involving African American, European American, and Hispanic adolescents noted that thus, friends or peers act as an important source in social support rather than parents and family members even though peer influence has both positive and negative influences on adolescent behaviour such as social initiative, self esteem, empathy, aggression, delinquency and depression. The WHO's "Adolescent mental health" reports that 10-20% of adolescents worldwide have mental health problems and that 50% of such problems can be diagnosed by the age of 14 years. Among the behavioural problems of Sri Lanka's school going adolescents, as found in W. Jayawickrema's "Emotional and behavioural problems of school going adolescents aged 13-15 years in the Medical Officer of Health area of Maha Oya. Prevalence, correlates and association with school performances", P.A.S. Senarathne's "Emotional, psychological problems and their correlates among school going adolescents (12-14 years) in the Polonnaruwa District and the psycho-social environment of their schools" and P. Lukumar's "Mental health of adolescent school children (14-15 years) in the Jaffna District and some of their psychosocial correlates", peer related problems were the most common problem. As per S. Senanayake, S. Gunawardena, M. Kumbukage, C. Wickramasinghe, N. Gunawardena, A. Lokubalasooriya and R. Pieris's "Smoking, alcohol consumption, and illegal substance abuse among adolescents in Sri Lanka: Results from the Sri Lankan Global School Based Health Survey 2016", in Sri Lanka, one third of school children are being bullied and one fifth are being physically attacked. These may be related to the students' peer related problems and poor social interactions. It seems that there is a gap between mental health service provision and the related needs. Hence, properly trained teacher counsellors at schools, identifying at high risk adolescents and school based interventions to develop life skills among students are recommended. Sri Lanka has been impressive in most health indicators for many decades. However, mental health resources (psychiatrists and psychologists) and the physical infrastructure for mental health are, as pointed out in H. Minas, J. Mendis and T. Hall's "Mental health system development in Sri Lanka", very limited in Sri Lanka, especially in rural areas where the services are poor.
Interventions in the form of U. Amarasinghe, A. Balasooriya and N. Fernando's "The assessment of life skills among 13-15-year-old school-going adolescents in a District of Sri Lanka and an interventional study to assess the effectiveness of a life skills promotion package", an Indonesian study and the District Secretariat - Ampara's "District Development Plan 2018-2022" have shown promising results to improve the mental health of adolescents and youths.
Therefore, a life skills based intervention was designed, implemented and evaluated by Nadeeka et al. to assess its effectiveness in reducing peer related problems, improving friendships among them and ultimately improving the mental health of school going adolescents in Sri Lanka.
Ampara is one of the three districts in the Eastern Province. Agriculture is the main livelihood for more than 95% of the district's population. A high level of poverty is reported from the area. In addition, the area was severely affected by the civil war which lasted in the said area for about 18 years. In the context of this unfavourable background, S.M.M. Ismail's "Post-war socio-economic development in the Eastern Province: A case study of the Ampara District" and S.J. Pocock's "Clinical trials: A practical approach" found that about one quarter of the students leave school early and show unfavourable behaviours such as using alcohol.
Hence, Nadeeka et al. conducted this study in a remote, agriculture based, conflict affected area, in order to examine the effectiveness of a life skills-based intervention module to improve the mental health of students.
This quasi experimental study was conducted from January to March 2019, in the Ampara Educational Zone of the Ampara Regional Director of Health Services Area, which is one of the two health areas of the Ampara District. From the Ampara Educational Zone, considering the facilities available (electricity and overhead projectors), three schools were randomly selected from the Ampara Division to conduct the intervention while four schools from the Uhana and Damana Divisions were selected as the control groups. The schools of the intervention and the controls were more than 20 kilometres apart. All Grade 10 students of the selected schools were recruited for the study. A total of 368 secondary school students (187 in the experimental group and 181 in the control group) participated in the study. The socio-demographic characteristics were well matched in the two study groups.
Nadeeka et al. developed the life skills based educational package after conducting an extensive literature search. The WHO's "Life skills education for children and adolescents in schools'' has described participatory teaching methods for building skills and influencing the attitudes of individuals and the advantages of active participatory learning. According to A. Bandura's "Social learning theory of aggression", children learn to behave through formal instructions and observations. R. Goodman's "The strengths and difficulties questionnaire: A research note" observes that children's behaviour is reinforced or modified by the consequences of their actions and the others' responses to their behaviour. These concepts have been used in developing this education module. Nadeeka et al. developed a teachers' manual on adolescent development, a powerpoint presentation on life skills, a cartoon video on empathy, and worksheets.
