ABSTRACT
Introduction:
Perception of self is a primary source for fostering negative influences in an adolescent’s life. This stage may increase the risk for various psychiatric disorders.
Objectives:
To assess the grade of anxiety and depression and to study their relationship with various factors of perception of self, among adolescent girls.
Materials and Methods:
School-going adolescent girls from two government schools at Lucknow were selected using a two-stage random sampling technique. A total of 200 participants were personally interviewed for their socio-demographic details, perception of self, and screened for symptoms of anxiety and depression.
Results:
Of the 200 school-going adolescent girls who participated in the study, 63.5% screened positive for the symptoms of anxiety and 73.0% for symptoms of depression. A total of 11.5% and 3.5% school-going adolescent girls had severe anxiety and major depression; severe severity, respectively. Both anxiety and depression among school-going adolescent girls were significantly associated with factors like possessing qualities that they are ashamed of (P = 0.005 and 0.011), body image dissatisfaction (P = 0.004 and 0.017), and getting suicidal thoughts in times of difficulties (P < 0.001).
Conclusion:
A fair number of adolescent girls had severe anxiety and major depression of severe severity. Therefore, adolescents must be screened for mental disorders from time to time and those at high risk must be identified.
Keywords: Adolescent girls, anxiety, depression, perception of self
Introduction
The word “adolescence” originated from the Latin word “adolescere” meaning “to grow into maturity.” The World Health Organization (WHO) defines an adolescent as any person between the ages of 10 and 19 years.[1] India is a country with the largest share of world’s adolescent population, that is, 20.5%, amounting to around 243 million.[2] Adolescents in India account for one-fifth of the total population.[3]
Adolescence is a phase of transition from childhood to adulthood. A central process during this transition is the development and stabilization of the concept of self and psychosocial self.[4] Such factors of psychosocial self that come into play in adolescent health include self-esteem, sense of coherence, body image satisfaction, life orientation, optimism, resilience, confidence, etc.[5] As compared with adolescent boys, adolescent girls have been shown to score less favorably on self-esteem and sense of coherence.[4]
According to WHO (2018), it is estimated that 10.0%–20.0% of adolescents experience mental health conditions but remain under-diagnosed and undertreated, globally.[1] Symptoms of anxiety and depression among adolescents are often unnoticed or misinterpreted as behavioral or academic concerns. If not treated, these disorders tend to persist and increase the risk for medical illnesses, impaired well-being, and various psychiatric disorders.[6]
Adolescents have specific biological, psychosocial, and health needs. They often lack the understanding of their own health needs. Despite being such a vulnerable age, adolescents are rarely studied as a separate group. They are either treated as a part of children or adult population albeit they belong to none. More so, the needs and requirements of adolescent girls are quite different from those of boys and unfortunately, often ignored. Thus, this article focuses on the vulnerable group that adolescent girls are.
Objectives
The objectives of this study were to assess the grade of anxiety and depression and to study their relationship with various factors of perception of self, among adolescent girls.
Materials and Methods
This study was a descriptive cross-sectional study conducted in secondary government schools, located in the study district of Lucknow which had classes from 9th to 12th standard. It was conducted from July 2019 to October 2020.
Individual school-going adolescent girls, of classes 9th, 10th, 11th and 12th, who were enrolled in urban government secondary schools of Lucknow district during the academic year 2019–2020, participated in the study. Those who gave assent to the study were included. While uncooperative school-going adolescent girls and those suffering from any severe illness were excluded from the study.
Considering the drop-out rate as 10.0%, prevalence as 10.8%[7] and margin of error as 5.0%, the sample size was calculated to be 197, at 95.0% confidence interval. The calculated sample size was rounded off to 200.
Two-stage random sampling technique was used to obtain the requisite number of participants [Figure 1]. First, a comprehensive list of all government, senior secondary schools in Lucknow city was charted after reference from the District Inspector of Schools, Lucknow. Simple random sampling was used to select two such schools in Lucknow. The selected schools were approached for the total strength of the classes from 9th to 12th and for the permission to conduct the study in that school. In case permission was not granted, the procedure of selection of school was repeated. In the second stage, from both the schools, the total strength of each class was obtained. A sample of 100 adolescent girls from either school was equally divided into 25 participants among the four classes, that is, 9th, 10th, 11th and 12th. These 25 participants were selected from the comprehensive list obtained for each class. Sampling interval for each class was calculated and study participants were selected using systematic random sampling. Thus, a sample of 200 adolescent girls was obtained from the two schools. The principals of both the schools were explained the nature and purpose of the study. Their prior permission and informed consent were taken to conduct the study in their school under their supervision. The students were assured of confidentiality and their assent was taken. In case a student refused to participate in the study, or gave a history of suffering from any severe illness, the next enrolled student of that class was asked for her permission to participate in the study. The participants were interviewed personally, in a quiet space, on the school premises, using a questionnaire. In case a participant screened positive for either the symptoms of anxiety or depression, she was counseled to seek help from experts, encouraged to talk to her family and referred to a psychiatrist at King George’s Medical College, Lucknow, Uttar Pradesh.
