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Mental Illness 2009; volume 1:exxxx

Study habits among Nigeriansecondary school students withbrain fag syndromeBolanle A. Ola,1 Olufemi Morakinyo21Department of Psychiatry, Lagos StateUniversity College of Medicine, Ikeja,Lagos;2Department of Psychiatry, College ofHealth Sciences, University of Benin,Benin, Nigeria

Abstract

Brain Fag Syndrome (BFS) is a psychiatricdisorder associated with study affecting two tofour out of every ten African students. One ofthe consequences of this illness is early fore-closure of education in affected students.Etiological factors such as nervous predisposi-tion, motivation for achievement, and psycho-stimulant use have been found associated withit. However, the contributions of study habitsto the pathogenesis of this study-related ill-ness deserve more attention than has beengiven. We carried out this cross-sectional studyto ascertain the types of study habits associat-ed with BFS among a sample of senior second-ary school students in Ile-Ife, Nigeria. Fivehundred students from six schools in Ile-Ifewere selected using a stratified random sam-pling technique. The selected students com-pleted the Socio-demographic Data Schedule,the Brain Fag Syndrome Scale, and Bakare’sStudy Habit Inventory. The prevalence of BFSwas 40.2% (201). There were no significantsocio-demographic variables identifying BFSstudents apart from those without BFS. Thesignificant measures of study habits that pre-dicted BFS were homework and assignments,examinations, and written work. Those withBFS had 3.58 times the odds to perform poorlyon homework and assignments, 3.27 times theodds to perform poorly on examinations, and1.01 times the odds to perform poorly on writ-ten work compared to those without BFS. Weconcluded that the results of this study suggestthat homework and assignments, examina-tions, and written work were significant studyhabit variables associated with BFS.

Introduction

In recent years the economic success ofnewly industrialized nations has been linkedto substantial prior investment in humanresources.1 In these nations institutional andpolicy choices have been made to guide their

educational systems. In sub-Saharan Africathe situation is different. For instance, theNigerian population is a very important agen-da that is a single point that involves theissues of poverty, education, employment,health, food, and all other aspects of nationalgrowth.2 Nigeria accounts for the highest pop-ulation rate in the continent of Africa.However, the economy is not among the best;rather it rates among the twenty poorest coun-tries of the world.2 The Nigerian population,according to World Bank research and theUnited Nation Population Funds estimate in2000, has a population of at least 126.9 million.The country’s population growth rate was esti-mated at an average of 2.5%, which in someyears would cause a greater challenge toattempts to eradication poverty. With the popu-lation growth in Nigeria, health hazards andprogressive educational attainments are majorissues.

Primary education in Nigeria enrolls 81% ofthe relevant age groups and graduates 69% ofthese.3,4 Therefore, just over half of all childrencomplete primary school. School drop-out rateshave been rising and educational standardsreportedly have declined.5 Secondary educationenrolments grew at roughly 10% yearly duringthe 1990s, but access remains constrained(fewer than half of secondary school-age chil-dren attend school). Technical education isneglected substantially and oriented to theteaching of traditional hand skills that oftenare divorced from labour market requirements.Higher education enrolls a very modest 4% ofthe relevant age cohort. This level comparespoorly with economic competitors such asSouth Africa (17%), India (7%), Indonesia(11%), and Brazil (12%).6

In addition, a literature search has revealedthat educational attainment is related todiverse health outcomes.6 The poor state ofmental health among adolescents in industri-alizing nations jeopardizes their chances ofachieving optimum educational goals, andindirectly, their economic successes. Hence, inNigeria the mental health of students shouldbe of public importance if the country is toachieve economic success.

Brain Fag Syndrome (BFS) is a culture-bound syndrome associated with study thataffects two to four of every ten secondaryschool students in Nigeria.7 One of the conse-quences of this illness is early inability to con-tinue schooling. Etiological factors such asnervous predisposition, motivation forachievement, and psycho-stimulant use havebeen found to be associated with this illness.However, the contributions of study habits toBFS pathogenesis deserve more attentionbecause of the possible implications for inter-vention studies. From a diligent review of stud-ies, there is a dearth of information on possi-ble relationships between study habits and

BFS. We carried out this study to ascertain therelationship of study habits to BFS, and if therewere a relationship, what types of study habitswould be associated with BFS.

