Children’s perspectives of psychosocial help-seeking in Kenya

Context and participants

The study was carried out in a deprived neighbourhood of Nakuru city. This is characterised by overcrowding, lack of sanitation and electricity, poor housing, and under-resourced schools (Kenya National Bureaeu of Statistics, Citation2019, Water Sanitation for the Urban Poor, Citation2020). Young participants were purposively sampled from a representative primary school, through a local non-governmental organisation (NGO). The County (local) government and school principal (administration) granted permission for the study. Parents of all 40 children in Middle Grade 4 were approached by the class teacher for their voluntary permission for their children to be engaged in the study, and informed consent was given for 28 children. Children provided additional verbal assent. Both parents and children had the option to refuse. The study received approval by the institutional Psychology Research Ethics Committee of Leicester University in the UK. The sample consisted of 28 children (14 girls and 14 boys). Their age range was 7 to 10, with an average age of 8.5 years. All participants spoke Swahili as their mother tongue but were also learning English at school.

Data generation

Data were generated through focus groups, to promote interactive activities and discussion, that lead to help-seeking solutions. Focus groups can engage marginalised young participants in ‘collective conversations’ in relation to their experiences, insights, and perspectives (Adler et al., Citation2019; Onwuegbuzie et al., Citation2009). Each group engaged with three scenarios, all relevant to the Kenyan context. The scenarios were intended to facilitate an understanding of how children, aged 7–10 years, conceptualised supports, and how they used these in the course of help-seeking. Scenarios focused on contextually salient risk factors and were informed by a previous study in Kenya (Vostanis et al., Citation2020). Scenarios tapped into different sociological levels (community, peers, family), each explored through a broad question: What or who can help you or another child feel OK, when:

1. There is no water or electricity in the neighbourhood?

2. Someone does something bad to you, like calls you names, fights with you or hurts you?

3. People (grown-ups) around you fight with each other?

After each scenario was introduced, children were invited to draw and/or talk about what/who can help them manage the risk referred to in the given scenario (Mitchell et al., Citation2011). Children were divided into three mixed gender groups, to encourage discussion between girls and boys, although it was not possible to stratify to focus groups. The three focus groups included 5 girls, 3 boys; 2 girls, 6 boys; and 7 girls, 5 boys, respectively. Each group was facilitated by two researchers, one of whom was a native Swahili speaker. Children spoke Swahili, with occasional use of English words. Scenarios were hypothetical and framed as ‘what would you do to get help or help a friend?’, without discussing own experiences. Facilitators diverted discussion from personal issues, when necessary. The host NGO operated in the participating community, had stringent safeguarding policies, and routinely addressed sensitive issues by protecting confidentiality whilst maintaining community trust. As children lived in the same community, no personal sociodemographic details were collected, except for age and gender. Children’s responses were audio-recorded and transcribed verbatim. In general, their responses were brief. This is not uncommon when adult researchers interact with child participants in LMIC contexts (Theron, Citation2016). Transcribed group discussions were translated into English.

Data analysis

Both inductive and deductive methods were utilised, as the researchers had not adopted a pre-existing coding frame whilst searching for new concepts in the dataset, yet identified themes related to the research aims and wider literature. Data were thematically coded (Braun & Clarke, Citation2006) using the NVivo software. Development of initial codes was followed by identification of similar codes, consideration of themes, review and definition of four themes (Braun & Clarke, Citation2006; Nowell et al., Citation2017). The data was merged into a final coding frame via a verification process and open dialogue. We reported the findings according to the Consolidated Criteria for Reporting Qualitative Research (COREQ framework – Tong et al., Citation2007). We have not specified participant codes in excerpts reported below, as children often gave brief responses and talked simultaneously, and we did not wish to discourage spontaneous interaction.

Theme 1: Internal resources

Children showed an awareness of actions they could take individually in order to manage challenging situations. Self-regulation was often linked with initiation of informal community resources, described under Theme 3. For example, sports and creative activities were often used to regulate their emotions ‘when I play football, I feel better’; ‘when I sing, I feel better’. Understanding the meaning of conflict often precipitated problem-solving or seeking external resources ‘because they can fight and kill themselves’.

