Understanding and Addressing Academic Stress in Urban, Middle-Clas

217 Pages·2017·2.59 MB·English

VRIJE UNIVERSITEIT
‘The most stressful period of my life’
Understanding and Addressing Academic Stress in Urban, Middle-Class Indian Youth

ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad Doctor aan
de Vrije Universiteit Amsterdam,
op gezag van de rector magnificus
prof.dr. V. Subramaniam,
in het openbaar te verdedigen
ten overstaan van de promotiecommissie
van de Faculteit der Bètawetenschappen
op maandag 30 oktober om 11.45 uur
in het auditorium van de universiteit,
De Boelelaan 1105

door
Emma Emily de Wit
geboren te Westzaan
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Summary
Background and research question
Stress and related mental health issues have become a prominent public health concern among youth,
globally, and particularly in rapidly developing countries such as India. Suicide, for example, has become one
of the top three causes of death among youth in the age bracket 19 to 25 years old in India, and both stress
and depression are among the leading causes of illness and disability in the lives of adolescents. As such youths
are at the crucial stage of maturation and increased independence, these mental health problems bring up
serious concerns related to personal wellbeing, often affecting aspects of economic, family and social life.
While, globally, mental health problems are mostly witnessed in low- and middle income countries (WHO,
2001), the burden is not necessarily only experienced by the poorest groups. In India, for instance, suicide
rates are noticeably high among higher-educated people, and highest in the richer (Southern) states. Equally,
there are many studies which depict the elevated levels of stress, depression and anxiety experienced among
middle-class youth, most notably students. Furthermore, a wealth of Indian studies have continuously shown
the relation between stress and education, indicating particularly the influence of competition, academic
pressure from parents, parent-child conflicts as well as the effect of peer relations on the wellbeing of
students. More specifically, stress in youth (often described as ‘academic stress’) has been explained by fear
of failure, exam results, as well as features of modernization (including substance use and increased
individualization in society, for example) often seen in students living in urban, middle-class contexts.
Regarding the latter, India has seen major social-economic changes, particularly after economic reforms which
have opened up India’s market to an increased global foreign exchange of goods, ideas and knowledge. The
withdrawing influence of the State and increased reliance on international economies has forced Indian
industries to modernize and become more specialized, making India one of the fastest growing large
economies in the world. Liberalization has also had an accelerated impact on the growth of the new middle
class, the influx and spread of the Internet, ICT and mass media, and, simultaneously, the distribution of
various ‘Western’ values such as individualism and meritocracy.
Similarly, features of the current academic system, family life in Indian society, as well as the coping strategies
available for Indian youths today, seem to play a role in affecting the mental health status of many young
Indians. Academically, students are generally pushed to adhere to a relatively rigid form of rote learning, with
tedious examination processes and, what becomes, an intense competition between peers to gain placement
into one of the most reputed universities, in order to obtain the required qualifications necessary to secure a
job in the future. Families, and particularly parents, are often described as a major part of the issue, as they
are the first to install a sense of (academic) achievement in their children, spurring them on to take extra-
curricular activities and private classes, and comparing their results with other peers. Moreover, whenever
students feel a sense of loneliness, anxiety or depression, it is likely to go unnoticed and/or untreated as India’s
mental health system is still very much in its infancy. This has mainly to do with the history of political neglect
towards mental health in India, which has led to a situation where only 0-3 psychiatrists per 100,000 people
and between 1-5 clinical psychologists per 100,000 people were available in 2013; accounting for a staggering
deficit of around 97 percent.
It is in the absence of sufficient governmental support and scarcity of public health resources, that the
treatment gap has therefore been mostly responded to by the private sector (mainly in the cities), Non-
Governmental Organizations (NGOs) and community workers, following the practices of Community-Based
Health (CBH). Learning from CBH practices could therefore be urgently required to effectively reduce the
burden of mental health problems for young people in India. There is a general consensus, after all, that many
of the mental, behavioral and psychological problems that exist in Indian youth could be averted if
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interventions would take place at an early stage, for instance through population-based interventions with
students (in school settings) as well as with other relevant actors in the community.
