1. Introduction

Enuresis is associated with emotional distress in children which is reversible once children become dry. Achieving continence is therefore the main goal of treatment and will lead to an improvement of self-worth and self-confidence (Caldwell, 2013). On the other hand, (20%) to (40%) of all children with enuresis have additional, comorbid psychological disorders, not only externalising conditions such as attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) but also internalising disorders such as depression (Sureshkumar and Caldwell, 2009). These comorbid conditions require separate assessment and treatment in addition to the symptom-oriented treatment of the child’s elimination disorder. Evans, Radunoah and Heidi (2016) explain that most children who had nocturnal enuresis in Florida developed behavioural problems such as guilt, fear, poor self- concept and aggressiveness. In addition, such children had social problems that made them stay away from friends and avoided sleep over outings. Therefore, in Florida, the treatment for nocturnal enuresis included: limit of fluid taking, motivational therapy, emotional support to remove shame and embarrassment, behavioural conditioning such as use of moisture alarm and medication. Most types of enuresis can be treated effectively with counselling and cognitive-behavioural approaches but some may require additional medication. These therapies can in most cases be provided in primary care outpatient settings provided that they are based on a correct diagnosis and that child and parents are given adequate professional care with sufficient time (Inan, 2008).

The prognosis for bed-wetting is usually spontaneous resolution; however, (1%) of these cases are resistant to all treatment modalities in school age children in Rafsanjani in Iran (Tarkashvand; Rezaeian; Bagheani; Dawarani; Zarafshan; Mostafavi and Bidaki, 2014). Nocturnal enuresis is an important developmental problem for school age children and can cause emotional and social problems for children and their families. According to Theunis and Hoecke (2012), the self-esteem of children with nocturnal enuresis was lower compared to children without nocturnal enuresis. According to Kiddoo (2012), the commonness treatment to nocturnal enuresis in children in Canada included: limiting of fluid drinking in large amount, use of motivational therapy by removing shame or embarrassment, behavioural conditioning such as use of moisture alarm and medication. According to the World Health Organization (WHO) (2007), many children with a bed-wetting problem suffer from low self-esteem, shame, and guilt and have feelings of failure and see themselves as different from other people in Jamaica. Diagnostic and statistical manual of mental disorders (DSM) -5 states that Primary nocturnal enuresis (PNE) consists of never having established urinary continence at night, while secondary nocturnal enuresis (SNE) refers to the development of enuresis after a period of established urinary continence. Nocturnal enuresis, also called bed-wetting, happens during the night while the child is sleeping (American Psychiatric Association, 2013).

In Nigeria, Nwokocha; Onukwuli; Ujunwa; Okafor and Onyemelukwe (2014) report enuresis as a developmental urologic disorder affecting children and is always under reported. The study further adds that there is affectation of normal development and social stigmatization of the enuretics apart from it being a real social nuisance and the problem of nocturnal enuresis among the African children is often neglected and traditional treatment methods are often used. Therefore, other implications in the nocturnal children may include: emotional, social and mental maladjustments (Mbibu, Ameh, Shehu and Wamanda, 2005). Ashok andSarzoo (2015) reiterate that nocturnal enuresis was more common among the children in schools in Ethiopia and that the children who were bedwetting felt guilty, withdrawn the next morning after bedwetting at night, have a feeling of no control over the problem. They further reveal that in schools, bedwetting lowers social skills and performance. The children who experienced bedwetting feared being teased by their peers in class and stayed away from friends.

