1. Introduction

Nocturnal enuresis is a common health problem all over the world, although it seems to be ordinary, is crucial to be diagnosed and treated as soon as possible as it can result in some psychological consequences such as low self-esteem (Unalacaki, 2004). Parents like waiting for self-recovery or using traditional methods. Nocturnal enuresis is a common disorder which is genetically complex and heterogeneous problem among children in Urma, Iran (Mahmoodzadeh; Amestejani; Karamyar; Nikibakhsh, 2013). According to Theunis and Hoeck (2012) an average of six million children wet the bed annually in the United States. Stephen (2012) posits that bedwetting that persists into adulthood has greater consequences in Sweden in terms of psychological, social and financial implications. Nocturnal enuresis can be defined as any intermittent incontinence while asleep in a child being at least five years old (Ghahramani; Basirymoghadam and Ghahramani, 2008).

Sinha and Raut (2016) explain that nocturnal enuresis often causes considerable distress or dysfunctional impairment to patients and their parents, necessitating a multidisciplinary approach from paediatricians, psychiatrists and urologists in India. Neveus (2011) argues that bedwetting that persists into adulthood have greater consequences that include: distressing disorder that carries significant burden, psychosocial, social and financial implications. Therefore, the successful treatment of bedwetting remains on the burden placed upon the child and the family. In Scandinavia, nocturnal enuresis is a prevalent and potentially distressing experience for children and their parents in Scandinavia (Butler and Heron, 2008). Taylor and Francis (2009) emphasize that the psychological impact of nocturnal enuresis has been consistently hampered by inter-changeability of terminology, varied inclusion criteria, diverse methodologies and equivocal findings. Stephen (2012) explains that there are intermittent episodes of wetting the bed while asleep in the children above five years in Sweden. Furthermore, this distressing disorder carries significant burden such as psychological, social and financial implications. Bollomley (2011) states that in Hongkong, a number of children who wet their beds are worried that their bedroom smells of urine hence are always reluctant to invite their friends.

In Egypt, enuresis is a medical term for bed wetting during sleep and is derived from a Greek word enouren meaning to make water or to void urine enuresis. Nocturnal enuresis is wetting episodes that occur in discrete amounts during sleep. Diurnal enuresis is unintended voiding of urine that occurs during the day or wake portion of twenty-four hours^. Enuresis is common in childhood than daytime incontinence with about (80%) of children with enuresis wetting only at night. Enuresis that persists beyond the age of eight to 10 years may be associated with a poor self-concept or other psychological problems (Hanan and Mona, 2015).

Enuresis is considered as common among children throughout the world and that it remains both underestimated and under reported in South Africa (Dyk, Duvenhage, Coetzee, Segone, Fockema, Smart and Haffeiee, 2008). Fockema (2012) adds that nocturnal enuresis is very distressing to children in South Africa, however, creating an impact and it is trivialised by parents and doctors and that lack of understanding may also cause parents to be frustrated and this is likely to contribute to the child’s sense of failure and shame, reinforcing the social stigma surrounding bedwetting. The prevalence rate of students who had nocturnal enuresis in secondary schools in South Africa was (16%). An independent, unbiased national evaluation and treatment guideline based on patho -physiological subcategory was proposed in South Africa using an updated, evidence based approach (Ahmed, Claassen, Coovadia and Maayer, 2018). Nocturnal enuresis is a distressing condition manifesting as emotional problems including withdrawal and over-activity. The psychosocial problems may develop due to peer pressure therefore social activities involving sleep overs may be avoided. Notably, caregivers are overly concerned resulting in several harmful traditional practices. Ahmed (2017) identifies night waking and sleep disordered breathing as commoner in children with nocturnal enuresis in South Sudan and that physiological abnormalities were observed in areas which were involved in arousal. The enuretic children had psychological and social complications. In Uganda, psychological stress, severe effects on the child’s self-esteem as they grow up and in some children, bedwetting may continue to haunt them in their teenage years (Odyek, 2009). The parents and the children with nocturnal enuresis find it quite embarrassing to talk about nocturnal enuresis. Moreover, some children have been subjected to severe punishments, ranging from standing in cold water or having long bath as remedies.