Materials and Methods

Setting of the studyThe study was carried out in Ile-Ife, Osun

State, Nigeria. Ile-Ife is a sub-urban city in theSouth West geopolitical zone of Nigeria and isabout 200 km from Lagos, the commercial cap-ital of Nigeria. Within this city are thirty sec-ondary schools, which are spread over two localgovernment areas: Ife Central and Ife EastLocal Governments.

Ethical considerationsThe Research and Ethical Committee of

Obafemi Awolowo University TeachingHospitals Complex, Ile-Ife, approved the studyprotocol, after which the permission to carryout the study was obtained from the LocalInspectors of Education in the two local gov-ernments. The principals and teachers of theschools involved and the students (includingtheir parents) who participated in the studywere informed formally and their consent wasobtained.

Correspondence: Bolanle A. Ola, Department ofPsychiatry, Lagos State University College ofMedicine, Ikeja, Lagos, Nigeria.E-mail: wobola@yahoo.com

Key words: brain fag, study habits, students.

Contributions: BAO conceived of the study anddesign, analyzed the data, participated with theinterpretation of data, and drafted the article andits final version; OM contributed to the design ofthe study, participated in the interpretation of thedata, revised the article critically for importantintellectual content, and agreed with the finalversion to be published.

Conflict of interest: the authors report no con-flicts of interest.

Received for publication: 7 October 2009.Revision received: 21 December2009.Accepted for publication: 21 December 2009.

This work is licensed under a Creative CommonsAttribution 3.0 License (by-nc 3.0).

©Copyright B.A. Ola et al., 2010Licensee PAGEPress, ItalyMental Illness 2010; 2:e2doi:10.4081/mi.2010.e2

Mental Illness 2009; volume 2:e2

Article

Sampling methodA stratified random sampling technique was

used to select six schools for the study. Initialstratification of Ile-Ife was done on the basis ofthe two local governments. Simple ballotingwas used to select: (a) two mixed and the only“girls only” school in Ife Central local govern-ment, and (b) three mixed schools from IfeEast local government. From senior secondaryschool (SSS) classes only, two and three stu-dents were recruited from the six schoolsbecause of time constraints and better compre-hension of English. A further stratification wasdone to select the four arms of the SSS 2 andSSS 3 classes that finally participated in thestudy through simple balloting. Each selectedclass formed a cluster from which all the stu-dents participated. A preliminary investigationby the authors showed that the average num-ber of students in a class was 37 (range of 33-41).

Before the administration of the instru-ments to the selected clusters, the studentswere told that: (a) their participation was vol-untary and there was no foreseeable risk inparticipation, (b) those who refused to partici-pate would not be penalized or have loss ofbenefits, (c) they should not liaise with eachother to answer the questions, and any ques-tion they might have should be directed to theresearcher, (d) their anonymity was assured,and (e) this was not a test, and they shouldanswer the questions honestly.

The sample size used for this study wascomputed using the formula:

N = p (1-p) [z/d],2 where the prevalencerate for psychopathology (p) is 22.9%; z is thescore at 95% confidence level; and d is thedegree of accuracy desired and set at 4%.7 Thelevel of significance was set at 5%.

InstrumentsBrain Fag Syndrome Scale (BFSS): this scale

was first developed by Prince in 1962 to assessBFS among students.8 With BFS delineated asa distinct nosological entity, Prince andMorakinyo refined the questionnaire into aseven-item scale. The possible responses toeach item on the questionnaire are three(often, sometimes, and never) with scores 2, 1,and 0, respectively. The scores obtainable onthis scale range from 0-14. The higher thescore, the more severe the syndrome is. A BFScase must have a minimum total score of 6 onone hand, which must include at least a scoreof 1 on each of the items 4 and 5 on the otherhand because these items are the core con-struct of BFS. Items 4 and 5 are concerned withthe presence of symptoms in the head (such ascrawling sensation or heat) and their interfer-ence with study. The validity of the scale restssquarely on the construct of the syndrome.7,9,10

