In this section, the perspectives of pupils, teachers, and parents on mental health problems and causes, as well as first ideas for intervention strategies, are described. Most attention is paid to the pupils’ perspectives and the mental health problems they face. After describing the pupils’ perspectives, we consider whether parents and teachers recognize pupils’ stories.
Study participants
The study participants included 36 teachers, 55 pupils, 34 parents, two researchers, and two psychiatrists who were invited to participate in the study. Most of those invited to participate agreed to do so. The male: female ratio was 40:60 for each group. The pupils ranged from 15 to 18 years of age. The teachers had 2–22 years’ experience of teaching at secondary schools.
Pupils’ perspectives
Occurrence of mental health problems
According to the pupils, mental health was a large problem among them. At least a quarter of the 10–15 pupils in each FGD complained that they felt very stressed, anxious, and often worried. For example, one girl from CVL stated,
“I get a stomach ache, feel anxious, and find it difficult to concentrate when I have examinations or tests. My parents are over-anxious for me. I feel pressured and worry too much.”
Many students remembered other students with symptoms of depression. A group in an FGD concluded, “About 10% to 20% students are often quite silent and seldom speak to anyone. They did not want to do anything in class even when they were asked to do something, and they did not care if they had good or bad results.”
Poor mental health may lead to poor somatic health, as one boy illustrated:
“I felt dizzy when I sat or lay down and then stood up immediately. It was more severe when I had insomnia. I often have it because I worry about my examination and test results.”
Another girl added: “I sometimes feel very sad and could not study anymore and do not want to have lunch or dinner anymore.”
Though exact numbers were not available, in all three schools there have been several suicide attempts in recent years. Suicide is a sensitive topic for both family and school, but the number of reported suicides among pupils has apparently increased. Some pupils shared their personal story in the FGD. For example, one girl recounted:
“When my parents quarreled, my study declined because I kept thinking about my parents’ conflict and couldn’t focus on study. Sometimes I was scolded by my parents with no legitimate reasons and with very strong language. Some weeks ago, I felt very sad and had suicidal thoughts. I took sleeping pills and was admitted to hospital for about 1 week… I think if my parents keep acting like this, my study will not improve any more. Also, I often have insomnia because of worrying. Currently, I feel better and my parents pay more attention to me.”
In this case, parental conflict seemed to have caused the problems, but most pupils reported that academic pressure is the main cause for (thoughts of) suicide among students.
Factors contributing to poor mental health
According to the pupils, the following factors contribute to poor mental health 1) academic pressure, 2) indulging in pleasures like online gaming, and internet, tobacco smoking and substance use, and 3) love-life, especially homosexuality.
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1.
Academic pressure
The pupils consider academic pressure to be a huge problem. They pointed to an overloaded academic curriculum and to pressure from teachers, parents, peers, and themselves to do well. One girl commented:
Unfortunately, this is not an exceptional case, as teachers explained, but rather a common reality.
High expectation of their teachers increases the pressure, as one boy reported: “The numbers of subjects and lessons are too many and the demands from teachers are too high. Therefore, students cannot satisfy teachers’ demands.” A girl explained: “Sometimes, we get high results from examinations but teachers are still not satisfied or think that high grades are a coincidence and not due to pupils’ skills or hard work.” Other students confirmed that pressure from teachers distressed pupils, and could lead to despondency and loss of confidence. One girl explained: “Because of fear, some students did not dare to look at the teacher’s face when they were reciting lessons in class. This fear impacts student’s ability.” Pressure from teachers can have serious consequences, as described by one boy:
Along with concerns about the demands of teachers, parental pressure was raised as a common and serious problem; parents are very keen for their children to have a good career. One girl explained:
In Vietnam, parents are very focused on their children’s success and future career. One girl commented: “Parents are less interested in care for their children but have high expectations of them. They require their children to study well like other children.”