Despite their young age, children exhibited extensive knowledge of their environment and ability to navigate it, in order to problem-solve. They offered diverse responses, which displayed broad awareness of the area they inhabited, including resources in their natural environment ‘we get water from a river or a well’; ‘we get water from rain, and connect and collect’. Children gave examples of reflective and realistic problem-solving skills when faced with a community crisis and were able to propose feasible alternatives ‘you can get water with a wheel cart’; ‘we buy water from a wheelbarrow’.

Young participants implied that they held themselves to be self-able rather than helpless when reacting to predicaments. This was apparent whilst witnessing family conflict ‘by controlling ourselves’ and experiencing an environmental crisis ‘we can go to another district’. They exhibited self-agency when actively succouring those close to them in times hardship ‘I will help you when you have a problem kama wewe ni mgonjwa (if you are ill)’; ‘we will try to encourage our friend to go through the hard times with ease’. They equally possessed confidence delivering counsel ‘I will give my friend advice … to stop fighting’, including their parents ‘by telling parents not to fear’.

Children articulated preventive strategies for violence ‘tell them to love each other and not to do it again’. When directly confronting violence, children displayed an empowered approach by means of verbal ‘you tell them to calm down’ or physical actions ‘I can separate them to stop fighting’. Overall, they reported several non-confrontational approaches ‘we won’t take revenge and will stay patient’; ‘we will treat them with hospitality’. In conflict resolution, particularly, bullying, children made several references to forgiveness. This was linked to emotional regulation ‘Q: What is this that will make you feel better? A: Forgiveness’; and observing religious beliefs ‘even now I have forgiven him, I pray for him’. Children periodically referred to faith ‘God said I can forgive my friend and my enemy’. One child alluded to local spiritual beliefs ‘I will tell him I will bewitch him’; ‘you will be cursed’.

Theme 2: Family resources

Children utilised multiple familial connections when coping with stressors. They confided in their mother for security ‘when I see my mother, calls me baby, I feel better … I feel better because I love my mother’ and emotional support ‘my mother can tell me good stories, so that I can feel better’ and. References were made to sourcing the wider family network, including both parents ‘we will call our parents to help’, siblings; and extended family, predominantly grandparents ‘I can visit my grandmother, so that she might tell funny stories’; Babu (grandfather), Uncle, Aunt, cousins”. Children sought family support for both practical ‘I’d ask my aunt and just tell her my mum is sick, please care for me’, and emotional needs ‘you feel better by talking to them’.

Family support was sought to respond to external conflict such as peer fighting ‘mother will go to separate them’. This often followed unsuccessful strategies from the child or in conjunction with their own attempts ‘I will try to stop them, but if they won’t listen to me and continue to keep fighting; so, I will tell my father upon his return and he will handle it all himself’. Their peers’ parents were an alternative source ‘I will tell their mother that they are fighting … so that they can stop fighting’.

Theme 3: Community informal resources

Friendships were viewed as a transactional support process, for water or food shortages ‘I will request her to share it with me by saying that we can eat together from this’; peer conflict ‘give them advice to stop fighting’; facing domestic violence ‘I will go and hide in her home’; emotional needs ‘tell each other sorry’; or ill health ‘when you are sick, she can help you, because she is a friend’. Peers could bypass parents as the first resource ‘he will get me water without his mother being aware of’. Children acquired support from other individuals in their neighbourhood, whom they referred to as ‘neighbours’ or ‘landlord’. Children stated that they would independently approach them, predominantly to acquire water, which could also be linked to emotional support ‘when there is no water, you can borrow from the neighbour … it will make you feel better’.

Children displayed esteem for teacher authority that could enforce order ‘you tell the teacher to give him the punishment’. This expectation was related to an elevated source of proficiency by providing them with education ‘because he teaches me important things’. Academic and social learning were similarly connected ‘because she stops us fighting and corrects us’. Interestingly, children often deemed teachers as possessing a higher authority than their parents ‘the mother will go to the teacher to get help’. Availability was extended to support for psychosocial problems ‘I will feel better because the teacher will … can help me’; ‘she even come at our home and solve it’. In contrast, children considered community leaders when in the same vicinity, as opposed to actively seeking them out for help ‘you go and report when the chief is near’. These were typically reported in relation to environmental crises, whilst church groups were viewed as offering both basic needs ‘to give us clothes … to give us uniforms … shoes’ and psychosocial support ‘take them to the pastor’. This connotes that children utilised different community resources when acquiring support for different issues.

