International Journal of Research in Medical Sciences

Alshammari SA et al. Int J Res Med Sci. 2022 Aug;10(8):1582-1589

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: https://dx.doi.org/10.18203/2320-6012.ijrms20221824
Original Research Article

Knowledge, attitudes and practice among high school teachers toward

students with mental disorders in Riyadh, Saudi Arabia
Sulaiman A. Alshammari1*, Shuliweeh Alenezi2, Abdullah Alanzan1, Ahmed AlHawamdeh1,
Omar Alsulaiman1, Nawaf Alqarni1, Saad Aldraihem1, Nasser Alsunbul1

1
Department of Family and Community Medicine, College of Medicine, King Saud University Medical City,
King Saud University, Riyadh, Saudi Arabia
2
Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Received: 19 June 2022

Revised: 04 July 2022
Accepted: 05 July 2022

*Correspondence:
Dr. Sulaiman A. Alshammari,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Mental disorders are highly prevalent among adolescents, and they correlate negatively with students’
achievement, performance, and leadless school engagement and participation. School Teachers can contribute
significantly to the early detection and intervention strategies for mental disorders among adolescents. This study
estimates high school teachers’ knowledge, attitude, and practice toward mental disorders and determines the
association between selected demographic factors.
Methods: The ethical committee of King Saud University, Riyadh, Saudi Arabia, approved this cross-sectional study.
Multistage random sampling was done, which included 62 male and 48 female high schools in Riyadh between
August and December 2021. An Anonymous self-administered questionnaire consisting of 39-item was used for data
collection.
Results: A total 487 responses were received from the high school teachers, on a scale of 10 maximum score, only
(60.4%) showed adequate knowledge regarding mental disorders. Even though, Majority of teachers (76.2%) show a
favorable attitude toward mental disorders on a scale of 24 maximum scores. Furthermore, approximately one-third of
study participants (34.4%) on a scale of 4 points maximum show good practice toward mental disorders.
Conclusions: This study revealed teachers’ lack of knowledge about mental disorders with poor practice. Even
though school teachers have shown favourable attitudes in most aspects toward mental disorders, implantation of the
mental health literacy program is recommended to enhance the essential role of school staff in providing the needed
support for promoting student mental health.

Keywords: Knowledge, Attitudes, Practice, School teachers, Mental disorders

INTRODUCTION can produce successful and fruitful work, and contributes

to her or his community".2
A people's ability to lead a satisfying life, which includes
developing and maintaining close personal relationships, The importance and burden of mental disorders can be
is strongly influenced by their state of mental health or observed worldwide. Mortality and morbidity due to
psychological wellness.1 According to the World Health mental, neurological, and substance abuse disorders are
Organization (WHO) Mental health is defined as "a global problems.1 According to the WHO, a mental
condition of well-being in which every individual fulfills illness affects one member of every four families.2
his or her potential, copes with the usual demands of life, Furthermore, mental and addictive disorders affect about

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 Alshammari SA et al. Int J Res Med Sci. 2022 Aug;10(8):1582-1589

one billion people, about 16% of the world population in gender, years of experience, marital status, teaching
2016, with the prevalence of these conditions being specialty and type of school with knowledge, attitudes,
similar in men and women.3 and practices.