Bakare’s Study Habit Inventory (SHI): wasdeveloped specifically for Nigerian secondary

school students using existing inventories andpublished studies.11 It is a self-report inventorythat consists of 45 items in the form of directquestions toward tapping eight aspects of thestudy habit. The responses to each item aregraded on a five-point Likert-type scale. Thepossible responses to each item on the ques-tionnaire are five (almost never, less than halfof the time, about half of the time, more thanhalf of the time, and almost always) withscores 1, 2, 3, 4, and 5, respectively, for a posi-tive question and the scores reversed for anegative question. The scores for all questionsin each section are totaled and converted tothe Stanine equivalent using the Table of

Stanine Norms for the SHI. The Stanineequivalent of the total score on the inventory(i.e. addition of all section’s scores) is provid-ed as SHI TOTAL. The Table of Norms for theSHI was obtained by testing a nationwidesample of 520 secondary school studentsselected from the northern, eastern, and west-ern parts of Nigeria. The schools includedboys, girls, and mixed schools, as well asurban and rural schools. All classes in the sec-ondary schools were represented in this sam-ple. The eight aspects of the study habit inthis scale are: (i) Homework andAssignments, (ii) Time Allocation to Work,(iii) Reading and Note-taking, (iv) Study

[Mental Illness 2010; 2:e2] [page 7]

Table 1. Comparison of socio-demographic characteristics of BFS cases and non-BFScases.

Variables BFS Cases Non-BFS cases Total Test of significance

Age (years) χ2 = 5.32811-13 7 (3.5) 14 (4.7) 21 (4.2) df=414-16 158 (78.6) 223 (74.6) 381 (76.2) P=0.25517-19 30 (14.9) 58 (19.4) 88 (17.6)20-22 4 (2.0) 4 (1.3) 8 (1.6)23-25 2 (1.0) - 2 (0.4)Total 201 (100) 299 (100) 500 (100)Mean (SD) 15.6 (±1.6) 15.4 (±1.5) t = 1.058Median 15.0 15.0 df = 498Range 12-24 12-21 P= 0.301

Gender χ2= 0.143Male 92 (45.8) 142 (47.5) 234 (46.8) df = 1Female 109 (54.2) 157 (52.5) 266 (53.2) P = 0.387Total 201 (100) 299 (100) 500 (100)

Class χ2 = 0.003SSS 2 95 (47.3) 142 (47.5) 237 (47.4) df = 1SSS 3 106 (52.7) 157 (52.5) 263 (52.6) P = 0.96Total 201 (100) 299 (100) 500 (100)

Course χ2 = 0.869Science 128 (63.7) 181 (60.5) 309 (61.8) df = 2Arts 67 (33.3) 111 (37.1) 178 (35.6) P = 0.647Social science 6 (3.0) 7 (2.3) 13 (2.6)Total 201 (100) 299 (100) 500 (100)

Religion χ2 = 1.984Christianity 170 (84.6) 238 (79.6) 408 (81.6) df = 1Islam 31 (15.4) 61 (20.4) 92 (18.4) p = 0.195Total 201 (100) 299 (100) 500 (100)

Nationality χ2 = 0.674Nigerian 201 (100) 298 (99.7) 499 (99.8) df = 1Others - 1 (0.3) 1 (0.2) P = 0.412Total 201 (100) 299 (100) 500 (100)Family type χ2 = 2.665Monogamous 143 (71.1) 232 (77.6) 375 (75) df = 1Polygamous 58 (28.9) 67 (22.4) 125 (25) p = 0.114Total 201 (100) 299 (100) 500 (100)

Residence χ2 = 1.976Parents 183 (91) 282 (94.3) 465 (93) df = 2Guardian 17 (8.5) 16 (5.4) 33 (6.6) P = 0.372Friends 1 (0.5) 1 (0.3) 2 (0.4)Total 201 (100) 299 (100) 500 (100)

Years Spent in SchoolFive 97 (39.8) 147 (60.2) 244 (48.8) χ2 = 1.225Six 102 (40.6) 149 (59.4) 251 (50.2) df = 3Seven 2 (50) 2 (50) 4 (0.8) P = 0.747Eight - 1 (100) 1 (0.2)Total 201 (100) 299 (100) 500 (100)

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Period Procedures, (v) Concentration, (vi)Written Work, (vii) Examinations, and (viii)Teacher Consult-ation.