In Kenya, Nocturnal enuresis is a challenge and that all children start life being incontinent of urine both by day and by night, and as neurological maturation occurs, voluntary urinary control is gained, sequentially graduate from voiding by spinal cord reflex, to voluntary cortical bladder control (Nzamu, 2015). Primary nocturnal enuresis occurs when there is involuntary passage of urine during sleep by children aged 5 years or older, who have never achieved consistent night time dryness. Secondary nocturnal enuresis occurs when a child who has previously been dry for 6 months or more begins wetting the bed again. The symptom of wetting might become a chronic stress, and if persistent might have a negative effect on the child’s personality and on the child’s self-concept. In Makueni County, Nyakundi (2014) affirms that the prevalence of nocturnal enuresis among school children was (14.5%) between June and August, 2011. The study also reported that age, family set up, family history of bedwetting, deep sleep and experience of stressful events are factors associated with Nocturnal enuresis. Mwendia (2016) reiterates that psychological, hormonal and genetics are some of the causes of nocturnal enuresis and that the disorder is often an embarrassment to the bed wetter particularly if they do not speak about it. There is a probability of (40%) by a daughter or son wetting the bed if their parent was wetting the bed, stress is also associated with nocturnal enuresis and anti-diuretic hormone (ADH) causes the body to produce less urine at night so the people whose bodies do not produce that hormone have much urine at night when asleep (Mwendia, 2016).

The present study was informed by Erik Erikson’s psychosocial theory of 1907. Psychosocial theory identified a series of eight interrelated stages in which a healthy developing individual should pass through from infancy to late adulthood. Each stage builds upon the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future (Alan, 2016). This stage was relevant to this study in that it gives an account of an adolescent in terms of identity and role confusion. Moreover, the present study focused on students in secondary schools who mostly fall within the adolescent of between ages 12 to 19 years as explained by Eric Erikson. Nocturnal enuresis lowers their self-confidence and inability to please self and others, hence, a hindrance to identification with peers. According to Erick Erickson, the adolescent experiencing a crisis should not be criticized but should be empowered to go over the problem. This age group does not relate with what lowers their self-esteem such as nocturnal enuresis.

Literature on lived experiences by persons with nocturnal enuresis exists. Wilson (2012) explored on the lived experiences of bedwetting in West Australian male youths. They realized that their bedwetting might be present for the rest of their lives. Sureshkumar, Jones and Caldwell (2009) evaluated risk factors for nocturnal enuresis among school children in Sydney, Australia. The study concluded that psychosocial factors contributed to moderate but not severe nocturnal enuresis. Shah, Zehra, Mobin, Mirza (2018) determined the frequency of nocturnal enuresis in Pakistani children aged 5 to 16 years.The results revealed that some of the older children were given responsibilities at home and school. Zhu, Arsovska and Kozovska (2017) examined the social prevalence of nocturnal enuresis among the adolescence in China. The study concluded that most of the children were actively involved in social activities such as sports and were given responsibilities. Melina, Juliana, Fernando, Ronaldo and Eloisio (2009) study described the frequency of domestic against Brazilian children and adolescents due to episode of enuresis as well as associated risk factors. All cases were characterised by verbal punishment associated or not with other types of aggression. Finnikin (2017) study investigated the prevalence of bedwetting among school going children in USA. The study concluded that the children participated in school activities and were also given responsibilities. Guangming, Wenjuan and Jinjin (2016) investigated on the prevalence of nocturnal enuresis among the children. The results revealed that the children who were bedwetting stayed away from their parents.

Mahmoodzadeh, Amestejani, Mohammad, Karamyar and Nikibakhsh (2013) study examined the Prevalence of Nocturnal Enuresis in School Aged Children in Iran. The study reported that the children who wetted their beds had social problems with teachers and their families. Alkot and Mohsen (2012) investigated Nocturnal Enuresis among School Children in Menofia Governorate, Egypt; a Hidden Problem. The study revealed that there was a poor academic achievement among children with nocturnal enuresis in schools. Anochie and Ikpeme (2011) determined the prevalence, causes and effect of Nocturnal enuresis among secondary school students in Port Harcourt, Nigeria. The study found out that students felt embarrassed about bedwetting, the parents were very angry and had to beat them.Etemad, El-Shereef, Medhat, Saleh, Ghada, El-deen, Al-Attar, (2011) determined the prevalence, risk factors and impact associated with nocturnal enuresis among children in some rural areas of Assiut Governorate, Cairo. The study reported that parents felt that their children were embarrassed, shy and hesitant to spend the night away from home. Etuk, Ikpeme, Essiet (2016) determined the frequency of enuresis among primary school children in Calabar, Nigeria. The study concluded that there was good relationship between the children and their parents. Elbahnasawy and Elnagar (2015) assessed the psychological impact of nocturnal enuresis on self-esteem of school children in Egypt. The findings revealed that there were no significant difference between psychological problems of the studied children and their positive self-esteem. In Kenya, Nocturnal enuresis is a challenge and that all children start life being incontinent of urine both by day and by night, and as neurological maturation occurs, voluntary urinary control is gained, sequentially graduate from voiding by spinal cord reflex, to voluntary cortical bladder control (Nzamu, 2015).