Pupils also experience pressure from their peers, as competition is fierce. A girl from LTT stated, “If we have low marks, we have to leave the specialized class or to leave the group of excellent students, eligible for provincial and national competitions.” Finally, academic pressure also comes from students themselves. A school girl from CVL, in answer to a question about why she easily gets upset and quarrels with other students, frankly said:
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2.
Problems associated with pleasure seeking
Although entertainment is part of normal life, most of the pupils thought that too much pleasure seeking could have a negative impact on students’ study and health [14]. Pleasure seeking behaviour that they thought could lead to problems included following media personalities, friendship, gaming, internet, and cigarette smoking. They also thought that these problems mostly occurred among pupils from rich families because they could use money for pleasure instead of needing it all for their study. According to the respondents, pupils who indulge in pleasures also often break school rules and show resistance to school regulations.
Students said that addiction to online computer games is high. According to one boy (CVL), “The rate of online gaming is about 50% among boy pupils, (and this has) a negative impact on study results, due to spending too much time on it.” Another girl remarked: “Consequently, they did not spend enough time to study and received low results. Finally, they felt despondent and let things run their course.” The main reason for game addiction is said to be academic pressure. Because of the overloaded academic curriculum, pupils have little time to reduce stress and gaming is an easy and quick way to relax.
Although smoking and substance abuse are prohibited in schools, some boys smoke. They usually smoke tobacco in the coffee shops close to schools and in the toilets. The students said that those who smoke tend to break school rules often and show resistance toward school and teachers.
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3.
Love and Sex
Some parents do not allow their children to be involved in relationships before finishing secondary school, especially girls, since they are afraid that their children will not focus on their studies. A girl from TDN:
According to the pupils, relationships may have negative consequences for scholastic success, and may lead to fighting, early sexual intercourse, unwanted pregnancy, and even suicide attempts. A girl from TDN School said: “I know some friends who had boyfriends and started to have sexual intercourse. Some then had less study success. One girl became pregnant but her boyfriend’s family didn’t agree for them to marry. Then she had the baby, but the child died after birth.”
Another girl, from CVL, stated, “Some good students’ study results declined because of love problems and attempted suicide.” A girl from TDN recounted: “A girl student attempted suicide because her boyfriend didn’t want to marry her. He was still a secondary school pupil. This girl left her home after she was rescued from the suicide attempt.”
Homosexuality was also mentioned in most interviews and FGDs with pupils, and was seen to be linked to mental health problems. Pupils considered that homosexual relations are appearing more frequently among young people, linked to greater personal freedom and a modern life style, far from the concepts of the feudal society of the past. Homosexuality was linked by pupils to early sexual intercourse, lost concentration on studies, and even suicide attempts. In a FGD among CVL students, a girl explained:
“There are 13 subjects in school, and I have to study the whole day (morning and afternoon) on even days (Monday, Wednesday, Friday) and half the day on the other days (Tuesday, Thursday, Saturday). In addition, I have extra lessons from private centres or from my teachers from 6:00 pm to 9:00 pm, and then I study by myself up to 11.00- 12.00 pm at night. During examinations, I have to get up especially early around 4:30 am to revise lessons.”
“Last year, a very good student in this school attempted suicide by jumping from the second floor. We think the reason was pressure from teachers. She was a specialized biology student and attended a provincial competition for two subjects - biology and using a calculator. However, her marks in class were not high. Teachers were not fair to her in class and often openly complained about her.”
“My parents put pressure on me, like I have to do better than other people. My parents also want me to be equal to or even better than my brother who is excellent at school work. When my results did not reach my parents’ expectations, they were very sad, angry and dissatisfied so that I feel very sad too.”
“Because of myself, I feel jealous of some friends whose study was less successful than mine before, but now they study better than me. I put high pressure on myself to be better than my friends. My study results used to be very good but now they are not as good as before. Therefore, I feel angry with myself. I don’t want to be inferior to my friends in any way.”
“My parents did not allow me to go out with friends and have a boyfriend because they were afraid that I would not concentrate on my studies. Sometimes I want to have a boyfriend to share things with and confide in, but I have to refuse many boys.”