(i) Homework and Assignments cover thehabits that students adopt in studying outsidethe class hours. It assesses how the studentorganizes his/her academic schedule at hometo facilitate learning. It evaluates a student’shomework and bedtime routines, and howhe/she organizes books, notebooks, and papersfor return to school. (ii) Time Allocation toWork is the dimension that assesses the habitof a student to avoid certain factors that mightdistract his/her focus from succeeding in thecourse of studying. Other habits assessed hereare allocation of time to subjects and the num-ber of hours in studying. (iii) Reading andNote-taking is the dimension that assessesstudents’ habits of note-taking in class.Orderly, labeled, and legible notes written in astudent’s own words and the use of key wordsand some supporting details are habits thathave been correlated with positive academicoutcomes. Other habits of reading such asrecitation, reflection on main ideas, and anypoorly understood concepts and periodicalreview of notes are assessed also in thisdomain. (iv) The Study Period Procedures sub-scale assesses habits related to spread-ing/spacing studying. The domain of (v)Concentration assesses the habits a studenthas formed to avoid distractions while study-ing. (vi) Written Work assesses a student’shabit in expressing his/her thoughts in anorganized manner with attention to neatnessand mistakes. (vii) The Examinations dimen-sion looks at the habits of a student in prepar-ing for examinations. Habits to avoid exces-sive anxiety are assessed. (viii) TeacherConsultation evaluates a student’s habit ofinteracting with the teacher in studying effec-tively. The instrument has a test-retest reliabil-ity of 0.83 with one group of students, and 0.64with another group of students over a timeinterval of three weeks and six weeks, respec-tively. In addition, it has been found by otherNigerian authors to be reliable and validamong Nigerian students.12-14

Data analysisThe Statistical Package for the Social

Sciences (SPSS) for Windows version 11 wasused to process the data.15 The analysis wasbased on the total number of respondents. Forscales and questions with defined categories,frequencies and percentages were calculatedfor each of the dimensions of BFS and for studyhabits.

The χ2- and student’s t-test were used to testfor the differences in the responses betweenthe groups. Multiple correlations were con-ducted using Pearson’s χ2-test. Logistic regres-sion was used to test for the relationshipbetween study habits and BFS. All the tests

were two-tailed and the level of significancewas set at 0.05. Odds ratio and the 95%Confidence Interval were calculated for signif-icant variables.

Results

The mean age of the respondents was 15.5years (S.D±1.5). About three quarters of thetotal cohort (76.2%) were aged between 14

and 16 years. Higher proportions of therespondents (53.2%) were females. Two hun-dred and thirty seven (47.4%) were in the SSS2 while 263 (52.6%) were in the SSS 3 groups.The majority (81.6%) were Christians. Othersocio-demographic details are shown in Table1.

Socio-demographic characteristicsand Brain Fag Syndrome

The comparison of BFS cases and non-BFScases on socio-demographic characteristics is

Article

Table 2. Comparison of students with and without BFS on study habits’ dimensions.

Study Category BFS Non-BFS Total Test of significanceHabit n (%) n (%)Dimension

Homework Poor 129 (64.2) 108 (36.1) 237 (47.4) χ2 = 38.136and Average 55 (27.4) 151 (50.5) 206 (41.2) df = 2Assignment Good 17 (8.4) 40 (13.4) 57 (11.4) P ≤ 0.001

Total 201 (40.2) 299 (59.8) 500 (100)Time Poor 118 (58.7) 137 (45.8) 255 (51.0) χ2 = 8.153Allocation Average 66 (32.8) 125 (41.8) 191 (38.2) df = 2

Good 17 (8.5) 37 (12.4) 54 (10.8) P = 0.017Total 201 (40.2) 299 (59.8) 500 (100)

