Public school €™ teachers’ perceptions about mental health.

OBJECTIVE To examine public school teachers' perceptions about general health and mental health, and the way in which they obtained this information. METHODS Qualitative research was conducted with 31 primary and secondary school teachers at a state school in the municipality of Sao Paulo, SP, Southeastern Brazil, in 2010. The teachers responded to a questionnaire containing open-ended questions about mental health and general health. The following aspects were evaluated: Teachers' understanding of the terms "health and "mental health," the relevance of the need for information on the subject, the method preferred for obtaining information, their experience with different media regarding such matters, and perceptions about the extent to which this available information is sufficient to support their practice. The data were processed using the Qualiquantisoft software and analyzed according to the Discourse of the Collective Subject technique. RESULTS From the teachers' perspective, general health is defined as the proper physiological functioning of the body and mental health is related to the balance between mind and body, as a requirement for happiness. Most of the teachers (80.6%) showed great interest in acquiring knowledge about mental health and receiving educational materials on the subject. For these teachers, the lack of information creates insecurity and complicates the management of everyday situations involving mental disorders. For 61.3% of the teachers, television is the medium that provides the most information on the topic. CONCLUSIONS The data indicate that there is little information available on mental health for teachers, showing that strategies need to be developed to promote mental health in schools.

INTRODUCTION

Mental disorders are highly prevalent in childhood. In Brazil, one of the key studies in this area evaluated individuals aged 7-14 years living in the Southeast region and found that 12.7% of the children enrolled in schools had some mental disorder requiring specialized care. Young people affected by mental illness have worse school performance, a low standard of social interaction, problems with the law, higher school dropout and teenage pregnancy rates. , ,

From a neurodevelopmental perspective, interventions focusing on mental health in schools could prevent the manifestation or reduce the intensity of mental illnesses, preventing problems in the family, academic, and social spheres. Recent systematic reviews have described the effectiveness of various types of preventive interventions in schools for depression, anxiety, and substance abuse, among other disorders. ,

Globally, health programs targeted at schools evolved in three distinct moments:

Moment 1: focus on physical health. Actions: Immunization campaigns, tracking of specific illnesses, such as vision problems, and the prevention of communicable diseases.

Moment 2: psychosocial focus. Actions: Campaigns to prevent drug usage, teenage pregnancy, and initiatives to promote a safe and healthy environment in schools.

Moment 3: focus on mental health. Actions: Campaigns promoting mental health, preventive interventions in healthy individuals or those at risk, and early identification and intervention for ill individuals.

For school programs focused on mental health to be satisfactorily developed in the country, it is necessary to evaluate Brazilian teachers’ and students’ understanding of mental health and the way in which they obtain information on this topic. Therefore, understanding these individuals’ daily lives, needs, behaviors, and social expectations, will enable us to develop effective actions in the process of knowledge construction.

In Hong Kong, a study was conducted on educator perceptions about general health. For the sample studied, physical health was related to physical functioning and mental health with the ability to think clearly and coherently. Furthermore, psychosocial health referred to the ability to relate to others.

An evaluative study of attitudes toward mental health problems in the classroom showed that the teachers lacked knowledge of handling such situations, as they received little training. However, trained teachers can improve their students’ health conditions by guiding parents and helping children acquire healthy habits.

This study aimed to analyze public school teachers’ perceptions about mental health, and the way in which they obtained this information.

METHODS

A qualitative study was conducted in a public school in Sao Paulo, SP, in Southeastern Brazil. The study is a part of Projeto Cuca Legal, which seeks to train teachers to promote mental health in schools.

The teacher training was conducted in eight meetings, through informative lectures, case studies, and discussions.

The sample studied comprised 45 primary education teachers – cycle II – and secondary education teachers in the morning, afternoon, and night shifts. The inclusion criteria consisted of attending the Collective Pedagogical Work Hour (CPWH) and a classroom workload of at least 12 hours per week. Teachers with a weekly workload of less than 12h or those who did not participate in the CPWH were excluded from the study.

A self-administered questionnaire including ten essay questions was used, with open- and close-ended questions, to document knowledge and concern about mental health and the way in which information about mental health reached the teachers (Table 1). This evaluation occurred two months after the psychoeducational activities of Projeto Cuca Legal were concluded.