The research question of the study was stated as follows: Which are the social experiences of students who have nocturnal enuresis with teachers in boarding secondary schools in Kenya?

2. Research Methodology

Baskarada (2014) described research design as a structure of research that holds all the elements in a research project, provides conditions for collection and analysis of data in a manner that aims to combine relevance with the purpose. Paradigm is a world view with a whole framework of beliefs, values and methods within which the research takes place (Creswell, 2014). Phenomenology research design was identified to be the most suitable method for this study because the researcher is interested in understanding participants’ lived experiences of having nocturnal enuresis that have not been previously captured in the literature (Edmond and Kennedy, 2012).

Qualitative research approach was utilised and particularly the phenomenological research design was used. The researcher employed saturated sampling to select all the 6 boarding secondary schools because they are few. The schools were stratified into two strata as follows: Boys’ schools (3) and Girls’ schools (3). Gay (2011) argues that a minimum population sample should be (10%) for large population and (20%) for small population. Therefore, the present study obtained a sample size of 20 students using simple random sampling. Purposive sampling was used to sample 6 Principals and 6 Boarding Teachers. Morse (1994) recommends a sample size of between 30 to 60 interviews while Guests (2006) suggests the minimum sample size as 15 but does not explore on the maximum. According to Creswell (2014), a minimum of 50 interviews is suitable for a study. Interview schedules were used to collect data. Mason (2010) emphasized that a few interviews would yield a much more expansive data using less energy. For these reasons, the sample size for the study was 32. Qualitative data was analysed using Giorgi’s four characteristics of phenomenological analysis to this research.

3. Results & Discussions

The study explored the social experiences of students who have nocturnal enuresis with peers in boarding secondary schools in Kenya. From qualitative data, the main themes that emerged through thematic narratives participants were: reciprocal cordial relationship, inclusive responsibility appointment.

Reciprocal Cordial Relationship

According to Cambridge Advanced Learner’s Dictionary (2010), reciprocal action or arrangement involves two people or groups of people who behave in the same way or agree to help each other and give each other advantages. An interview with students revealed that teachers are motherly, loving, friendly, caring and treat the students with nocturnal enuresis with a lot of humane. Therefore, the students with nocturnal enuresis are close with teachers and easily approach them whenever they are faced with challenges. Some respondents reported that:

‘In most cases, teachers are friendly, caring and good. I like our teachers and they have made us to be closer to them. Therefore, we are closer to them too. Moreover, they give us good pieces of advice. At times, I approach the boarding mistress when I feel embarrassed over my situation and her approach is motherly and caring. She encourages me a lot like my mother would do’ (Student, 1).

‘I relate with teachers freely, they are my friends. I am very close to my class teacher who has been very cooperative. I confide in her my problems and she helps me. I am in form two and I can say that all the teachers in that class except one are lovely’ (Student, 9).

This means that there is good understanding between the teachers and some of the students with nocturnal enuresis. The two parties seem to be committed to each other. Therefore, the students feel accommodated and that their problems are felt by teachers. This finding agrees with Haid (2017) reported that the children who were bedwetting had close relationship with adults. In contrast, Adekanmbi, Ogunlesi, Feluga, Oluwole, Alabi and Kehinde (2011) reiterated that the children with nocturnal enuresis had low social relationship with other people.

