By Jessie Pinchoff, Karen Austrian, Faith Mbushi, Population Council & Julie Mwabe, Kenya Executive Office of the President, Policy and Strategy Unit
“I had anxiety because we left school when we were just about to sit for the exams, and then we left school being told that we wouldn’t know when we would go back to school. So, it was giving me stress because I wonder when we would go back to school and when would it be announced”Adolescent boy, 14 years, Nairobi
The first case of COVID-19 reached Kenya in March 2020, triggering a national response, including closure of businesses and schools and strict curfews. While these measures may have saved lives, they also had widespread unintended secondary impacts on Kenyan households. Globally, researchers are finding higher-than-normal reports of depression, anxiety, and other mental health concerns. In Kenya specifically, recent news reports highlight worrisome trends of fires in schools, potentially linked with increased stress and difficulty adjusting as schools reopen. However, there is limited research available in African contexts on what works to address adolescent mental health, and the long-term impacts of the pandemic on education and mental health outcomes in the region are unknown.
Population Council researchers, in collaboration with the Kenyan National Emergency Response Committee for COVID-19 and the Kenyan Executive Office of the President’s Policy and Strategy Unit (PASU), set out to explore this by surveying adult–adolescent pairs across four locations in Kenya. The findings presented here are for three of these sites: Kisumu, Kilifi and Nairobi. The first adolescent surveys were conducted between June and August 2020 (during school closures), with a follow up survey in February 2021 (after schools reopened). We sampled 1,022 adolescents in Nairobi, 1,063 in Kilifi, and 602 in Kisumu, in a ratio of 1:3 male to female participants. Survey questions covered topics including remote learning and school, economic impact, food insecurity, and COVID-19 beliefs and behaviours. Qualitative surveys were also conducted.
At the time of the first survey, in mid-2020, all schools were closed. Almost all adolescents surveyed (85%) were enrolled in school before COVID-19 related closures, and most (80%) were doing some learning from home, including reviewing documents from the school, reading ‘other’ books, or learning via mobile phone. The first survey found that over a third (36%) of adolescents reported depressive symptoms (as measured by the PHQ-2 scale), with the highest rates among older adolescent boys (15-19 years).
In January 2021, schools reopened. Re-enrolment overall was quite high, however, older adolescents (15-19 years) and older adolescent girls specifically were the least likely to return, with 16% of girls 15-19 not returning to school compared to 8% of their male counterparts. The main reason cited for not returning to school was the cost of school fees. The second most common reason was pregnancy for girls (10%) and work for boys (14%). Among those who were back in school, their PHQ-2 scores were much improved (21% experiencing depressive symptoms), but the proportion with a low score had increased even further among those who were not re-enrolled (37.5% reporting depressive symptoms).
These findings are supported by our qualitative survey results. During focus group discussions, adolescents used terms such as “stress”, “anxiety”, “troubled mind”, “worry”, “loss of hope”, “confusion”, and “anguish” to express their experiences during school closures, often associated with concerns regarding delays in completing school, sitting for examinations, making it difficult to concentrate on remote learning. Others expressed anxiety over passing examinations, as they had forgotten concepts learnt during the previous school year. A few found it difficult to cope with additional time and lack of social activities. Girls identified early pregnancy and sexual violence during school closures as drivers of psychological trauma. Community stakeholders attributed pandemic-related mental health problems with increased domestic violence and tension witnessed by adolescents at home.
“(School closure) has impacted them in a big way because there were candidates in form 4 and class 8 who were studying hard knowing they were to proceed to the next stage in their lives but now they are left at home with anxiety and stress not knowing when they will complete school.”Stakeholder, Kisumu
This highlights the importance of returning to school for mental health among adolescents. However, as 21% continued to report depressive symptoms even after they returned, this suggests that a myriad of additional factors influence adolescent mental health. Even prior to COVID-19, a study investigating the prevalence of depressive symptoms among adolescents in Nairobi public schools found that about 27–29% of the students were exhibiting clinically significant depressive symptoms, highest at boarding schools. Of concern was that these high rates did not lead to referral for professional support. Without a clear baseline for our sample, or for the region at all, it is not possible to attribute how much the pandemic has caused any changes or declines in mental health, although this is strongly suggested from other countries. In China, a study found that 22% of surveyed youth reported clinical depressive symptoms due to COVID, compared to the 13% estimated prevalence generally.
How can we help adolescents recover from the pandemic?
A systematic review of 63 studies covering over 50,000 children and adolescents globally had alarming findings suggesting that social isolation and loneliness in children and adolescents could increase the risk of depression up to 9 years later. They found the duration of loneliness was most strongly associated with mental health symptoms later, suggesting an urgent need for intervention, as the pandemic continues.
Addressing adolescent mental health is critical but often neglected. The role of early, especially school-based, intervention is often overlooked . Kenyan policies to support children and adolescents do not highlight mental health as a priority; meanwhile, mental health specific government policies do not specify the needs for children and adolescents, and there is no formal mental health plan in the Kenyan COVID-19 response. Despite direction from the Kenyan Mental Health Policy 2015-2030 to include mental healthcare provision during and after disasters, this has not been applied to COVID-19 response to date.
The COVID-19 pandemic is having adverse effects on adolescent mental health and educational attainment. These two things are inextricably linked. Building resilience and ensuring that adolescents are healthy and productive is critical. We advocate for more research on effective interventions and policies, and make the following suggestions:
- School-based psychosocial services: While challenging in a context like Kenya, as trained staff are often not available, teachers are already stretched thin, programmes may not be socio-culturally contextualized, and not all high-risk adolescents are in school, a recent randomized evaluation in Kenya found that a brief, lay-provider delivered, school-based intervention reduced depression and anxiety symptoms, worthy of further testing and potential for scale.
- Community-based psychosocial interventions: Such interventions are better placed to reach high-risk adolescents that are out of school.
- Community-based girl groups: These may mitigate adverse mental health effects, as evidence suggests.
- Income-related interventions: Some interventions, such as cash transfers, may have secondary effects, including on adolescent mental health. A study in Kenya found a poverty-targeted unconditional cash transfer program improved mental health of young people who had lost a parent.