Child Maltreatment, Mental Health Problems and Prevention of Violence among Secondary School Students in Tanzania

Child maltreatment is a worldwide societal phenomenon of concern that has continuously subjected children to various health risks (Gershoff, 2010; Lansford et al., 2015; UNICEF, 2010). Research findings in high-income countries have reported a high prevalence of child maltreatment in families and schools, which were consistently associated with children’s mental health challenges (Lansford, Sexton, Davis-Kean, & Sameroff, 2012; Weaver, Borkowski, and Whitman, 2008). Moreover, findings from global researches have consistently reported the different forms of child maltreatment which include physical violence, emotional violence and child neglect as prevalent in families and schools and its strong contribution to mental health and behavioral challenges in children ( Durrant, 2008; Gershoff, 2017; Lansford et al., 2015). However, studies in Sub-Saharan African countries indicated a much higher prevalence of the different forms of child maltreatment in families and other settings outside families, such as schools (Global Initiative to End All Corporal Punishment of Children (GIEACPC), 2016a; Morantz, et al., 2013; UNICEF, 2014). Subsequently, the reported high prevalence of child maltreatment in Sub-Saharan African countries has been strongly associated with different behavioral and health challenges, such as aggression, delinquent behaviors and conduct disorders in children (Kinyanda, Kizza, Abbo, Ndyanabangi & Levin, 2013; Ismayilova, Gaveras, Blum, To-Camier, and Nanema, 2016). Consistent with other Sub-Saharan African countries, child maltreatment has been reported as highly prevalent in families and schools in Tanzania (Feinstein & Mwahombela, 2010; Hermenau et al., 2011; UNICEF, 2011) and has been strongly linked to mental health complications and behavioral problems in children (Hecker, Hermenau, Isele, & Elbert, 2014; Hecker, Hermenau, Salmen, Teicher, & Elbert, 2016; Hermenau, Eggert, Landolt, & Hecker, 2015). However, the large body of literature reported from Sub-Saharan African countries and from Tanzania in particular has only provided information about the prevalence of different types of child maltreatment and the associated mental health challenges from settings with either an at-risk population (Hermenau, Eggert, et al., 2015; Lekule, 2014; Morantz, Cole, Vreeman, et al., 2013), or has included non- representative samples (Feinstein & Mwahombela, 2010; Hecker et al., 2016; Semali & Vumilia, 2016). In line with this, very few school-based violence prevention interventions (e.g., Devries et al., 2015; Kaltenbach, Hermenau, Nkuba, & Hecker, 2017) have been empirically evaluated. Therefore, as an extension to the previous studies in Tanzania and Sub-Saharan African countries, the present thesis examined the prevalence of child maltreatment and mental health problems, as well as the associations between child maltreatment and mental health problems among secondary school students in Tanzania. Both children's and parents' perspectives were considered in a nationally representative sample. Subsequently, the feasibility and efficacy of a preventive intervention approach (ICC-T) with the aim of preventing secondary school students from violence by teachers was evaluated. The thesis consists of three articles. The first article examined the prevalence of different forms of child maltreatment in families using a nationally representative sample of secondary school students and their parents. Findings in this article indicated that more than 90% of students were exposed to violent disciplining by parents within the past year. Concurrently, more than 80% of parents acknowledged using violent disciplining methods in managing their children's misbehavior. Using a path model, we found that violent disciplining by parents was associated with parental stress. Familial risk factors such as family income and family size contributed to parental stress but were not directly linked to child maltreatment. The findings imply that in societies with different social and financial challenges, children are at more risk of violence due to parental stress and other challenges existing in families, particularly in many countries in Sub-Saharan Africa. These findings are consistent with previous studies in Sub-Saharan Africa (Morantz, Cole, Vreeman, et al., 2013; Morantz, Cole, Ayaya, Ayuku, & Braitstein, 2013; Oburu & Palmérus, 2003) and results from high income countries (Gershoff, 2013; Stoltenborgh, Bakermans-Kranenburg, & Van Ijzendoorn, 2013; Straus, 2010). The second article examined the prevalence of mental health problems among secondary school students as well as its association with exposure to violence and maltreatment in Tanzanian families. Overall, 41% of the students reported mental health problems. The reports of parents also indicated a prevalence rate of students' mental health problems of 31%. These findings are in line with previous studies that reported a high prevalence of mental health problems among children and adolescents in Sub-Saharan Africa (Kinyanda et al., 2013; Ndetei et al., 2008). Importantly, the current findings extend the previous findings from Tanzania (e.g., Hecker et al., 2014, 2016; Hermenau et al., 2014) that have documented the burden of children. Moreover, analysis in the present study revealed that physical violence (but not emotional violence) by parents was related to self-reported mental health problems of students. In addition, peer violence and emotional violence by teachers were found to be associated with the mental health problems of students. In general, the findings indicate an agreement between the reports of students and their parents regarding the effects of physical violence by parents on students’ mental health, underlining the strong association between physical–but not emotional violence–by parents or caregivers in Tanzanian families with mental health problems among secondary school students. Thus, the findings of this study are partly consistent with previous studies, which found associations between physical violence, emotional violence, peer violence, parental stress and mental health problems in children in different countries (Infurna et al., 2016; Ismayilova et al., 2016; Kinyanda et al., 2013; Neece et al., 2012; Norman et al., 2012). To contribute to the prevention of school violence in Tanzania, the third article presents findings of a cluster randomized controlled trial that evaluated the feasibility and efficacy of the preventive intervention Interaction Competencies with Children for Teachers (ICC-T). The study was conducted in government secondary school teachers in Tanzania. The trial consisted of four intervention schools (where the intervention was offered) and four control schools that received no training. The intervention with teachers of the randomly assigned intervention schools lasted for 5.5 days. Before and three months after the ICC-T intervention, data from both teachers and students at intervention and control schools were assessed regarding positive attitudes towards violence and the use of emotional and physical violence (teachers) as well as exposure to emotional and physical violence at school. Furthermore, to assess feasibility data trained participants completed a survey before, directly after, and three-months following the intervention. Findings indicated a very good feasibility and first hints about the efficacy of the ICC-T intervention: teachers reported good integration of the interventions' core elements in their daily works three months after the training. Subsequently, a stronger decrease in the use of (teachers) and exposure to (students) emotional and physical violence was reported in intervention schools compared to control schools after the intervention. On top of that, teachers in intervention schools reported a stronger decrease in positive attitudes towards violent disciplining compared to teachers in control schools. The current findings converge with previous findings (Kaltenbach et al., 2017) in a Tanzanian primary school. This indicates that ICC-T intervention can be a helpful approach in reducing violence by teachers in school settings in Tanzania and possibly elsewhere in Sub-Saharan Africa. The present thesis emphasizes that violence and child maltreatment in families and schools is highly prevalent in Tanzanian families and at school and are negatively associated with children’s mental health. ICC-T is a feasible and effective approach to reducing violence in the school setting and can bridge the gap in teachers' regular professional training that has a deficit in teaching non-violent approaches of dealing with misbehavior at school (e. g., Nkuba & Kyaruzi, 2015; Yaghambe & Tshabangu, 2013; Mweru, 2010). Furthermore, ICC-T intervention results might be scaled up not only in Tanzania but also in similar settings in other Sub-Saharan African countries. To consider the negative consequences of violence and maltreatment among children in Sub-Saharan Africa, more interventions are needed, in order to help parents and teachers successfully manage children's disciplinary challenges without compromising their mental health.publishe