“It happens in both boy and girl students, but boys manifest it more clearly. I think the rate of boys who have homosexual orientation is about 5%. Some students’ families did not approve of their children’s sexual orientation, and some of those students attempted suicide.”
Parents’ perspectives
Parents agree that academic pressure is the main cause of mental health problems among students. They consider that Vietnamese youth has to study too much. According to the parents, the government has not developed good academic curricula. One male parent of an LTT pupil stated: “Innovation is lacking in the policies on education and training, especially in academic curricula and teaching methods.” Academic pressure seems to be higher for academically poorer pupils. “Depression often happens in students who have low study results because they are often scolded and under pressure from teachers, friends, and parents.” according to the father of a CVL pupil. But, as the mother of a CVL pupil explained: “The level of anxiety also depends on factors in the student’s home environment, including economic conditions, parental problems, and unhappy family.”
Pleasure seeking, put on the agenda by the students, was also recognized. A father remarked:
“Indulging in watching TV and playing games – if a pupil’s brain spends too much energy on playing games, they do not have enough energy to study. Consequently, children lose the focus on their study, sleep late, and get bored with studying.”
Although parents admitted that parental pressure contributed partly to student’s mental health problems, they put the main blame on teachers and the government. As one mother of a CVL pupil complained: “Parents share the teaching role for children only at home; children spend half or more of their time in schools.” In addition, parents are of the opinion that schools and teachers do not provide a happy learning environment for pupils. Schools are very strict, requiring that students listen to teachers but not promoting discussion with fellow students or working in groups, as the father of a CVL pupil explained:
“Pupils have little time and opportunity to communicate in class because they have to listen to teachers and they have no permission to talk in class during study time. They will be scolded by teachers if they talk in class.”
Some parents accused teachers of not being interested in the wellbeing of pupils. As one mother expressed it, “In schools, teachers lack concern for their pupils. There is poor teaching capacity and schools do not create suitable recreation grounds including sport facilities for students to help reduce stress.”
Parents also reported quarrels and fights between students during and after school, and within and between schools.
Like the students, parents related suicide to the high academic pressure. The father of a CVL student explained: “About two months ago, a girl jumped from the second floor in the morning at school, after she had been scolded by her father. She was under academic pressure but no one around, including parents and teachers took care of her; teachers and parents put her under academic pressure. They still argue about the causes of her suicide. She had already tried to commit suicide once before, last year.”
Teachers’ perspectives
Teachers admit that academic pressure due to an overloaded academic curriculum is a main cause for mental health problems and unhealthy behaviours, such as addiction to games and internet and fighting among students. A female teacher from TDN said:
“Most pupils are severely stressed (even depressed) because of the heavy burden of knowledge required after the curriculum reform. Time in class is not enough to acquire the knowledge and students have to have private tuition to enter and stay in good schools and to pass university entrance examinations. Consequently, some students are often in a state of anxiety and do not know how to do simple work at home, then they do not totally integrate into society.”
Teachers are obliged to follow the regulations of the Ministry of Education and Training; the heavy curriculum puts high pressure on students, but also on teachers. This pressure on teachers is increased because they also receive low salaries. A female teacher explained:
“Teachers’ salaries are too low. They have to find other jobs or run extra classes at home to support themselves. If teachers’ salaries were high enough, they could pay more attention to teaching.”
Teachers also complained about the parents’ role in teaching their children manners and good behaviour, and about parents’ lack of concern. One middle aged female teacher from TDN complained: “Nowadays, young people don’t know how to restrain their temper, they lack problem-solving skills, and feel heavy stress, and therefore they get angry easily and are quarrelsome, even fighting among themselves.”
All of the teachers are familiar with this serious problem, as the painful example given by a male teacher illustrates:
“We had a boy student who was very excellent at biology. He was chosen to enter the competition in biology for excellent students at provincial level. However, because of the pressure, he chose to commit suicide by cutting his wrists when the competition date was near.”