Considering the complex and dynamic relationships that exist between societal actors and other factors that
continue to impact the wellbeing of Indian students, the way stress is addressed requires a socio-ecological
approach that is sufficiently comprehensive to evoke sustainable change. As such, this thesis is concerned with
understanding and addressing stress from a social-ecological perspective, aimed at reducing academic stress
in Indian, middle-class youth in Pune, a relatively large city in the state of Maharashtra, India. It is in the context
of this rapidly expanding educational hub (often referred to as the ‘Oxford of the East’) that this
transdisciplinary research was implemented, following the steps of an Interactive Learning in Action (ILA)
approach, in order to develop, evaluate and scale-up Community-Based Health initiatives for the promotion
of mental wellbeing in Indian students between 15 and 24 years old. The main research question to be
addressed by this thesis comprises:
‘How can academic stress in middle-class, urban India, be understood and addressed from a social-
ecological perspective?’
The approach of this thesis is therefore deliberately interventionist, and aims to both understand (part 1) and
develop socially embedded solutions (part 2) to the issue of academic stress. In doing so, I relied on the close
collaboration with a Pune-based suicide prevention NGO, as well as various mental health professionals,
parents, teachers and students.
Part 1: Understanding academic stress
Part 1 aims to answer the following research questions:
1a) How do middle-class Indian students experience and cope with stress in the context of their
academic development?
1b) What role does the social-ecological system play in either stimulating or reducing stress in
students?
To address this question, and as part of the first stages of the ILA process, I undertook three different studies
aimed at exploring: 1) the self-reported experiences of stress and related problems of Indian students over
the course of their academic career, 2) the perspectives and experiences of parents regarding parenting stress,
parental pressures and their hopes and expectations regarding the future of their children, 3) the perspectives
and experiences of unschooling parents (parents who choose to not send their children to school) regarding
the issue of academic stress and the role of parenting and education in their lives.
More specifically, regarding the first study (chapter 4), my colleague and I employed a Life Course Perspective
in order to understand how stress, as experienced by students, can be traced back to surrounding social
structures and their geographical locations, which can change over time. Based on in-depth timeline
interviews with 12 students, as well as a focus group discussion with 8 students, we were able to abstract a
number of personal and more commonly experienced events that contributed to their feelings of stress,
including stressful role transitions, health issues, academic failures and conflicts with peers or parents. We
also reflect upon the mediating factors that play an important role in how intensely stressful such events are
experienced, including social networks, coping styles and mastery.
Regarding mediating factors, we saw that students are often limited in using their social environment for
emotional support, either due to personal factors (self-esteem, level of openness, communication skills etc.),
or the absence of ‘good friends’ and ‘accepting parents’ in the prevailing culture. For some students, a sense
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of disconnection led to feelings of loneliness and depression. In terms of coping, we distinguished three
separate pathways of approaches in the self-reports of students, from which they (implicitly) choose: 1) a
social vs individual approach, 2) an avoiding vs attacking approach, and 3) a denial vs accepting approach.
Finally, we witnessed that some students, over the course of time, had developed a sense of mastery and locus
of control, which enabled them to understand and navigate their situation with more clarity and
responsibility.
With regards to the second study (chapter 5), we aimed to understand the deeper causes of parental pressures
on children (which can lead to academic stress) by specifically examining parenting stress as expressed by
various actors, as well as experienced by parents themselves, along with the emotions, needs and fears
underlying parenting behaviour. Through a qualitative study, including in-depth interviews and focus-groups
with parents, high-school students, mental health professionals, teachers and educational experts, we were
able to find three commonly perceived parenting issues which lead to parenting stress, comprising: 1) the
education system and societal pressures to ‘not fall behind’, 2) the generation gap and increased complexities
inherent within modern cities, and 3) emancipation and changing family structures. The results are discussed
with regards to the broader social-ecological context of India, referring to key aspects of social, cultural,
political and economic importance.
Finally, regarding the third study (chapter 6), we employed a narrative approach to explore how, based on the
parenting journey of three families, stress can be understood in the context of unschooling. Three in-depth
interviews were conducted to explore the motivations and experiences of parents who do not send their
children to school, in relation to the concept of academic stress. Two important results from this study reflect
the ambiguity and subjective nature of the concept of ‘stress’, and how stress is perhaps a natural part of the
human development process, regardless of the influence of formal schooling. It also shows that formal
schooling, in the way that it is currently practiced in India, brings up critical questions regarding how
educational institutions benefit the overall wellbeing, and intrinsic motivation, of children. As such,
unschooling parents instead attempt to allow their children to follow their own natural learning processes. In
these contexts, children experience stress as part of a ‘creative energy’ resulting from a self-induced quest for
improvement or transformation, and less as a product of educational processes which subject students to
aspects of standardization, achievement, competition and comparison, as is often evident within India’s
formal education sector.