Reading Poor 127 (63.2) 145 (48.5) 272 (54.4) χ2 = 10.626and Average 51 (25.4) 111 (37.1) 162 (32.4) df = 2Note-taking Good 23 (11.4) 43 (14.4) 66 (13.2) P = 0.005

Total 201 (40.2) 299 (59.8) 500 (100)Study Poor 99 (49.2) 120 (40.1) 219 (43.8) χ2 = 12.852Period Average 92 (45.8) 135 (45.2) 227 (45.4) df = 2Procedures Good 10 (5.0) 44 (14.7) 54 (10.8) P = 0.002

Total 201 (40.2) 299 (59.8) 500 (100)

Concentration Poor 77 (38.3) 76 (25.4) 153 (30.6) χ2 = 9.891Average 70 (34.8) 117 (39.1) 187 (37.4) df = 2Good 54 (26.9) 106 (35.5) 160 (32.0) P = 0.007Total 201 (40.2) 299 (59.8) 500 (100)

Written Poor 118 (58.7) 108 (36.1) 226 (45.2) χ2 = 30.066Work Average 60 (29.9) 108 (36.1) 168 (33.6) df = 2

Good 23 (11.4) 83 (27.8) 106 (21.2) P ≤ 0.001Total 201 (40.2) 299 (59.8) 500 (100)

Examinations Poor 72 (35.8) 69 (23.1) 141 (28.2) χ2 = 18.714Average 92 (45.8) 126 (42.1) 218 (43.6) df = 2Good 37 (18.4) 104 (34.8) 141 (28.2) P ≤ 0.001Total 201 (40.2) 299 (59.8) 500 (100)

Teacher Poor 40 (20.1) 42 (14.0) 82 (16.5) χ2 = 3.306Consultation Average 144 (72.4) 230 (76.9) 374 (75.1) df = 2

Good 15 (7.5) 27 (9.0) 42 (8.4) P = 0.192Total 199 (40.0) 299 (60.0) 498 (100)

Total Poor 128 (63.7) 116 (38.8) 244 (48.8) χ2 = 34.153Study Average 65 (32.3) 140 (46.8) 205 (41.0) df = 2Habit Good 8 (4.0) 43 (14.4) 51 (10.2) P ≤ 0.001

Total 201 (40.2) 299 (59.8) 500 (100)

Table 3. Regression analysis to determine measures of study habits predicting BFS.

Variables - t P Odds 95% C.I Partial ratio correlation

coefficient

Homework and assignments -0.176 -3.94 ≤0.001 3.58 1.44-5.94 -0.485Examinations -0.140 -3.029 0.003 3.27 1.65-6.72 -0.423Written work -0.119 -2.499 0.013 1.10 1.01-1.12 -0.461

C.I. = confidence interval.

[Mental Illness 2010; 2:e2] [page 9]

shown in Table 1. The two groups had a simi-lar age distribution. They both had a slightpredominance of the female gender. Themajority of students in both groups were inthe science class, were Christians, and livedwith their parents in a monogamous setting.The differences between them were not statis-tically significant.

Prevalence of Brain Fag Syndrome The prevalence of BFS was 40.2%. The

severity of BFS was graded thus: mild = hav-ing a range of scores of 6 to 8 on BFSS; mod-erate = having scores of 9 to 11; and severe =having scores of 12 to 14. A higher proportionof BFS (178 [35.6%]) were mild; 21 (4.2%)were of moderate severity; and 2 (0.4%) weresevere. This classification is elementary andwithout empirical support; but may be of clin-ical significance.

Study habits and Brain FagSyndrome

These are shown in Table 2. The subjectswere regrouped into three categories accord-ing to their Stanine scores as follows: Stanine1-3 = “Poor”; Stanine 4-6 = “Average”;Stanine 7-9 = “Good”. There were significantdifferences between BFS students and non-BFS students in all the dimensions of thestudy habit except in teacher consultation.Using total SHI scores, BFS students also hadsignificantly poorer performance. Specifically,BFS students had more problems in homeworkand assignments, reading and note-taking,time allocation, and written work.