Thinking of solutions
There were few differences among pupils, parents and teachers in the proposed solutions to reduce pupils’ mental health problems and the results are combined in this section. The students would like reduced academic pressure, more attention from their family, more recreational activities supported by schools, and a friendlier learning environment. Parents would like teachers and schools to take more responsibility for the quality of teaching and to find better ways to teach their children. The teachers would like to see pressure on them reduced by lowering academic pressure and increasing salaries, and they also want the parents to take some responsibility for teaching children. Combining their ideas, the solutions outlined below were proposed to reduce students’ mental health problems. The following actors need to play a role in these solutions: 1) the Ministry, 2) schools, 3) local government and community 4) parents and 5) students themselves.
Firstly, it is thought that the Ministry of Education and Training needs to revise and renew the academic curricula. One boy at CVL School suggested key strategies:
“Reduce the pressure from the academic curriculum and develop good methods to teach students. Choose the key subjects and invest enough time in them. Reduce less important subjects to leave time for students to study what they want.”
In addition to reducing the curriculum load, the Ministry could play a role in establishing regulations relating to gaming, alcohol, and violence. It could promote new, modern ways of teaching. Raising the salary for teachers is also considered important, since it would reduce pressure on teachers to find extra sources of income and increase their commitment to their teaching in the schools.
Secondly, the schools could play a role in reducing academic pressure and creating a friendlier learning environment: “Create a friendly environment between teachers and students in study and examinations.” was the suggestion from a girl at LTT. Having a playground was considered important. The schools have a few sport facilities and music lessons, but not enough for the large numbers of students. The academic schedules also leave pupils little time to use the few facilities available. Some students suggested that schools should organize extra activities to strengthen social cohesion, provide social and life skills, reduce academic stress, increase friendship, and reduce discrimination and disunity among students. One boy student at CVL stated,
“Pupils need extra courses about sexual education, student relationships, students and family, adolescence and school health. These activities could improve the understanding among students and between students and teachers. That could reduce study pressure on pupils, and reduce discrimination among them. They would feel less isolated, especially those with sexual issues like homosexuality. Sexual education would increase pupils’ understanding of sexual health and help them to avoid doing the wrong thing. I also joined a group to promote education on sexual health. I think it is effective. I hope the school will create good conditions for pupils to develop.”
Pupils also proposed that schools should organize meetings to bring teachers, parents and pupils together, and organize short training courses for them, to provide knowledge about adolescent psychology: “Schools should have a group to support pupils and recognize problems that arise.” According to the parent of a TDN pupil, “Psychologists are needed to train students in life skills and problem-solving skills.” Many parents and teachers remarked on the necessity to “combine activities of school and family.”
Thirdly, the community should take part in teaching and educating young people. “Local government should control online gaming and ban alcohol and tobacco consumption of pupils, with strict laws on violation.” according to one male parent of a TDN pupil. Collaboration among associations and unions, such as the Parents’ Association, Women’s Union and Youth Union, were also suggested to strengthen support for students, teachers and parents. A teacher from TDN stated: “We should create a forum for students to exchange ideas and a psychological counseling group to support students when they have problems.”
Fourth, parents should create a friendly environment so that children feel comfortable to share their cares, and they should let children decide some things for themselves, as one boy recommended:
“I think we should tell our parents that they should not forbid children to go out with friends. Because if children only stay at home they will not understand what is happening outside and they will not adapt to the social environment.”
Finally, pupils need to find ways to cope with stress. One boy in TDN noted:
“I often write a blog. I put my sadness and my emotion in the blog, and then my friends can share and give me advice. Then I can find solutions and think less about the bad things. I also reduce stress by listening to music and watching movies online.”
Seeking advice or help outside the family is also necessary because pupils cannot easily share their feelings with their parents. Schools do have Secretary Boards, Youth Unions and Parents’ Associations, and some schools have medical professionals that can be consulted, but these institutions do not yet function well. One reason is that pupils have little knowledge and skills on mental health and psychology. In addition, pupils with mental health problems may not recognize their own problems and may not seek help.