Part 2: Addressing stress from a socio-ecological perspective
The second part of this thesis comprises four chapters and attempts to respond to the following research
questions:
2a) What factors play a role in the development of social-ecologically sensitive interventions that
help to prevent academic stress?
2b) How can the mechanisms of interventions be shared in other contexts in order to proliferate
their potentially positive outcomes?
Chapters 7, 8 and 9 reflect on the development and results of three distinct interventions aimed at reducing
stress and related mental health issues in Indian youth. In the first study we reflect on the development and
implementation of a university-based stress management program in two different universities in Pune. The
program comprised of four sessions, developed to address challenges commonly experienced by students,
including fear of failure and low self-esteem, conflicts with peers and friends, and various issues related to
academics and other daily life struggles. Research-based methods such as Emotional Freedom Technique,
Interplay and Arts-Based therapy (e.g. poetry) were used to evoke a sense of relaxation, reflection and play in
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the students. Baseline study results indicate a significant drop in self-reported levels of stress after the
program, and qualitative data reflects the overall positive feedback from the participating students, as well as
high acceptability from teachers and school authorities.
In Chapter 8 we describe the development and results of a Creative Stress-Relief Program for parents based
on a Theory of Change (ToC). In the ToC, the objectives of parents, as well as the pathway of change to relieve
parents from excess stress and improve relevant parenting practices, are visualised and described. More
specifically, the ToC depicts the theory-based methods employed in this particular context to support parents
in their learning process, including Non-Violent Communication and Rational Behavioural Emotional Therapy
(REBT) principles, in order to evoke change. Qualitative data collected before and after the program suggest
that, after the program, parents were able to spend more and improved quality time together with their
families, communicate more dialogically with their children, as well as their partners, and also felt a sense of
overall comfort in sharing their challenges with other parents.
In Chapter 9, we evaluate the effects of a Peer-Education Program (PEP) aimed at reducing suicidality,
depression and anxiety in students, and implemented in 8 different high schools in Pune. The objective was to
explore the effects of the PEP program on the development of students who were involved as Peer Educators
(PEs), based on the perspectives of parents, teachers and students. More specifically, this study explores how
PEs were motivated, empowered and otherwise impacted through the trainings they received during their
involvement. Results show that the SALT trainings, focused on aspects of empathy, self-healing, appreciative
listening and leadership, empower PEs to effectively respond to the needs of themselves and their peers, but
also in relation to other actors within their broader social environment.
Finally, in Chapter 10, I address the issue of upscaling, and the question of how lessons derived from the
aforementioned programs can be shared with a wider community. For this project, four parenting videos were
developed based on transformative stories for parents with children in the age groups of 0-6, 6-12 and 12-18
years old, and young adults aged between 18-24. For this study, we employed 8 different focus groups to
evaluate the impact of these videos on parents, regarding any evidence of vicarious learning and other
therapeutic benefits. Results from this explorative study indicate that videos, when sensitively developed, are
a great medium to evoke learning and therapeutic priming in parents regarding various parenting issues. At
the same time, as similarly shown by the parenting programs, videos can provide a sense of comfort and relief
to parents, as they can relate their parenting challenges with those of the fictional characters in the film, as
well as other parents in the group. Regarding this last point, it is recommended to use videos in combination
with, or complementary to, parenting workshops, therapy sessions, or parent discussion groups in order to
foster long-lasting change.
Main findings and conclusions
The focus of this thesis was on improving the well-being of students, through the development of several
distinct interventions, and to explore how these could improve several aspects of the social-ecological
environment that were found be related to academic stress in urban, middle-class India. In the discussion, I
refer to these interventions as ‘niche experiments’, a term borrowed from System Innovation and Strategic
Niche Management (SNM), to explain how, in the context of protected spaces (e.g. a school, university or
parenting workshop), local knowledge and resources can be used to create socially acceptable (robust)
solutions to the issue of academic stress, and eventually create ‘a ripple of change’ through the diffusion of
such learned lessons.
With regards to the facilitation of change processes, I discuss in depth the concept of empowerment, and
particularly, what I define as, ‘double empowerment-loops’ in socio-ecological contexts, to understand how
an effective power balance can be maintained in the context of intervention programs. Double empowerment
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loops occur when facilitators or trainers aim to empower participants who, in turn, obtain a role in
empowering others (e.g. empowering parents to evoke a sense of independence and autonomy in their
children). I suggest that programs which (implicitly) create double-empowerment loops arguably require tools
necessary to identify the current level of understanding and attitudes of participants, as well as facilitators, to
define the best starting position for the intervention and identify the successive steps necessary to reach
further beyond it.