An interview with Boarding Teachers reveal how the teachers value the students with nocturnal enuresis and do the work of parenting. A representative statement is hereby quoted:

The teachers treat these girls who wet the bed well with a lot of humane. They are caring and ready to help them. They assist me to be close and friendly to the girls. The girls are free with me and most of them come and share their problems with me’ (B/T, 1).

The students with nocturnal enuresis feel comfort and safe with teachers who seem to have clearly understood the nature of their problems. This finding agrees with Haid (2017) reported that the children who were bedwetting had close relationship with adults. In contrast, Adekanmbi, Ogunlesi, Feluga, Oluwole, Alabi and Kehinde (2011) reiterated that the children with nocturnal enuresis had low social relationship with other people.

An interview with Principals shows how teachers relate with the students who have nocturnal enuresis. The students love their teachers for that compassion and care. An interview excerpt transcript cites:

‘Most of my teachers are social and friendly to all students irrespective of whether or not they are bedwetting. The teachers provide parental care to the students who are bedwetting. The students who are bedwetting love their teachers too’ (Principal, 2).

This means that there is a conducive environment created by teachers towards students with nocturnal enuresis. Because of this rapport, the students are free with their teachers and reach out to teachers for help. There seems to be close understanding between teachers and students. The teachers have realised that by becoming closer to the students, they would fully understand them. This finding agrees with Haid (2017) reported that the children who were bedwetting had close relationship with adults. In contrast, Adekanmbi, Ogunlesi, Feluga, Oluwole, Alabi and Kehinde (2011) reiterated that the children with nocturnal enuresis had low social relationship with other people. From the interview excerpts, it can be concluded that students with nocturnal enuresis experience reciprocal cordial relationship with teachers. The teachers have understood the students with nocturnal enuresis and are closer to them perhaps for proper healing to take place. In other words, this is a step towards healing. Similarly, Haid (2017) reported that the children who were bedwetting had close relationship with adults. In contrast, Adekanmbi, Ogunlesi, Feluga, Oluwole, Alabi and Kehinde (2011) reiterated that the children with nocturnal enuresis had low social relationship with other people. The close relationship between the teachers and the students is a positive step towards management of nocturnal enuresis.

From FGD, the study revealed that the teachers treated the students with nocturnal enuresis with care, love and understanding. The teachers relate socially well with the students and provide empathy whenever the students are faced with enuresis. Some respondents reported that:

‘Our boarding mistress is loving and treating all of us equally. I am always free with teachers and most of them are aware that I wet the bed. What I can say is that they are understanding and caring. I too love the teachers’ (Student, 6, FGD 4).

‘In most cases, the teachers are friendly, caring and social. When we are in class, the subject teachers do not segregate us. They try to treat us well without any favour. According to me, I love the teachers and they love me too’ (Student 3, FGD 2).

This means that the teachers show empathetic feelings towards students with nocturnal enuresis hence the students feel a sense of belonging. Moreover, the students have developed positivity towards life with the phenomenon. It can be concluded that some of the students who have nocturnal enuresis have cordial reciprocal relationships with their teachers. This relationship has improved on the students’ self image and the way they look at self and others. Similarly, Keuhas, Djakovic and Henfellner (2011) reported that making close friends and family interactions were least affected by enuresis. This study finding contradicts Anyanwu (2015) who reported that the children who had nocturnal enuresis had social problems relating with their parents and other members of the family. The students with nocturnal enuresis encounter challenges which need interventions, therefore, this cordial relationship shows a positive move towards the healing. More intervention approaches towards students with nocturnal enuresis should be put in place.

Inclusive Responsibility Appointment

This refers to when someone has been officially chosen for a job or position of leadership (Cambridge Advanced Learner’s Dictionary, 2010). In an interview with students, the study reported that teachers are not biased when making appointments; the appointments are free and fair to all students. The appointments are made based on ability of the students to such positions. For instance, some students who have nocturnal enuresis have been appointed as prefects, and hockey captains. A representative statement cites:

‘I am the scouts’ leader despite wetting the bed. I was appointed to be the troupe leader by the teachers. I want to say that teachers are fair when appointing students to various responsibilities. They look at competence and discipline’ (Student, 19).