Ecological systems theory was developed by Bronfenbrenner in the 1979 who believed that a person’s development was affected by everything in their surrounding environment (Eysenck, 2004). The system gives an account on the way psychologists and others approach the study of human beings and the environment. He divided the person’s environment into five different levels: microsystem, mesosystem, exosystem, macrosystem and chronosystem (Bruno, Stachowicz and Bertness, 2003). According to Bronfenbrenner, microsystem is the system closest to the person in which they have direct contact and it is the smallest and most immediate environment in which children live. For instance home, school, day care and work are the systems closest to a person (Prosser, Bohannan, Curtis and Ellis, 2007).

A microsystem includes family, peers, teachers and caregivers and the relationship in a microsystem is bi-directional (MacLeod, 1998). In other words, your reactions to people in your microsystem affect how they treat you in return. Interactions within the microsystem typically involve personal relationships with family members, classmates, teachers and caregivers. How these groups or individuals interact with the children affect how they grow. Consequently, how children react to people in their microsystem also influence how they treat the children in return (Ainsworth, 1978). Therefore, a more nurturing and supportive interactions and relationships will foster the children‘s improved development (Alport, 1935).

Torkashvand, Rezaeian, Bagheani, Dawarani, Zarafsha, Mostafavi and Bidaki (2014) study in Iran found out that nocturnal enuresis was the cause of emotional problems between enuretic children and other school age children. Sherah, Elsharief, Barkat and Jafery (2019) examined the prevalence of nocturnal enuresis in school age children in Saudi Arabia. Students with nocturnal enuresis registered low school performance, emotional stresses and family conflicts were rampant among the students and their families. Alexander, Jong, Badawi, Kathleen, Mitchel, Leppink, Cardozo (2017) revealed that the children experienced stressful life events, school related stressors, trauma while the adults were worried.Butler (2009) reviewed the impact of Nocturnal Enuresis on Children and Young People in Scandinavia. Generally, the findings suggested that children experience bedwetting as distressing but those with mono-symptomatic nocturnal enuresis are no different from the normal population or from matched controls across all aspects of functioning. Mohsen, Parsa, Masoud, and Saharet (2018) study investigated the correlation between parents’ emotional intelligence and enuresis in children for a more effective management of this problem. All indicators of emotional intelligence were significantly different between the case and control groups.

Wafik, Yasser, Ehab, Ibrahim, Mohammad and Amira (2018) conducted a study on Primary mono symptomatic nocturnal enuresis in Egypt. The child behaviour checklist showed higher anxious depressed symptoms, social problem, attention problems, and internalizing problems in enuretic children than control subjects. Birdal, and Dogangun, (2016) study investigated the frequency of behavioural problems in children with enuresis. The results of this study indicate that children with enuresis exhibit behavioral problems with a higher rate compared to their healthy peers.Akyüz, Orhan, Bilal, Zeynep, Metin, Musab, and Muhammet (2016) studied the behavioral and emotional patterns of patients with nocturnal enuresis (NE) and compared them with those of healthy subjects. There were no significant differences in anxiety or attractiveness problems between the groups; however, patients with enuresis were more likely to exhibit these behavioral problems than healthy subjects. Kanata, Koike, Ando, Nishida, Usami and Yamasaki (2016) examined whether enuresis correlates with hyperactivity-inattention after controlling for the effects of other behavioral problems. The hyperactivity-inattention score was significantly higher in the enuretic group than the non-enuretic group. Bayne (2015) explored on the impact of bedwetting, an approach to assessment and medical treatment of children in India. The findings revealed that the children who were bedwetting suffered from low self-esteem, stress and anxiety.

The research question of the study was stated as: What are the psychological experiences of students who have nocturnal enuresis with their peers in boarding secondary schools in Kenya?