I conclude by addressing the lessons that practitioners in the field of CBH could take from this thesis, firstly
asserting that continuous attention to the relational aspects involved in personal stress is required to
understand the deeper causes of stress in each new context. Secondly, finding and employing psychological
theories that are focused on ‘individual appraisal mechanisms’ (including fundamental fears and values) and
exercises based on experiential learning, creativity and play, are shown to be useful in empowering individuals
to better address stress in urban, middle-class societies; as appose to providing ready-made answers or pre-
determined coping strategies to deal with it. Particularly in India’s current phase of modernization, a lot of
stress, internal chaos, conflict and doubts can be evoked, requiring a certain amount of reflexivity within young
people in order to remain connected to the world around them. In many quickly changing contexts (including
other Asian countries for instance) similar issues might also be encountered, and for which the outcomes of
this thesis might too be useful.
Finally, with regards to the methods employed in health-promotion interventions, I recommend professionals
to make use of locally available resources and knowledge, as well as to find readily available entry points to
effectively engage and reach out to people, such as schools and universities. I also state the importance of
continuous learning within such spaces, by stimulating the adoption of the programs’ successful features into
their broader regimes (e.g. the curriculum, examination processes, and overall structure of educational
Institutes). As such, I conclude by endorsing further research that focuses on the practice of learning for
wellbeing, with concepts such as ‘holistic approach’, ‘interactive learning’, ‘self-evaluation’ and ‘school-family
partnerships’ being integral, effective and sustainable solutions to stress, and other related mental health
concern among students, not just in India, but many other contexts alike.

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Contents
ACCOUNT ............................................................................................................................................... 10
PROLOGUE ............................................................................................................................................. 11
CHAPTER 1: INTRODUCTION.................................................................................................................... 12
1.2 India’s globalizing economy; a brief history ....................................................................................... 14
1.3 The Indian Education system ............................................................................................................. 15
1.4 India’s family system ......................................................................................................................... 16
1.5 India’s mental health system ............................................................................................................. 16
2 THEORETICAL FRAMEWORK ................................................................................................................. 18
2.1 Bronfenbrenner’s Bio-Ecological Systems Theory ............................................................................... 18
2.2 Stress theories .................................................................................................................................. 20
2.3 Community-based health promotion ................................................................................................. 26
3 METHODOLOGY ................................................................................................................................... 31
3.1 Research questions ........................................................................................................................... 31
3.2 Research approach ............................................................................................................................ 32
Table 3.2: Overview of methods and participants in each study. .............................................................. 39
CHAPTER 4: STRESS IN INDIAN STUDENTS; CONNECTING THE DOTS FROM A LIFE COURSE PERSPECTIVE .. 42
4.1 Introduction ...................................................................................................................................... 44
4.2 Methods ........................................................................................................................................... 46
4.3 Results .............................................................................................................................................. 49
4.4 Discussion ......................................................................................................................................... 55
CHAPTER 5: UNDERSTANDING PARENTING IN RAPIDLY CHANGING CONTEXTS; A QUALITATIVE STUDY ON
PARENTING STRESS IN PUNE, INDIA. ....................................................................................................... 59
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5.1 Introduction ...................................................................................................................................... 61
5.2 Parenting stress ................................................................................................................................. 61
5.3 Methodology ..................................................................................................................................... 63
5.4 Results ............................................................................................................................................... 65
5.5 Discussion .......................................................................................................................................... 73
CHAPTER 6: ‘UNSCHOOLING’ IN THE CONTEXT OF GROWING MENTAL HEALTH CONCERNS AMONG INDIAN
STUDENTS: THE JOURNEY OF THREE MIDDLE-CLASS UNSCHOOLING FAMILIES. ......................................... 77
6.1 Introduction ...................................................................................................................................... 79
6.2 Methodology ..................................................................................................................................... 80
6.3 Results ............................................................................................................................................... 81