The WHO estimates that between 10% and 20% of METHODS

children and adolescents worldwide have a mental
illness.4 Two of the most prominent psychiatric issues Study design and setting
globally are depression and anxiety.5 Depression or low
mood affects approximately 12 percent of adolescents in We conducted an analytical cross-sectional survey in
the United States between 12 and 18.4 Riyadh, Saudi Arabia, from August to December 2021.
Based to the General Authority of Statistics in Saudi
The burden of psychiatric disorders among adolescents Arabia they estimated the population in Riyadh city
and children was not reported in any national studies. around 8,660,885 in 2019.
However, some reports on subgroups of the population
indicated a prevalence of 36.3-48.0%.6,7,8,9,10 Among Sample size and sampling technique
other indicators addressing prevalent health problems
among nationally representative samples of adolescents, The required sample size to conduct this study was
14% and 6.7%, respectively, were found to have calculated using the following formulae:
symptoms suggestive of depression and anxiety. 11 In
addition, a Study in Hail region of Saudi Arabia showed
that despite the favorable attitude of teachers within the
targeted population toward students with mental health
issues, they reported having limited information about
most aspects needed for early detection dealing with and We referred to Kamel A, Haridi HK study, which
referral for specialized mental health counseling available estimated the level of teacher knowledge about mental
in their school and community.12 health as 54%. At a confidence level of 95% and a 5%
precision, the estimated sample size was 382. All high
Most teens spend most of their waking time in school school teachers are considered our target population,
with their teachers more than anyone, making schools the excluding teachers with a history of mental illness.
prime setting for early detection and intervention strategy
for mental health problems among children and Sampling starts by obtaining a list from “Makani,” The
adolescents.13 Unfortunately, unless the symptoms of Educational Administrative Office Website. A total of
mental illness are extremely distressing, they are often 251 male high schools and 165 female high schools are
ignored and considered due to signs of weakness on the located in Riyadh city. Multistage random sampling was
person's part. That is why teachers play a vital role in done by assigning each school to one of the five areas in
identifying students with mental health issues who Riyadh (North, south, east, west, and Center). Further, we
present with clinical or subclinical symptoms.13 However, divided the schools based on sex, either male or female
some studies found a gap between teachers' roles and high schools. Approximately 12 schools have been
mental health; teachers needed to be informed about randomly selected from each area for males and female
mental disorders because they served as gatekeepers to schools. Of the 120 schools, we received the permission
child and adolescent mental health services.14 Although of 63 male schools and 48 female schools to distribute the
the prevalence rate of mental disorders is high in Saudi online self-admirative questionnaire among the teachers
Arabia, there is still a lack of local studies that focus on through the school’s manager. A total of 487 participants
knowledge, attitudes, and practice toward mental was achieved. The participants provided informed
disorders among high school teachers. Furthermore, the consent after clearly defining the purpose of the study
results of this study might help identify areas where and the right of the participant to withdraw. In addition,
teachers lack basic knowledge about mental disorders and they were assured of maintaining their privacy and
areas where school teachers may show negative attitudes confidentiality with no personal identifiers being
toward students with mental disorders for further requested.
education to be implemented. Furthermore, it would
emphasize the initiation of training programs to qualify Tool and data coding
teachers in providing assessment and closing the gap
between the onset of the disease's symptoms and The tool that has been used in this study to measure the
initiating treatment to mentally ill students. teachers’ knowledge, attitude, and practice toward
students with mental disorders was self-generated after an
Therefore, our study aimed to estimate and evaluate the extensive review of the literature and other instrument
levels of knowledge, attitudes, and practices among high tools. Furthermore, it has been reviewed and edited by
school teachers toward students with mental disorders in experts in psychiatry, family medicine, and education. It
Riyadh and try to determine the association, if any were consists of 39 questions, divided into four main sections,
there, between selected sociodemographic factors such as teacher sociodemographic characteristics (13 items),

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teacher knowledge about mental disorders (10 items), Table 1: Distribution of socio-demographic
attitude toward students with mental disorders (8 items), characteristics of study subjects (n=487).
and lastly, teacher practice (8 items). We use (Yes and
No) answers for the knowledge and practice section. Variable (%)
Moreover, we give 1 point for the correct or positive Age
response and zero for an incorrect or negative response. <40 173 (35.5)
However, 3-point Likert scale was used for the attitude 40-45 173 (35.5)
section, (3 = agree, 2 = neutral, and 1 = disagree). for >45 141 (29)
each of the three sections, a total score was calculated by Mean (SD) 41.43 (7.509)
summing all items and using the 75th percentile as a cut-
Gender
off point in which it could predict statistically strong and
Male 237 (48.7)
true levels for a certain parameter.15 A pilot study was
done on 20 teachers, ten male and ten female high school Female 250 (51.3)
teachers, to check the clarity of the questionnaire. For the Marital state
internal consistency and reliability test of the tool, Married 423 (86.9)
Cronbach’s alpha measure for each subset showed (0.73) Single 64 (13.1)
for knowledge, (0.74) for attitude, and lastly (0.71) for No. of children
practice. 0 76 (15.6)
1-3 197 (40.5)
Statistical analysis plan ≥4 214 (43.9)
Years of experience
The data analysis was done using SPSS 26.0 version ≤10 years 166 (34.1)
statistical software. Descriptive statistics (frequencies,
11-21 years 183 (37.6)
percentages, and measures of central tendency and
≥20 years 138 (28.3)
dispersion) were used for the sociodemographic variable
(i.e., sex, age, gender, marital status, and type of school). Educational level
Above or below 75th percentile is used to define Diploma 8 (1.6)
adequate or inadequate knowledge, positive or negative Bachelor’s 403 (82.8)
attitude, and good or poor practice. In addition, Chi- Master 62 (12.7)
square and fisher's exact tests were used to assess the PhD 14 (2.9)
association between selected sociodemographic factors Region of school in Riyadh
like gender, years of experience, marital status, teaching North 107 (22)
specialty, and type of school. P-values were considered South 87 (17.9)
statistically significant when less than 0.05. East 95 (19.5)
West 125 (25.7)
RESULTS Central 73 (15)
Type of school
Sample characteristics
Public 367 (75.4)
Out of four hundred and eighty-seven respondents, four Private 120 (24.6)
hundred and ten (92.8%) were aged 30 years or more, Teaching specialty
with a male to female ratio of 0.95:1. The mean age was Science subjects 206 (42.3)
41.43, with a standard deviation of 7.5. Most teachers Humanitarian subjects 281 (57.7)
were married (86.9) and had children (84.4%). The mean First degree relative diagnose with mental disorder
years of experience were 15 years ± 8 SD. The majority Yes 68 (14)
of teachers, 75.4%, were from public schools. Teachers Data are presented as number and percentages of
specialized in Humanitarians subjects comprise 57.7% of participant
respondents (Table 1).
The maximum knowledge scale was 10, in which the
Teachers’ knowledge study participant mean score was 6.7 ± 1.45, and
Participants who scored higher than the 75th percentile
Approximately (40%) of the teachers think that mental were identified as having adequate knowledge. They
disorder is rare among adolescents, and almost all of the comprise (60.4%) of our study sample, with no
teachers (99%) correctly responded that depression association between the selected sociodemographic
among adolescents could affect their academic grades. characteristics. However, we discovered a statistically
However, only (16.6%) of the teachers know if it is right significant association between teachers who participate
or wrong to ask depressed students about suicidal in mental health training programs on coping with pupils
thoughts. Moreover, most of the teachers (89.5%) replied who have mental disorders and better levels of
correctly that students with anxiety disorders tend to be knowledge of mental diseases (p-0.026) (OR: 1.752; CI
more irritable than other students. 1.064-2.883) (Table 2).