Table

Summary of the teachers’ responses to the questions on the questionnaire administered, based on the Discourse of the Collective Subject (DCS) method. (N = 31)

1. What does the word health mean to you?
Category	%a	DCS
A. Social, physical, mental, and spiritual well-being	58.1	“Health is physical, mental, and spiritual well-being existing together. It is being well disposed and healthy in every way, which leads a citizen to have self-confidence. It is when you are well both existentially and physically, in the most intimate and profound part of the human being. When you are healthy, you can have a complete harmony of physical and mental metabolism, as it’s possible to be healthy in every way.”
B. Balance	19.4	“Being healthy is being physically and mentally balanced. This does not mean not having an illness but rather having mental and social balance.”
C. Caring for mind and body	19.4	“Health is caring for body and mind in order to be able to do what you want, with no negative feelings. Being healthy is eating well, playing sports, and participating in daily activities without restrictions.”
D. Organism functioning	9.7	“Health is having perfectly working organs, i.e., it is synonymous with something that is working correctly or having a healthy body. It is a term used not only for the medical field but also to describe the status of various body processes.”
E. Quality of life	6.5	“The term health involves a set of actions such as leisure, living together in harmony, physical activity, i.e., having quality of life.”
F. Linked to happiness	6.5	“Being healthy requires minimal conditions to lead a life with dignity, which is necessary to be happy.”
2. In your opinion, what is mental health?
A. Mental and physical well-being	22.6	“Mental health is when you’re physically and mentally well. It’s when there is a good relationship between students and teachers and you can do whatever you want, without any negative feelings.”
B. Living well in society and overcoming difficulties	32.3	“Mental health is a condition that a person has when he or she exhibits positive thoughts about life and that they are capable of guiding the phenomena around them with autonomy and clarity. This doesn’t explain it, but I think it would be a person who has a non-traumatic relationship with the cultural and social environment, who knows how to have ethical and moral attitudes. It is thus possible to live with life’s difficulties, have positive thoughts, to overcome and know how to deal with adverse situations, in order not to suffer any illness.”
C. Balanced functioning of body and mind	41.9	“Mental health is the ability to be free of disorders that cause an emotional imbalance between what we have and what we desire, without letting emotional problems upset our daily life. It’s the mind functioning within the standards established by medicine for this area, i.e., the balance of brain functions, the nervous system, and nervous impulses throughout the body. Thus, mind and body work in harmony so that there are no negative feelings and we can overcome difficulties, without needing to use alcohol and drugs to overcome problems.”
D. Requirement for happiness	3.2	“Having mental health is a requirement for happiness.”
E. Mental illness	6.5	“Mental health refers to illnesses related to the mind and behavioral disorders.”
F. Awareness of one’s actions	3.2	“Mental health is being aware of your actions and thoughts.”
3. How would you like to receive information and guidance about mental health?
A. Lectures	54.8	“I would like to receive information through lectures and group discussions, directly from a medical specialist. I believe that verbal communication is still the best way to raise people’s awareness.”
B. Printed material	25.8	“I would like to receive printed information through handouts and brochures that exemplify situations scientifically, i.e., the difference between a phenomena and an existing problem.”
C. Multimedia material	19.4	“I would like to receive information through videos, containing documents and drawings that may facilitate understanding.”
D. Through the Internet	22.6	“I would like to receive information through email and would like to consult websites.”
E. Connected to reality	9.7	“I would like to receive information through a movie followed by reading some informative documents. The movie could awaken our attention to the reality of mental health issues, in a less formal and more lucid way, connecting the examples to reality.”
F. Courses	6.5	“I would like to receive information through courses.”
G. Dynamics	6.5	“I would like to receive information through dynamics.”
H. Mass media	6.5	“I would like to receive information through newspaper and TV ads.”
4. In your opinion, is using informative material important for learning about mental health? Why?
A. Yes, for better clarification on the subject	80.7	“Yes, informative material helps because usually information obtained through other media may be superficial, and thus, informative material can clarify what is a myth and what has been scientifically proven. It would be another way of orienting ourselves, since we have little knowledge about it and very often we do not know which course of action to choose because we feel insecure. We need to receive conceptual information about the subject in order to stay updated and know the ways in which to deal with it in our daily lives. Sometimes, we seek professional help because we lack information. Information through any media is important; the more information is available, the greater is the understanding of the illness. The informative material should be easy to read and comprehend. Moreover, the written material should serve as a research source.”
B. Yes, to improve communication	16.1	“Yes, because it makes my job easier. When something is spoken, it may not register at a particular instance at a particular time. Combining the structure of verbal communication is of utmost importance. The cause of this is an expansion of the field of speech coherent with images and other references, because only talking is too vague. You must have means and ways to use it, because you need to follow a line of work, a communication strategy for properly conveying the information.”
C. Yes, to help the students with mental health problems	9.7	“Yes, informative material helps us to understand a bit about mental health and in some way to help students who may have these symptoms, because we don’t know how to work with people who have such problems. Furthermore, this contributes to the development of a healthy relationship between teacher and student.”
5. Have you already received informative material about mental health? Where?