This means that the students feel a sense of belonging and empowered by being considered for appointments. This is a step towards promoting leadership skills and care even for the students own situations. This finding agrees with In agreement, Kaerts (2016) reported that some of the children who were bed wetting were given responsibilities in schools. Similarly, Dodds (2016) found out that the children with nocturnal enuresis socially mixed with their peers.

An interview with Boarding Teachers reveal how the teachers appoint students with nocturnal enuresis to leadership positions without being biased. An interview excerpt transcript is hereby presented:

‘The teachers give responsibilities to students without being biased or discriminative. For example, some of them have been appointed to key areas such as dining hall prefect by the staff. There are also some students who wet the bed and they were given leadership responsibilities in classes, games and sports among others by the staff’ (B/T, 3).

This means that the students with nocturnal enuresis feel wanted, loved and a sense of belonging when the students are appointed or vetted to leadership positions. In agreement, Kaerts (2016) reported that some of the children who were bed wetting were given responsibilities in schools. Similarly, Dodds (2016) found out that the children with nocturnal enuresis socially mixed with their peers.

An interview with Principals highlights how some of the students with nocturnal enuresis have qualities of leadership and are equally appointed to leadership positions. An excerpt interview transcript is hereby cited:

Most of these students who wet the beds are very bright. We normally look at academic performance among other qualities when making appointments. Some of these students who wet the beds have been appointed to various positions’ (Principal, 1).

This means that students who have nocturnal enuresis are also appointed to leadership positions. This helps in preventing stigmatization and isolation as all the students feel a sense of belonging. The students are trained and nurtured on leadership skills without segregation. In agreement, Kaerts (2016) reported that some of the children who were bed wetting were given responsibilities in schools. Similarly, Dodds (2016) found out that the children with nocturnal enuresis socially mixed with their peers. From interview excerpts, it can be concluded that students with nocturnal enuresis are part of the inclusive responsibility appointments in the schools. The students with nocturnal enuresis are appointed and given responsibilities just like other students. This enhances co- existence, unity and equality among all the students. In agreement, Kaerts (2016) reported that some of the children who were bed wetting were given responsibilities in schools. Similarly, Dodds (2016) found out that the children with nocturnal enuresis socially mixed with their peers. With the inclusive responsibility appointments, the students with nocturnal enuresis feel recognized and restore their self esteem.

From Focus group discussions, the study found out that some students with nocturnal enuresis are appointed in leadership positions. Some respondents reported that:

‘In an election presided over by teachers, I was elected Games captain. I am in form three and I still wet the bed. I agree that when it comes to responsibilities, there is no segregation. In fact, all teachers cooperate and ensure that those positions are given to deserving students’ (Student 2, FGD 4).

This means that some of the students with nocturnal enuresis are socially accommodated when they are given responsibilities. The students are not segregated by the teachers when they are included in terms of any tournament, friendly matches and leadership positions. The finding agrees with Kaerts (2016) who reported that some of the children who were bed wetting were given responsibilities in schools. Similarly, Dodds (2016) found out that the children with nocturnal enuresis socially mixed with their peers. The inclusive responsibility appointment has boasted morale, self esteem and gained a sense of belonging among the students with nocturnal enuresis. The students feel that they are part of the system despite having nocturnal enuresis. Moreover, it becomes easier to use these student leaders with enuresis to help other students with nocturnal enuresis.

4. Conclusions & Recommendations

This study concluded that the students with nocturnal enuresis enjoyed good social relationship with teachers such as reciprocal cordial relations and increased responsibility appointments. The students benefitted from an all inclusive responsibility appointments. Its recommended that the teacher counsellors should help students with nocturnal enuresis cope with psychosocial effects as a result of nocturnal enuresis. This is because the study reported that the students with nocturnal enuresis lacked the capacity to cope with stress, anger, low self esteem and anxiety.