2. Research Methodology

Qualitative paradigm is an enquiry into a social or human problem based on testing a theory based on variables measured in numbers and analyzed with statistical procedures in order to determine whether the predictive generalizations of the theory is true (Frankline, 2014). The qualitative approach was necessary for this study because it provided an opportunity to study individuals in their natural settings. This study was based in mixed secondary boarding schools where the students who have nocturnal enuresis are. Moreover, it allowed for extensive data collection and a detailed data analysis (Halkier, 2011). This study employed phenomenological research design. A phenomenological study describes the meaning of several individuals of their lived experience and that experience is a conscious process (Leverman, 2015). Polit and Beck (2010) state that qualitative research places emphasis upon individual aspects of human experiences, captures that context and the development of the essences of these experiences is captured. Qualitative research provides descriptions of the phenomena under study that are rich and expansive and illuminate what it means to be a person in a particular situation or experience (Schneider, Whitehead, Elliott, Lobiondo, Wood & Harper, 2007). Qualitative methods are especially useful for exploring the full nature of a poorly understood or conceptualized phenomenon (Finlay, 2010).

Purposive sampling was adopted to sample 6 Principals and 6 teachers. Mose (2015) states that the participants are selected because they have particular knowledge pertinent to the questions to be explored. According to Creswell (2014), purposive sampling is relevant in phenomenological studies because all individuals under study represent those who have experienced the phenomena. Mason (2010) explains that Purposive sampling allows for a smaller sample to be used in qualitative method than that used in quantitative research methods because it is concerned with garnering an in depth understanding of a phenomenon. The Principals and boarding teachers were ever in touch with the students who had nocturnal enuresis in boarding schools; therefore, they provided relevant information needed. Denzin & Lincoln, (2011) also noted that, qualitative data analysis involves such processes as data reduction, display, conclusion drawing and verification. Denzin & Lincoln, (2011) added that qualitative data analysis involves developing a detailed description of each case and situating the case within its context.

3. Results & Discussions

The study explored the psychological experiences of students who have nocturnal enuresis with peers in boarding secondary schools in Kenya. The themes on psychological experiences with Peers included: Low self-esteem, increased aggressive behaviour, paranoid behaviour, increased stress levels, increased anxiety and feelings of anger:

Low Self Esteem

Low self-esteem is lack of confidence and feeling badly about oneself and as observers of our own behaviours, thoughts and feelings, we not only register these phenomena but also pass judgement on them (Harter, 1993). It is made by an individual as an attitude towards self and that it is a harsh inner critic (Abraham, 1998). Results from interview with students revealed that some students who had nocturnal enuresis felt: useless, ashamed and worthless before other students who were not wetting the beds. The students have developed a feeling of worthlessness, awkwardness, guilt, reproach, make personal self-accusations and some feel like giving up in life. A representative statement is hereby quoted:

‘I felt different from other students because it seemed as if I was the first one to wet the bed among form ones in that dormitory. I found myself in an awkward position. Inwardly, I blamed myself and felt worthless before my fellow students. Actually, I felt bad’ (Student, 1).

The students’ response reveals that wetting the bed lowers the status of the students with nocturnal enuresis and make them feel indifferent from others who probably were not wetting the beds. The students have developed negative thoughts about self and lack self-motivation to perform even a simple task. When the students have done those tasks; they still felt that they have done the worst. The students lack courage to overcome nocturnal enuresis challenges. The students are stuck and are inwardly making self accusations. Therefore, some of the students with nocturnal enuresis experienced low self esteem with peers. This finding agrees with Latrous et al 2016 when they found out that enuresis was associated with low self esteem of the children. Similarly Goessaert (2015) reported that there was negative impact on self esteem of in children and adults. In disagreement, Furkan et al (2014) found out that there was no decline in the self-esteem of the control group who had nocturnal enuresis.

Increased Aggressive Behaviour

This refers to the physical or emotional harm to others. It may range from verbal abuse to physical abuse (Singer, 2001). A person in aggressive behaviour feels irritable, restless, impulsive and finds it hard to control their behaviours, for instance they may use aggressive behaviour to control, get revenge or provoke someone or act towards self (Zilmann, 1997). The results from interview with students reported that some students who have nocturnal enuresis showed extreme anger towards other students whom they felt had wronged them and when they were annoyed, they easily lost the power to reason out. Some of the students engaged in emotional or physical fight as reported in an excerpt interview transcript:

‘I was passing where a group of boys gathered and were talking. When they saw me, a form two student who was talking stopped abruptly. However, I had already heard him backbite me that they were fed up with me in the dormitory because I was bedwetting regularly. I became bitter but walked away. I physically confronted him when he was alone and we fought’ (Student, 11).