A. Yes, in Projeto Cuca Legal	12.9	“Yes, only here at Roldão through this project. Cuca Legal was the first.”
B. Yes, through courses	6.5	“Yes, only in the courses I have participated in. I took some courses at the Military Police of Sao Paulo State and the Universidade São Marcos.”
C. Yes, through a health professional or health center	6.5	“Yes, I already received some information through the psychologists who visited the school in past years and brochures at the health center.”
D. Yes, but without guidance	3.2	“I wouldn’t say something informative, but without guidance, habits and familiar customs.”
E. Did not receive	67.7
6. Have you watched a video or TV program that addresses mental health issues? What did you think?
A. Yes, superficially	12.9	“Yes, but I found it all too ridiculous; the sales policies and the programs aimed at their own interests, of promoting universities and selling books, mainly on TV and religious institutions. Once I watched a program that talked about depression and Alzheimer’s, which was interesting, but I thought it was a bit superficial. It’s always very generic and isolated from reality, from focusing on the problems that are causing the separation of mental illness from reality. On Globo Repórter I’ve seen issues related to mental health, but it was something depressing and very boring in nature.”
B. Yes, on TV Senado	3.3	“Yes, I watched something on TV Senado. A journalist discussed mental health and I thought it was very interesting for those of us who work in education.”
C. Yes, through the soap opera Caminho das Índias	12.9	“Yes, on the miniseries Caminho das Índias and I thought it was great, because through information provided by the TV I was able to understand some things that happened with a few students at workplace. The miniseries presented a complicated situation, which worsens because the family doesn’t accept it, and thus the diagnosis is delayed.”
D. Yes, TV Cultura	6.5	“Yes, on TV Cultura on the program Café Filosófico. I thought the approach was superficial and included cases that have already been proven. The subject was discussed by Flávio Gikovate.”
E. Yes, movie and television series	9.7	“Yes, I thought the series “Dr. House” was very enlightening and informative, because they talk about cases. I also recently watched the movie “O Solista.” I thought it was interesting because it didn’t categorize the mentally ill as someone to be pitied.”
F. No	38.7
7. Have you already listened to a debate or radio program that addressed mental health? How was the issue discussed?
A. Yes, about prejudice	6.5	“Yes, it was about prejudice within and outside the home.”
B. Yes, on CBN (radio)	3.2	“Yes, I was listening to CBN and the issue was discussed with listeners’ questions and responses from experts at Universidade São Paulo.”
C. Yes, on Jovem Pan (radio)	3.2	“Yes, I heard a debate on Jovem Pan and the subject addressed was schizophrenia.”
D. Yes, I thought it was superficial	3.2	“Yes, on some talk shows, but not on a specific subject, I thought it was superficial. The commentary, as usual, was subject to the program’s runtime.”
E. Yes, about gifted people	3.2	“I heard something about gifted and deaf people. The issue addressed was how to deal with some cases!”
F. No	80.7
8. Have you already researched or read something online regarding mental health?
A. Yes (without explanation)	16.1	“Yes.”
B. Yes, about Alzheimer’s	3.2	“Yes, I researched on Alzheimer’s.”
C. Yes, about depression	6.5	“Yes, I researched on depression for a while.”
D. Yes, about ADHD (Attention Deficit Hyperactivity Disorder)	3.2	“Yes, I researched on ADHD (Attention Deficit Hyperactivity Disorder).”
E. Yes, about schizophrenia	3.2	“Yes, I researched on schizophrenia.”
F. Yes, about dyslexia	6.5	“Yes, I researched on dyslexia.”
G. No	71.0
9. Have you already read articles about mental health in a magazine or newspaper? What did it address?
A. Yes, in the magazine Educação	3.2	“Yes, I read something in the magazine Educação.”
B. Yes, in the magazine Psychology	3.2	“Yes, I read something in the magazine Psychology and the theme was depression in young people.”
C. Yes, in Folha de São Paulo	3.2	“Yes, by a columnist who writes in Folha, Ferreira Gullar. It was about the psychiatric system and the hospitalization of patients, a familiar problem.”
D. Yes, about stress	3.2	“Yes, it was about stress.”
E. Yes, on self-help and dealing with current problems	9.7	“Yes, about aspects of how to turn things around and its relationship with the social phenomenon we are facing today and also human behavior when faced with passions (in the pathological sense), always connected to self-help.”
F. Yes, about depression	6.5	“Yes, I read something about symptoms of depression.”
G. Yes (without explanation)	9.7	“Yes.”
H. No	61.3
10. Do you believe the information conveyed by the media about mental health is sufficient? Explain.
A. Yes, the soap opera Caminho das Índias explained schizophrenia	3.2	“Yes, I think so. For example, the miniseries Caminho das Índias discussed schizophrenia, through the character Tarso.”
B. No, the information is superficial or misleading	29.0	“No, because it is always sensationalist, biased, and exaggerated. The information is not sufficient and needs to be clearer. The issue is always addressed very superficially. Currently, the media discusses mental illness when a crime or something serious happens in the ‘normal daily life’.”
C. No. The mental health issue is not addressed	16.1	“I don’t think so, because mental health is still seen as a taboo, something that shouldn’t be publically discussed. It is still believed that people with mental health problems should be removed from society. There has been a lot of talk lately about visual and hearing impairment, and the inclusion of people with these deficiencies in society and also about drugs, violence, and killing, but never mental health! I feel the absence of such communication and of groups like the UNIFESP group, conducting Projeto Cuca Legal.”
D. No, time and space are limited	22.6	“Of course not. It’s a complex issue and requires greater depth and these media don’t always have enough time, and the information is very restricted to certain time slots and channels. They normally broadcast at times when young people are not watching, and it’s very limited. As I already mentioned, the information is always subject to something larger than itself: time, standards, policy issues, and other factors. The media should provide more space to mental health information so that the majority of the population has access, such as, poor people, who suffer the most from psychological problems.”
E. No	32.3	“No.”