Figure 1.
Two-stage random sampling technique for obtaining requisite number of participants
A pre-designed and pre-tested semi-structured questionnaire was used to determine socio-demographic characteristics, anxiety, depression, and perception of self. Symptoms of anxiety were screened using the Generalized Anxiety Disorder 7-item (GAD-7)[8] scale. The responses are marked as numbers representing severity. The marked numbers are added to get a final GAD-7 score. Total score of 0–5 is indicative of no anxiety, 5–9 of mild anxiety, 10–14 of moderate anxiety, and ≥15 of severe anxiety. Symptoms of depression were screened using Patient Health Questionnaire 9-item (PHQ-9)[9] scale. The responses are marked as numbers representing severity. The marked numbers are added to get a final PHQ-9 score. A total score of 0–4 is interpreted as no depression, 5–9 as minimal depressive symptoms, 10–14 as major depression; mild severity, 15–19 as major depression; moderate severity and ≥20 as major depression; severe severity. An openly available Hindi translation for the Indian population of both the tools, GAD-7 and PHQ-9, as developed and validated by Pfizer Inc, in association with Spitzer RL, et al., was used to personally interview the participants.[10] For perception of self, extensive review of literature and brainstorming sessions with the experts were conducted. The designed questionnaire was pretested on 10% of the total sample. Relevant modifications were made to the questionnaire to overcome the difficulties that were faced during pre-testing.
Institutional ethical clearance (No. 322/Ethics/2020, Dated 26/05/2020) was taken from the King George’s Medical University, Lucknow, Uttar Pradesh, for the conduction of this study (Reg. No. ECR/262/Inst/UP/2013/RR-19).
Data were analyzed using SPSS, version 23. Descriptive summary such as frequencies percentage for categorical variable were determined, proportions, graphs and cross tabs were used to present study results. Chi-square test for independent sample was used to determine the relation between dependent and independent variables. The level of significance was set at 0.05. Missing variables were blocked from the analysis.
Results
Majority of the school-going adolescent girls in the study were in the stage of middle adolescence, that is, age 11–14 years (65.5%), residing in urban areas (95.0%), Hindu by religion (65.5%), from OBC social class (50.5%), living with their parents (93.0%) in a nuclear family (82.5%) and belonged to either lower middle (40.5%)/lower (41.5%) socio-economic class according to modified B.G. Prasad Scale.
Of the 200 school-going adolescent girls who participated in the study, 127 (63.5%) screened positive for the symptoms of anxiety and 146 (73.0%) for symptoms of depression. A total of 11.5% and 3.5%school-going adolescent girls had severe anxiety and major depression; severe severity, respectively. Majority of the participants with severe anxiety were studying in 12th standard (43.5%). Most of the participants with major depression were from either of the board classes, that is, 10th and 12th standard (28.6% each) [Table 1].
Table 1.