This means that some of the students with nocturnal enuresis have behavioural difficulties with other students and as a result, act violently towards them. The students with enuresis feel the pinch and pain caused by psychological assault by other students. Therefore, the students with enuresis remedy the situation by using acts of violence or becoming aggressive. This finding agrees with Alavinezhad et al. (2017) when they reported that enuresis made the children develop frequent aggressive behaviours towards other children. Similarly Nzamu (2015) reported cases of physical abuse by no enuretic children towards children with nocturnal enuresis. The findings disagree with Yousefichaijan et al. (2015) who revealed that most children with mono symptomatic primary nocturnal enuresis had no aggressive behaviour towards others.

From Focus Group Discussions, the study found out that some students with nocturnal enuresis were emotionally upset when fellow students talked ill or made a joke about their situations. The students resorted to physical fight or emotional outburst to release their anger. Their views are summarized in the following representative statements:

‘I can remember very well when I was new in form one, I was heckled by a form three student and he said that a snake should be tied round my neck to make me stop bedwetting. I became very emotional but I could not fight him because I was new in the school’ (Student 2, FGD 4).

Although the students became emotional towards their peers, they feared of the consequences of fighting in the school. The students were aware of what would happen if they broke school rules. This means thatsome of the students with nocturnal enuresis cannot control their tempers and easily react even on mere allegations by other students. The other students have realized that some of the students with nocturnal enuresis are emotional and continue to tease them. From the interviews, it can be concluded that some students with nocturnal enuresis have behavioural difficulties with other students. Some of the students bully those students who have nocturnal enuresis. The students who have nocturnal enuresis are also angered by the sarcastic, ill talks and bullying by other students. In agreement, Brownrigg (2017) concluded that the children who had nocturnal enuresis were emotionally upset towards other children. Similarly, Bakhtiar et al. (2013) revealed that the school children who had nocturnal enuresis were shy and emotional towards peers who teased them. Both the students with and without nocturnal enuresis have not been capacitated well so as to fully understand each other and live in coexistence. With strong guidance and counselling, the peers should be able to help their colleagues with enuresis.

Paranoid Behaviour

According to Cambridge university dictionary (2019) paranoid behaviour is when a person feels extremely nervous and worried because they believe that other people do not like them or are trying to harm them. It is the high levels of suspicion and mistrust, usually seen in the person’s belief or delusion that he or she is the target of other people’s belief or delusion that he or she is the target of other people’s hate, jealousy and resentment. In addition, some people develop paranoid behaviour because they do not feel that they can trust others. The results from interview with students revealed thatsome students with nocturnal enuresis are ever suspicious of students around them and have a feeling that other students are not comfortable with them because they have nocturnal enuresis. The students feel that they are the subject of discussion most of the time they are out for break, lunch and supper. An excerpt interview was presented:

‘It has made me feel that students talk ill about me in the school. Most of the time, I feel that students particularly from our dormitory discuss me with their friends during break, games, lunch and supper. I also feel angry with those students I feel talk ill about me’ (Student, 1).

This means that some of the students with enuresis feel guilty with their peers because they are aware of challenges brought about by nocturnal enuresis that may make other students uncomfortable. This finding agrees with Wilson (2012) who reported that the children used hiding the bed wetting problem as a means of coping because they did not trust others. In contrast, Durmaz et al (2016) found out that there was no difference for the scale on paranoid ideation.

From FGD, the study revealed that that some of the students with nocturnal enuresis did not feel safe and that other students discussed them in groups and branded them names. These made the students to become suspicious guilty and did not trust other students. The students became moody, walked in isolation and angry perhaps because they did not feel safe with other students. Some respondents reported that:

‘I reported to the boarding master that I do not feel safe in the classroom and dormitory. At times when I approach the dormitory from far I hear a group of students laugh and I think that I am always the subject because when I enter the dormitory, laughing stops’ (Student 1, FGD 3).