a In the DCS, people can have ideas that correspond to more than one category; hence the sum of the frequencies may differ from 100%.

The data analysis employed the Discourse of the Collective Subject (DCS) technique, developed for research on social opinion, seeking to determine the design of a given community from individually collected reports, in a qualitative and quantitative manner. DCS favors a recovery of the thoughts, values, and beliefs individually internalized via discourse. The Qualiquantisoft software was used to process the statements.

Analysis of the statements involves selecting the key expressions from each statement, identifying the central ideas of each key expression, and creating the DCS. Key expressions are the passages that best answer the questions. Central ideas describe the meaning present in each statement in a synthesized and precise manner, i.e., the respondents intended meaning. The combination of similar key expressions and central ideas in a “discourse synthesis” comprises the DSC.

Out of the initially selected 45 teachers, 12 missed the interview, one refused to participate, and another stopped working at the school. Thus, 31 teachers participated in the study [21 (67.0%) female, 10 (32.2%) male].

This study was submitted and approved in 2011 by the Research Ethics Committee at the Escola Paulista de Medicina, Universidade Federal do Estado de São Paulo (Protocol 0658/11). All participants signed a free and informed consent form.

ANALYSIS OF RESULTS AND DISCUSSION

Impressions of “Health” and “Mental Health”

The following data have been analyzed based on the teachers’ responses to the questionnaires administered (Table 1).