Study habit measures as predictorsof Brain Fag syndrome

A binomial logistic regression was conduct-ed to evaluate how well study habit measures(independent variables) would predict BFS(dependent variable). The overall percentageclassification was 68% and the Hosmer andLemeshow test of goodness-of-fit was non-significant (χ²=9.223; df=8; P=0.324), indi-cating that the model adequately fitted thedata. The Likelihood Ratio (LR) was signifi-cant (LR=609.69; P≤0.001) indicating that thehypothesis that all the predictors effects werezero was to be rejected. Conducting a forwardstepwise binomial regression analysisrevealed three of the study habit measures tobe significant; that is, homework and assign-ments; examinations; and written work. Theregression equation was significant withR²=0.097, adjusted R²=0.092, F change (1,496)=6.244 and significant F change=0.013.Table 3 shows the predictor variables in theregression analysis with their odds ratio andpartial correlation coefficients.

Discussion

BFS has been reported from other parts ofWest Africa, in other parts of Africa south ofthe Sahara, and in students from Africa whoare studying abroad.16,17 In this study its preva-lence is 40.2%. This is much higher than thereported prevalence of 22.9% among secondaryschool students in Ilesa by Fatoye andMorakinyo,7 and 22.4% among secondaryschool students in Osogbo by Eegunranti.18 Italso contrasts with 25% reported by Peltzer etal. among South African secondary school stu-dents.17 This difference might reflect the vary-ing degree of westernization in the differentpopulations of students studied.17 It could alsoreflect a possible increase in new cases of BFS.It is interesting to find out that the majority ofBFS students in our study belonged to the mildcategory of BFSS. Seeking medical attentionpossibly would be difficult among this catego-ry. Screening for BFS would be important inorder to help these people.

Age and gender were not found to be relatedto BFS in our study. This concurred with thefindings of Prince,19 Guinness,20 as well asFatoye and Morakinyo.7 Factors such as familytype, type of residence, and parental educa-tional and occupational statuses were not sig-nificantly associated with BFS. This is in con-trast with some studies that found BFS morecommon among people with low socio-eco-nomic status.8,10,21 Studies that compare ruraland urban students are needed to clarify this.

Even though the majority of BFS studentshad good study habits, a significantly higherproportion of students with BFS had poor studyhabits in comparison to students without BFS.This finding confirmed earlier suggestionsthat faulty study habits might play a significantrole in the etiology of BFS.7,21,22 In our study thesignificant measures of study habits that pre-dicted BFS were homework and assignments,examinations, and written work. Those withBFS had 3.58 odds of performing poorly onhomework and assignments, 3.27 odds of per-forming poorly on examinations, and 1.01 oddsof performing poorly on written work comparedto those without BFS.

Using the psychophysiological theory ofMorakinyo, high neuroticism in BFS-proneindividuals was likely to increase their levels ofanxiety over and above the optimal range thatwould increase academic performance.21 Thecognitive appraisal of homework and assign-ments as signifying examinations would wors-en their states especially when examinationswere close. This might result in studying poor-ly and written work would also be affected.Their concentration in states of anxiety wouldbe poor and distractions from academic focuswould be the rule. Subsequently academic out-comes would be affected negatively. This could

be noticed from the performance in homeworkand assignments. Poor academic outcomesmight portend failure to these individuals whohad a high achievement orientation. Theirself-esteems would be affected thereby. Theresultant effect would be a vicious circle asnoted by Morakinyo in his exposition of thetheory.

This study is not without limitations. First,it could not be ascertained to what extent thesubjects answered the questionnaires sincere-ly. Second, our study has established associa-tions between study habits and BFS. It wouldbe difficult to say which of the pairs gave birthto the other. Third, findings from our studymight be difficult to generalize to primaryschool pupils and students of tertiary institu-tions. This is because secondary school stu-dents, particularly the senior secondary schoolstudents who had better ability to understandthe questions and had been studied more,were sampled in our study. However, it is thefirst study to ascertain the associationbetween study habits and BFS.

Conclusions

Our study found a significant associationbetween study habits and BFS and found thatdimensions of home work and assignments,examinations, and written work were signifi-cant predictors of BFS. These factors should begiven consideration when planning any inter-vention program for BFS students.

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