From the interview excerpts, some of the students with nocturnal enuresis live on suspicion and feel offended. They are eager to investigate on what others are saying about them. Therefore, students who have nocturnal enuresis experience paranoid behaviours with their peers. In agreement, Anyanwu (2015) confirms this finding when they reported that children who were bedwetting had paranoid behaviour and poor sleep hygiene. Similarly, Neveus (2017) reported that the children with enuresis show signs of over reactivity and suspicion. The students suffer from stigmatization and live in fear. The students feel offended and humiliated by their peers. Therefore, there is need for strong guidance and counselling for students in boarding schools.

Increased Stress Level

Stress can be considered as a response to environmental conditions, defined on the basis of such diverse criteria as emotional upset, deterioration of performance, or physiological changes like increased skin conductance or increases in the levels of certain hormones (Davison, 2005). Stress became a stimulus and was identified with a long list of environmental conditions such as electric shock, boredom, uncontrollable stimuli, catastrophic life events, daily hassles, and sleep deprivation (Appley and Trumball, 1967). Interviews with Boarding Teachers revealed that some students who were bedwetting were sleepy in class and felt a lot of headache. An interview excerpt transcript is presented:

‘Some students who are bedwetting sleep a lot in class and feel a lot of headache. It is unfortunate that at times when teaching and learning is going on, some students whom I know wet the beds are dozing. Some girls who are my friends have share with me that wetting the beds are really stressing them.’ (BT, 5).

This means that students who wet the beds are not able to control stress related and affect them even in social activities. The students feel apprehended by nocturnal enuresis, therefore, appear troubled. This finding agrees with Ferrara et al. (2014) who concluded that headache was a common complain among the children with nocturnal enuresis. Similarly, Bahnasy et al. (2018) revealed that the child behaviour checklist showed higher depressed symptoms among the children with nocturnal enuresis. The findings disagree with Yousefichaijan et al. (2015) who revealed that most children with mono symptomatic primary nocturnal enuresis had no aggressive behaviour towards others.

An interview with Principals reveals that some students who were bedwetting appeared disturbed, confused, troubled and uneasy. The burden accompanied by nocturnal enuresis perhaps makes the students more stressed. A representative interview transcript is hereby presented:

‘It is noticeable when I move around the school I come across my girls who wet the beds looking stressed and disturbed. For instance when I walk into the dormitories early in the morning, I find the girls who wetted the beds that previous night looking uneasy, troubled and confused. I had to show them a lot of love and empathy’ (Principal, 5)

This means that students who are bedwetting suffer from stress and stress related challenges because the students are aware of the heavy burden resulting from nocturnal enuresis. At the same time, the students find it hard to overcome the burden from nocturnal enuresis. This finding agrees with Herzeele et al. (2015) when they reported that the children with nocturnal enuresis had high level of stress. In contrast, Abdel et al. (2017) argued that stress was not common among women and children. From the interview excerpts, it can be concluded that some of the students with nocturnal enuresis had low capacity to adjust to life threatening challenges hence suffered from stressful events. Due to the sensitivity of their situation, they hardly sought for help. This finding agrees with Alexander, Jang, Badawi, Kathleen and Mitchel (2017) who identified stressful events, school related stressors and trauma as environmental factors that were related to incontinence in adults and children. Similarly, Herzeele, Bruyne, Bruyne and Walle (2015) concluded that the children with enuresis had high level of stress, feeling of upset, lower quality of life, anxiety, depression and emotional symptoms in Iran. In support, Bahnasy, El-Heneedy, El-Seidy, Ibrahim, Saleem and Ahmed (2018) reported that the enuretic child behaviour checklist showed higher depressed symptoms in Egypt. Bayne (2015) reported that students who were bedwetting were suffering from stress. Butler (2016) concurs with the findings when they reported that the children who were bedwetting had the following psychological problems: stress, fear, guilt and anger. Another study by Alexander, Jong, Badawi, Kathleen, Mitchel Leppink, Cardozo (2017) supported the findings when they concluded that the children experienced stressful life events, school related stressors, trauma while the adults were worried.