According to the results of the DCS analysis, for 58.1% of the teachers, health is related to “physical, mental, and spiritual well-being existing together. It is being well disposed and healthy in every way, which leads a citizen to have self-confidence. It is when you are well both existentially and metaphysically, in the most intimate and profound part of the human being. Being healthy involves the full harmony of one’s physical and mental metabolism, as it’s possible to be healthy in every way”. As for mental health, 41.9% of the teachers defined mental health as follows: “the ability to be free of disorders that cause an emotional imbalance. It’s the mind functioning within the standards established by medicine for this area, i.e., the balance of brain functions, the nervous system, and nervous impulses. Thus, the mind and body work in harmony so that there are no negative feelings and we can overcome difficulties, without using alchohol and drugs to overcome problems”. The percentage of teachers who associated mental health specifically with mental illnesses was 6.4%.

Access to Mental Health information in the media

When asked about encountering mental health information via mass media, 80.6% of the teachers reported never having heard a debate or radio program that addressed the topic; 71.0% had never researched or read anything related to mental health on the Internet; 67.7% had never received printed information about mental health; 61.3% had never read articles on mental health in magazines or newspapers; and 38.7% had never watched videos or television programs that addressed mental health issues.

The percentage of teachers who had access to information through a Health Center was 6.4%. Within the school environment, the topic is considered to be infrequently addressed.

Perceptions about need for Mental Health programs in schools

The study investigated the importance of developing communication strategies to support teachers in their daily life. A large majority (80.6%) of the teachers said the following: “the informative material helps because usually information is superficial and it can clarify what is myth and what has been scientifically proven. It would be another way of orienting ourselves, since we have little knowledge about it, and very often we do not know which course of action to follow because we feel insecure. We need to receive conceptual information about the subject in order to stay updated and know the way in which to deal with it in our daily lives. Sometimes, we seek professional help because we lack information. Information through any media is important; the more information is available, the greater is the understanding of the illness. The informative material should be easy to read and comprehend. Furthermore, the written information should serve as a research source”.

The percentage of teachers identifying lectures and discussions with a medical specialist, printed materials, and online materials as the most interesting strategies is 54.8, 25.8, and 22.6, respectively.

It was found that, for the teachers, mental health is linked to the balance between mind and body, as a requirement for happiness. Few teachers described mental health as mental illness. No discriminatory rationales appeared in the teachers’ statements, but there were reports of insecurity in decision making when dealing with students having mental disorders. The teachers attributed this insecurity to a lack of information about mental health and demonstrated interest in acquiring knowledge on the subject, as they believe this may be useful in their daily interactions with students. Furthermore, developing information strategies was considered important in the learning process, as the teachers consider them as a way to consolidate knowledge.

The results of this study corroborate the data published in two studies that assessed teachers’ perceptions about mental health. Pavri & Monda-Amaya show that due to lack of training, teachers do not know how to deal with problems involving mental health in schools. Fisher reveals that the teachers interviewed did not negatively perceive students with mental health problems and recognized the importance of psychoeducational programs offered at school. The present study is a pioneering study in Brazil on this topic.

Among the various types of media, TV was the main source of information about mental health, due to greater number of programs related to the subject, when compared with other media. During the data collection period, schizophrenia received more attention on TV due to a soap opera that had a character with the illness. The information in the soap opera began to serve as a source of knowledge for the teachers. In addition to schizophrenia, other topics about mental disorders are also portrayed in miniseries and other programs that promote debates on TV, but they were not mentioned by the teachers. However, the teachers reported that the information obtained via the media is inadequate, superficial, or sensational.

One of the limitations of this study is the use of structured instruments, which potentially limit the extent of the respondents’ answers. However, such type of instrument was selected because it facilitates data standardization. The information obtained from the teachers may not apply to other social or cultural contexts. In addition, data collection was performed after the intervention program, which may have skewed the results. However, this study was the first to investigate public school teachers’ perceptions about mental health with a robust methodology.

The meanings attributed to mental health by the teachers indicate interest in obtaining knowledge on the subject of mental health, since this can be useful in working with students. The data obtained suggest that, in the educator’s view, little information on mental health is available for teachers, and therefore, there is a great need to develop educational strategies about mental health in schools.