6.4 Discussion .......................................................................................................................................... 87
CHAPTER 7: REDUCING STRESS IN YOUTH: A PILOT-STUDY ON THE EFFECTS OF A UNIVERSITY-BASED
INTERVENTION PROGRAM FOR UNIVERSITY STUDENTS IN PUNE, INDIA. .................................................. 92
7.1 Introduction ...................................................................................................................................... 94
7.2 Methodology ..................................................................................................................................... 97
7.3 Results ............................................................................................................................................. 100
7.4 Discussion ........................................................................................................................................ 109
CHAPTER 8: LEARNING ABOUT PARENTING TOGETHER: A PROGRAMME TO SUPPORT PARENTS WITH
INTER-GENERATIONAL CONCERNS IN PUNE, INDIA ................................................................................ 112
8.1 Introduction .................................................................................................................................... 114
8.2 Method ........................................................................................................................................... 122
8.3 Results ............................................................................................................................................. 123
8.4 Discussion ........................................................................................................................................ 130
CHAPTER 9: ........................................................................................................................................... 134
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WHAT IS IN IT FOR THEM? UNDERSTANDING THE IMPORTANCE OF A MINDFULNESS-BASED SUICIDE
PREVENTION PEER EDUCATION PROGRAM FOR PEER EDUCATORS ......................................................... 134
9.1. Introduction .................................................................................................................................... 136
9.2. Peer-Education: theoretical background and current intervention ................................................... 138
9.3. Methodology .................................................................................................................................. 140
9.4 Results ............................................................................................................................................. 142
9.5 Discussion ........................................................................................................................................ 146
CHAPTER 10: ‘HOW CAN THEY STAY SO CALM?’: USING TRANSFORMATIVE LEARNING VIDEOS TO
STIMULATE LEARNING AND THERAPEUTIC EFFECTS IN PARENTS LIVING IN URBAN INDIA ....................... 150
10.2 Method .......................................................................................................................................... 157
10.3 Results ........................................................................................................................................... 162
10.4 Discussion ...................................................................................................................................... 168
11. DISCUSSION AND CONCLUSION ........................................................................................................ 171
11.1 How is stress experienced in middle-class Indian students? ............................................................ 171
11.2 How can stress be addressed? ........................................................................................................ 177
1.3 Internal and external validity............................................................................................................ 187
11.4. Implications for research and practice ........................................................................................... 190
REFERENCES .......................................................................................................................................... 192

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Account
Chapters 4 to 10 are based on co-authored articles that are published, or under review for publication, in
peer-reviewed journals. I have maintained the ‘we’ form in co-authored articles.
Chapter 4
E.E. de Wit, W. Verstraete, J.G.F. Bunders-Aelen and B.J. Regeer (under review). ‘Stress in Indian students;
connecting the dots from a life-course perspective. International Journal of Qualitative Studies in Health and
Wellbeing.
Chapter 5
E.E. de Wit, B. Zachariah, J.G.F. Bunders-Aelen and B.J. Regeer (under review). ‘Understanding parenting in
rapidly changing contexts; a qualitative study on parenting stress in Pune, India. Journal of Child and Family
Studies.
Chapter 6
E.E. de Wit, D. Eagles, J.G.F. Bunders-Aelen and B.J. Regeer (accepted for publication). ‘Unschooling in the
context of growing mental health concerns among Indian youth; the journey of 3 middle-class unschooling
families. The Journal of Unschooling and Alternative Learning.
Chapter 7
E.E. de Wit, Adithy, J.G.F. Bunders-Aelen and B.J. Regeer (2016). ‘Reducing stress in youth: a pilot study on
the effects of a university-based intervention program for university students in Pune, India. Journal of
Educational and Developmental Psychology, 6(2). https://doi.org/10.5539/jedp.v6n2p53
Chapter 8
E.E. de Wit, Adithy, C. Chakranarayan, J.G.F. Bunders-Aelen and B.J. Regeer. ‘Learning about parenting
together: a programme to support parents with inter-generational concerns in Pune, India. Journal of
Contemporary Family Therapy. https://doi.org/10.1007/s10591-017-9429-7
Chapter 9
E.E. de Wit, B. Zachariah, J.G.F. J.D. Bahirat, Bunders-Aelen and B.J. Regeer (under review). What is in it for
them? Understanding the importance of a Mindfulness-based Suicide Prevention Peer Education Program
for Peer Educators. Journal of School Mental Health
Chapter 10
E.E. de Wit, B. Shukla, Adithy, D. Eagles, J.G.F. Bunders-Aelen and B.J. Regeer (under review). How can they
stay so calm?’: using transformative learning videos to stimulate learning and therapeutic effects in
parentings living in urban India. American Journal of Counseling Psychology.
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