Theme 4: External formal resources

Children did not appear familiar with external statutory or non-statutory agencies in health and social care that could offer psychosocial support. They seemed unsure whether to also position figures of authority as informal resources ‘chief … president … police … pastor … landlord … bishop … judge … MCA (politician – Member of County Assembly)’. Police were prominent in their thinking and experiences, even alongside their parents ‘report to our parent … report to the police as soon as possible’.

Children would only access help from NGOs when all other informal support systems had been initially approached, e.g. during severe drought ‘(NGO name) … water … they bring’. However, they seemed unclear on psychosocial support roles ‘(NGO name) will help you to feel better’.

Discussion

Understanding children’s perspectives of help-seeking and available support is important in designing child-centred and culturally sensitive mental health provision in MWC resource-constrained settings. Most findings were consistent with the help-seeking literature (Heerde & Hemphill, Citation2018; Persson et al., Citation2017), including studies in African contexts (Theron, Citation2020; Van Breda & Theron, Citation2018). Overall, available psychosocial resources were individual and relational (primarily family and peers) rather than structural. Help-seeking was construed within the children’s environment, availability and accessibility of resources (Skovdal & Daniel, Citation2012).

Psychosocial resources appeared inter-linked, as children used internal strategies such as problem-solving to initiate family or peer support, vice versa family or peer interventions facilitated their capacity to regulate their emotions. Children’s perspectives thus supported a dynamic interaction between different domains, as proposed by the socioeconomic systems theory (Bronfenbrenner, Citation1979). This finding indicates the importance of interdisciplinary working and multi-modal interventions in resource-constrained settings.

Children aged as young as 7–10 years positioned themselves as active agent in response to common daily events such as violence and environmental crises. This capacity suggests that they should be empowered to contribute to the design of culturally and developmentally sensitive interventions. Despite child participation in mental health care largely originating from minority world countries (Day, Citation2008), several studies in Kenya showed significant associations between child/youth empowerment in self-defence, life skills, education or micro-financing and positive outcomes (Kempe, Citation2012; Sarnquist et al., Citation2014).

These findings need to be interpreted within certain limitations of the research design. Only one age group from a Kenya community was included. It would thus be useful to replicate this research in different settings, and to stratify participants according to sociodemographic variables such as gender. By not analysing the visual data, we did not fully utilise their potential. It is important to acknowledge a disconnect between the objective of understanding children’s perspectives of mental health support and the actual findings, which related to coping strategies, sources of informal and more logistical or instrumental support (mainly protection). This disconnect could be attributed to limited mental health provision, mental health stigma, and the data collection procedure. Additional focus groups or interviews could help elicit such concepts from younger children. Juxtaposing children’s views with those of their parents and professionals such as teachers, is important for future research to inform service provision. The study involved different levels of ‘insider-outsider’ challenges in introducing potential bias. The central research team could be viewed as external. The local researcher could be viewed as insider in terms of context and cultural knowledge, whilst being outsider in relation to experiences of being older and not living in the community. We thus adopted Dwyer and Buckle’s (2009) positionality of researchers at all levels ‘creating space’ to function as ‘both’ outsiders and insiders and ensured data integration through sincerity (self-reflexivity and transparency) and credibility (member reflections and multivocality; Tracy, Citation2010).

Nevertheless, the findings presented in this paper are the first Kenyan child-directed accounts of the psychosocial resources that support them to seek help when challenged by locally prevalent risks. Giving voice, as it were, to a small sample of Kenyan children’s insights has important implications for service improvement in similar contexts of disadvantage in Kenya, as well as other MWC in Africa and globally. Agencies should draw on internal, family and community resources in engaging children and their parents, for example, in reframing stigmatising attitudes and beliefs on mental health. Psychosocial interventions should be linked to existing community and school forums, structures and initiatives. A collaborative approach and formation of local networks can maximise the use of limited resources (Vostanis et al., Citation2019). Children have unique knowledge of their needs and environment; therefore, they should regularly feed into service monitoring and transformation. As demonstrated in fields like sex education and HIV/AIDS prevention (Cobbett et al., Citation2013), children and youth can actively contribute as peer educators in mental health awareness and promotion.