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Table 2: Study subjects’ responses towards questions concerning their knowledge about students with mental
disorders.

Responses (%)
Question
CorrectIncorrect
Do you believe mental disorders are rare disorders among adolescents? 296 (60.8)
191 (39.2)
Do you believe depression in adolescents does not affect their academic
482 (99) 5 (1)
grades?
Do you believe increase or decrease in weight can be a sign of students with
326 (66.9) 161 (33.1)
depression?
Do you believe diminished interest in activities and hobbies can be a sign of
393 (80.7) 94 (19.3)
a student with depression?
People with depression often speak in a rambling and disjointed way? 112 (23) 375 (77)
Do you believe that Depression affects patients’ memory and concentration? 436 (89.5) 51 (10.5)
Do you believe that it is not a good idea to ask someone if they are feeling
81 (16.6) 406 (83.4)
suicidal in case you put the idea in their head?
Do you believe that Being easily fatigued can be a symptom of anxiety
249 (51.1) 238 (48.9)
disorder?
Is it true that students with anxiety disorders tend to be more irritable than
436 (89.5) 51 (10.5)
other students?
Do you believe that anxiety disorders are manageable? 456 (93.6) 31 (6.4)
Total score higher than 75th percent = 60.4%
Maximum score = 10
Overall level of knowledge among participants was Adequate in 294 (60.4%) and Inadequate 193 (39.6%), the
Mean ± =6.7±1.45

Table 3: Study subjects’ responses towards questions concerning their attitude about students with mental
disorders.

Responses (%)
Statement
Agree Neutral Disagree
I don’t mind having a student with a mental disorder in my
283 (58.1) 143 (29.4) 61 (12.5)
classroom
I believe that students with mental disorders should be placed
99 (20.3) 123 (25.3) 265 (54.4)
in a special school
I think that students with mental disorders are like other
288 (59.1) 52 (10.7) 147 (30.2)
students with organic diseases
I believe that mental disorders are merely a mix of black
25 (5.1) 101 (20.7) 361 (74.1)
magic and evil eye
I believe that faith healers are better at treating mental
86 (17.7) 175 (35.9) 226 (46 .4)
disorders
We should consider consulting a psychiatrist when
459 (94.3) 19 (3.9) 9 (1.8)
experiencing mental health problems
I believe that recognizing students with depression is a part of
309 (63.4) 109 (22.4) 69 (14.2)
my responsibility
I believe that students with mental disorders are dangerous
159 (32.6) 145 (29.8) 183 (37.6)
on their classmates
Total score higher than 75th percentile = 76.2%
Maximum score = 24
Overall attitude scores were positive in 371 (76.2%) and negative in 116 (23.8%) with mean
score=19.5 ± 2.7