To assess the effectiveness of the intervention, per M. Wijeratne, R. Seneviratne, N. Gunawardena, T. Østbye, C. Lynch and I.F. Sandøy's "Development of the Sri Lankan early teenagers' violence inventory: An instrument to measure peer violence in schools", Nadeeka et al. used two primary outcomes (violent and friendship related activities of students) and two secondary outcomes (the peer related problems score and the total abnormal strengths and difficulties questionnaire score). Per M.J. Mendelson and F. Aboud's "The McGill friendship questionnaire - friendship functions", the students' violent activities were measured using a self-reported questionnaire on aggressive behaviour which consisted of 21 questions on the physical violence of students. Per H. Perera's "Mental health of adolescent school children in Sri Lanka – A national survey", students' friendship related activities were measured using the friendship questionnaire which was developed after studying the McGill friendship questionnaire. Students' mental health status was measured, per G.V. Caprara, B.P.L. Kanacri, M. Gerbino, A. Zuffiano, G. Alessandri, G. Vecchio, E. Caprara, C. Pastorelli and B. Bridglall's "Positive effects of promoting pro-social behaviour in early adolescence: Evidence from a school based intervention" by the strengths and difficulties questionnaire.
Phase One involved the following: the principal investigator administering the questionnaire to the students after explaining the process of data collection; and an introductory session being conducted on the first day where the session lasted for two study periods around 1.5 hours and during which the students were taught about mental health and life skills while the participatory activities were based on self awareness.
Phase Two involved the following: students being taught about interpersonal relationships, empathy and effective communication where the participatory activities were based on the identification of good friends and effective communication; no such educational module was delivered to the students of the control group.
Phase Three involved the following: Post-intervention assessments of the primary and secondary outcomes were done 12 weeks after the initiation where feedback forms on the sessions were given to the students at the end of the intervention.
The mean friendship score was higher in the intervention group than in the control group at the post-intervention stage after three months of intervention. This difference was statistically significant. There was no statistically significant difference in the proportion of students involved in violent activities in the control group as well as the intervention group at the post-intervention stage. There were no statistically significant differences in the proportion of students who had abnormal scores for the peer related problems subscale or a total score for the strengths and difficulties questionnaire in the control and intervention groups at the post-intervention stage.
This life skills’ based education module aimed at a behaviour change in order to improve friendships and to reduce violent activities among them and to ultimately improve their mental health.
There was a significant increase in the friendship score among the intervention group when compared to the control group. However, there was no difference in the violent activities between the intervention and control groups. There was no difference in the percentage of students having an abnormal score in the intervention and control groups in the peer related problems subscale or the total scores. These results show the impact of the intervention on friendship which could be easily measurable and the short term results due to the change in the attitudes of the students with the intervention. To reduce violent activities, more focused and prolonged intervention would be needed along with a significant change in the scores for the strengths and difficulties questionnaire, thereby reflecting the improvement of the mental health of the students. Amarasinghe et al. assessed the effectiveness of a life skills’ based educational intervention to improve the knowledge of life skills and showed significantly favourable results. Caprara et al. showed the effectiveness of life skills to reduce violence and delinquency, and to promote mental health and coping skills.
This study showed the importance of using participatory teaching methods in the school system instead of teacher centred teaching methods. An Indonesian study has also emphasised the importance of using participatory methods in teaching life skills based programmes. The use of audio-visual and digital resources in teaching was appreciated by the study participants. Therefore, it is important to incorporate novel educational methods into the school health programme of Sri Lanka.
Further, the results of this study showed that even small scale training programmes would benefit to improve friendship related activities among students and to pave the path for large scale intervention projects.
The intervention was effective in improving friendship related activities of the students after 12 weeks of the life skills-based intervention. Therefore, it is recommended to strengthen the life skills education module of the school programme of Sri Lanka.
The public health related implication of this study is that life skills-based intervention has improved friendship related activities in the intervention group after 12 weeks.