Increased anxiety

Anxiety is an emotion characterized by an unpleasant state of the inner turmoil and it is a feeling of fear or apprehension of what is to come (Eysenck, 2004).The interview with students found out that students with nocturnal enuresis lived in fearand were ever suspicious of themselves and students around them. The students stayed awake most of the night or slept late for fear of wetting the bed. At times, the students slept on the floor to avoid wetting the beds. Some respondents reported that:

‘Sometimes I stayed awake most of the night for fear that if I fell asleep, I might urinate on the bed. To my surprise, the nights that I stayed awake, however short I fell asleep, I wetted the bed. On the other hand, a night that I did not think of wetting the bed, I ended up not wetting the bed either’ (Student, 9).

‘I sleep on the floor in our room for fear of voiding on the bed. This is because I sleep on the upper bed and I may wet the bed and interfere with my cube mate sleeping on the lower bed’ (Student, 20).

This means that the students developed fear as result of nocturnal enuresis that made them resort to other behavioural mechanisms such as sleepless nights and sleeping on the floor. The students are feeling lost and discouraged because they cannot cope with the embarrassment due to nocturnal enuresis. This finding agrees with Eakin et al. (2009) when they reported that the children with nocturnal enuresis were anxious towards getting medication and had greater parental stress. A similar finding by Zeng et al. (2015) found out that fear and anxiety were common among the children with nocturnal enuresis.

Feelings of Anger

Anger is a strong feeling of being upset or annoyed because of something wrong or bad (Fuster, 2005). This is a feeling that may prompt or trigger someone to hurt other people or shout at them. Anger is a substitute for emotion and in addition, people make themselves angry because they do not have to feel pain; therefore, they change their feeling of pain into anger. They feel irritated and may express their anger through verbal and non- verbal ways. An interview with students reported that some of the students who wet the beds sometimes felt angry with their colleagues who mocked, abused and backbite them. The students felt angry but did not report because of reproach or disgrace. Some respondents reported that:

‘I felt angry with a form three student who told me directly that I wet the bed at night and it was better if I joined day secondary school instead of boarding. I thought of reacting violently but I controlled’ (Student, 1).

‘I went to borrow uniform from my friend who is my classmate. She refused to lend me her cloth. I became angry when she clarified to another friend that she could not give me her uniform because I was bed wetting’ (Student, 6).

This means that some students with nocturnal enuresis feel that they are angered by statements that are meant to hurt them and associate them with nocturnal enuresis. As much as the students experience nocturnal enuresis, they are perturbed and not happy about it. This finding agrees with Sherah, Elsharief, Barkat and Jafery (2019) who reported that emotional stresses and family conflicts were rampant among the students and their families. In agreement, Wang, Zhang, Zhang (2018) reported that children with primary nocturnal enuresis were upset as compared to other children.

An interview with Boarding Teachers reveal how the students who do not have nocturnal enuresis tease and bully their colleagues with nocturnal enuresis and that the later became angry. A representative sample cites;

‘The students who wet the beds normally feel angry with some students who mock, tease and call them names’ (B/T, 3.)

This means that the students with nocturnal enuresis experience behavioural difficulties with their peers who do not experience nocturnal enuresis. The students without enuresis have not learnt to be accommodative and friendly to their peers with enuresis. The students with enuresis felt angered by other students. This finding agrees with Mason (2017) who concluded that the students with nocturnal enuresis had increased anger. Similarly, Mason (2017) concluded that children who had nocturnal enuresis had increased anger with emotions.

4. Conclusions & Recommendations

This study concluded that the students with nocturnal enuresis encountered a number of psychological experiences with peers. These experiences were: low self esteem, increased aggressive behaviour, paranoid behaviour, increased stress levels, increased anxiety and anger with peers. The students had low capacity to overcome psychological experiences with peers hence needed strong interventions. It’s recommended that schools should strengthen peer counselling among students in their respective schools because the study found out that some students with nocturnal enuresis unlearnt the behaviour after sharing with other students.