Teachers’ attitudes teachers do not mind having a student with a mental

disorder in their classroom, and approximately (54%) of
Tables 3 highlights the attitudes of school teachers the teachers disagree on placing students with mental
toward mental disorders. Fifty-eight percent of school disorders in a special school. However, most teachers

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(94.3%) would consider consulting a psychiatrist when (40%) of the schools' teachers stated that their school had
experiencing mental health problems. Furthermore, only written policy in how to deal with a student who has a
(17.7%) believe that faith healers are better at treating mental disorder, especially in private school (55.8%)
mental disorders. The maximum attitude score was 24, (p<0.001) (OR: 0.424; CI 0.279–0.644). However,
and the study participants attained a mean score of 19.5 (40.4%) of teachers did not know whether their schools
±2.7. The majority of the teachers score higher than the had written policies or not.
75th percentile (76.2%), indicating a favorable attitude
toward mental disorders, with a statistically significant Figure 1 highlights Teachers' selection for more than one
association between married teachers and overall higher proposed method on promoting awareness about mental
positive attitude toward mental disorders (p-0.033) (OR: disorders. Having a psychologist in every school was the
0.545; CI 0.310-0.959). most frequently selected choice between the other
proposed options by more than (80%). Social media
Teachers’ practice campaigns to increase the knowledge about mental
disorders come second (62.4%), while the third choice
Tables 4 highlight the practice of school teachers toward was workshops and webinars held at the school (57.9%).
mental disorders. Around (75%) of the study participants Lastly, the maximum attainable score of teachers' practice
encountered students with a mental disorder in their toward mental disorder was four, and the mean score of
career, and (57.1%) feel confident in helping a student the study participant was 1.9 ± 1.2. Moreover, the overall
with a mental disorder. However, only (18%) receive percentage of teachers who scored above the 75th
training on dealing with students with mental disorders. percentile was only (34.3%) with a higher proportion
among male teachers (p<0.001) (OR: 0.483; CI 0.33–
Reading books or articles on how to deal with a student 0.707) and in private school teachers (p-0.029) (OR:
having a mental disorder was reported by (43.9%) while 0.625; CI 0.409–0.955).
Table 4: Study subjects’ responses towards questions concerning their practice about students with mental
disorders.

Question Responses (%)

Yes No
Do you feel confident in helping a student with a mental disorder? 278 (57.1) 209 (42.9)
Did you get any training on how to deal with a mentally ill student? 89 (18.3) 398 (81.7)
Did you read any books or articles on how to deal with a mentally ill student? 214 (43.9) 273 (56.1)
Are you interested in participating in mental health education programs? 362 (74.3) 125 (25.7)
Total score higher than 75th percentile = 34.3%
Maximum score = 4
The overall practice scores were good in 167 (34.3%) and poor in 320 (65.7%)

Social media campaigns to raise awareness.

Offering mental health counseling via a telephone hotline.

Teachers' selection

Providing schools with audiovisual aids and print materials

benefits students' and teachers’ mental health

Workshops and webinars should be held at the school

every school should have a psychologist

0 10 20 30 40 50 60 70 80 90

Percentage of teachers

Figure 1: Teachers’ selects from proposed methods on how to promote awareness about mental disorder, value may
not add to 100% since teacher may choose more than one option.

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Table 5: Analysis of teacher sociodemographic characteristic associated with adequate level of knowledge, positive attitude and good practice.

Knowledge Attitude Practice

No. of
Variable Adequate P Positive Good
respondent OR (CI) OR (CI) P value OR (CI) P value
N (%) value N (%) N (%)
Gender
Male 237 139 (58.6) 1.150 184 (77.6) 0.855 100 (42.2) 0.491
0.450 0.463 <0.001*
Female 250 155 (62) (0.8-1.654) 187 (74.8) (0.563–1.299) 66 (26.4) (0.336-0.72)
Marital status
Married 423 255 (60.3) 0.921 329 (77.8) 0.545 142 (33.6) 1.187
0.921 0.033* 0.536
Single 64 39 (60.9) (0.600-1.761) 42 (65.6) (0.310-0.959) 24 (37.5) (0.689-2.047)
Years of experience
10 166 95 (57.2) 124 (74.7) 51 (30.7)
11-20 183 116 (63.4) 0.501 137 (74.9) 0.516 65 (35.5) 0.526
21 138 83 (60.1) 110 (79.7) 50 (36.2)
Teaching specialty

Humanitarian
281 165 (58.7) 1.178 219 (77.9) 0.797 102 (36.3) 0.791
subjects 0.384 0.288 0.229
(0.814-1.703) (0.524-1.212) (0.540-1.159)
Science subjects 206 129 (62.6) 152 (73.8) 64 (31.1)
Type of school
Public 367 218 (59.4) 0.847 278 (75.7) 0.907 115 (31.3) 0.617
0.445 0.696 0.025*
Private 120 76 (63.3) (0.553-1.297) 93 (77.5) (0.555-1.481) 51 (42.5) (0.404-0.943)
OR odds ratio, CI confidence interval, *Significant level <0.05.

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DISCUSSION Only 21.9% of teachers are adequately informed about

the resources available for school mental health services.
In addition to acting as a link between the home and the The teacher's knowledge about the available mental
community, schools are critical in identifying children health services for the school and student is essential.12
suffering from mental illnesses early.16 Nevertheless, However, (40%) of our study participants do not know if
despite this, the findings of this study and prior studies their school has written a policy on dealing with students
revealed that teachers lacked awareness concerning having mental disorders. Some teachers express a desire
mental problems among pupils.12,17,18,19 for additional support, training, counselor, and more
coordination between all mental health services to
Although local studies in Saudi Arabia reported that the promote students' mental health.20 Teachers perceived the
prevalence of mental disorders among adolescents ranged availability and accessibility of the mental health services
from 34.1% to 48%,5, 6 and our study participants as one of the challenges facing student mental health.16
reported that they had encountered students who have a Most of the teachers (81.5%) emphasized the importance
mental disorder at some point in their careers, forty of having a psychologist in each school to deal with a
percent (40 percent) of school teachers responded that mental health disorder, indicating that teachers are aware
mental disorders are uncommon among adolescents. of their lack of knowledge and inability to provide
sufficient support required to maintain their students'
However, on the other hand, teachers demonstrated a mental health.12 Also, (62.4%) of them suggested
great understanding of some signs and symptoms of utilizing Social media campaigns to increase their
mental disorders, such as a reduced internist, inactivity, knowledge about mental disorders.
and its effect on concentration in the case of depression.
However, poor comprehension of others was shown by Limitation
the vast majority of respondents (77%) who answered
incorrectly to questions such as: speaking in a rambling One of the study's limitations is the lack of a globally
manner is a sign of depression and being easily exhausted validated assessment tool that could be used to measure
is not a sign of anxiety. Furthermore, a lack of all of the levels of teacher knowledge, attitude, and
information on mental health issues may be a barrier to practice that were investigated.
counseling, supporting, and promoting students' mental
health. Furthermore, because it was limited to the Riyadh
metropolitan area, the findings may not generalize to
One of the school teachers attributed the lack of other parts of Saudi Arabia, such as the outskirts of the
knowledge to a high teaching load and other capital or other rural areas.
obligations.16 Additionally, this may explain why only
(63.4%) of school teachers believe that recognizing CONCLUSION
pupils with mental problems is a part of their
responsibilities. It is possible that insufficient training of Only a small percentage of teachers receive training on
school teachers (18.3 percent) on dealing with mental how to deal with students who have mental disorders,
diseases contributed to the fact that only (57%) of them even though the findings of this study revealed a lack of
were confident in their ability to help pupils with mental
knowledge in some aspects of mental disorders and poor
disorders. According to a recent study, this lack of
practice in some areas. Schools can serve as excellent
training is one of the possible explanations of school
environments for detecting and identifying students
staff's lack of understanding concerning mental
suffering from psychological stress. A mental health
problems.17
literacy program should also be implemented to
strengthen the critical role of school personnel in
Furthermore, most teachers stressed on the importance of
providing the necessary support for promoting students'
receiving training to spot the signs and symptoms of
mental health. Ongoing research on this subject in a
mental illnesses.20 Additionally, most schools staff (74%)
express an interest in engaging in a mental health literacy school setting is required and highly recommended.
program. Teachers' knowledge, confidence in assisting
students with mental disorders, and stigmatizing attitudes ACKNOWLEDGEMENTS
toward mental disorders improved due to the mental
health training programs.21 In addition, the effects of The author would like to thank all of Prof. Shaik Shaffi,
these programs extended beyond that, as evidenced by Dr. Mohammed Al Jaffer, and Mohammed Alhumud for
the fact that they indirectly improve pupils' knowledge of their diligent support, assistance, and valuable comments
mental health as a result of the information they received on the study.
from school personnel.22
Funding: No funding sources
Teachers who were married have demonstrated a more Conflict of interest: None declared
positive attitude toward students with mental disorders Ethical approval: The study was approved by the
than single teachers. This finding was similar to the Institutional Ethics Committee
findings made by others.12

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