Distribution of grade of anxiety and depression among school-going adolescent girls
| Grade of anxiety/depression | Standard/Class | Total N=200 | |||
|---|---|---|---|---|---|
|
| |||||
| 9th n | 10th n | 11th n | 12th n | ||
| Anxiety | |||||
| No anxiety | 23 (31.5) [46.0] | 14 (19.2) [28.0] | 23 (31.5) [46.0] | 13 (17.8) [26.0] | 73 [36.5] |
| Mild anxiety | 13 (20.3) [26.0] | 24 (37.5) [48.0] | 12 (18.8) [24.0] | 15 (23.4) [30.0] | 64 [32.0] |
| Moderate anxiety | 12 (30.0) [24.0] | 8 (20.0) [16.0] | 8 (20.0) [16.0] | 12 (30.0) [24.0] | 40 [20.0] |
| Severe anxiety | 2 (8.7) [4.0] | 4 (17.4) [8.0] | 7 (30.4) [14.0] | 10 (43.5) [20.0] | 23 [11.5] |
| Depression | |||||
| No depression | 14 (25.9) [28.0] | 12 (22.3) [24.0] | 16 (29.6) [32.0] | 12 (22.2) [24.0] | 54 [27.0] |
| Minimal depressive symptoms | 21 (27.6) [42.0] | 17 (22.4) [34.0] | 20 (26.3) [40.0] | 18 (23.7) [36.0] | 76 [38.0] |
| Major depression; Mild severity | 13 (32.5) [26.0] | 11 (27.5) [22.0] | 6 (15.0) [12.0] | 10 (25.0) [20.0] | 40 [20.0] |
| Major depression; Moderate severity | 2 (8.7) [4.0] | 8 (34.8) [16.0] | 5 (21.7) [10.0] | 8 (34.8) [16.0] | 23 [11.5] |
| Major depression; Severe severity | 0 (0.0) [0.0] | 2 (28.6) [4.0] | 3 (42.9) [6.0] | 2 (28.6) [4.0] | 7 [3.5] |
(%)=Row percentage, [%]=Column percentage
Figure 2 shows that among all the school-going adolescent girls, 83.5% responded that they did not possess qualities that they are ashamed of, 85.0% expected the best in times of difficulties, and 80.0% were optimistic about their future. Although a considerable number school-going adolescent girls did not think of themselves as confident individuals (17.0%) and many got suicidal thoughts in times of difficulties (33.5%).
Figure 2.
Perception of self among school-going adolescent girls
On applying Chi-square test of significance, none of the socio-demographic factors were found to be significantly associated with anxiety or depression. On the other hand, both anxiety and depression among school-going adolescent girls were significantly associated with perception of self-factors such as possessing qualities that they are ashamed of (P = 0.005 and 0.011), body image dissatisfaction (P = 0.004 and 0.017), getting suicidal thoughts in times of difficulties (P < 0.001), and being optimistic about future (P = 0.047 and 0.038) [Table 2].
Table 2.
Association of perception of self with anxiety and depression among school-going adolescent girls
| Perception of self (N=200) | Anxiety | P | Depression | P | ||
|---|---|---|---|---|---|---|
|
|
|
|||||
| Present n (%) | Absent n (%) | Present n (%) | Absent n (%) | |||
| Possess qualities that they are ashamed of | ||||||
| Yes | 28 (84.8) | 5 (15.2) | 0.005 | 30 (90.9) | 3 (9.1) | 0.011 |
| No | 99 (59.3) | 68 (40.7) | 116 (69.5) | 51 (30.5) | ||
| Consider themselves confident | ||||||
| Yes | 104 (62.7) | 62 (37.3) | 0.581 | 118 (71.1) | 48 (28.9) | 0.178 |
| No | 23 (67.6) | 11 (32.4) | 28 (82.4) | 6 (17.6) | ||
| Body image dissatisfaction | ||||||
| Yes | 72 (73.5) | 26 (26.5) | 0.004 | 79 (80.6) | 19 (19.4) | 0.017 |
| No | 55 (53.9) | 47 (46.1) | 67 (65.7) | 35 (34.3) | ||
| Expect the best when in a problem | ||||||
| Yes | 109 (64.1) | 61 (35.9) | 0.666 | 125 (73.5) | 45 (26.5) | 0.688 |
| No | 18 (60.0) | 12 (40.0) | 21 (70.0) | 9 (30.0) | ||
| Get suicidal thoughts in times of difficulties | ||||||
| Yes | 56 (83.6) | 11 (16.4) | <0.001 | 62 (92.5) | 5 (7.5) | <0.001 |
| No | 71 (53.4) | 62 (46.6) | 84 (63.2) | 49 (36.8) | ||
| Optimistic about future | ||||||
| Yes | 107 (66.9) | 53 (33.1) | 0.047 | 122 (76.3) | 38 (23.8) | 0.038 |
| No | 20 (50.0) | 20 (50.0) | 24 (60.0) | 16 (40.0) | ||
(%)=Row percentage
Discussion
In the present study, 11.5%school-going adolescent girls had severe anxiety, which is in accordance with Merikangas et al. but differs from the findings of Singh et al. as the tool used in this study was a screening tool.[2,11] About 3.5%school-going adolescent girls screened positive for major depression; severe severity, which is in accordance with findings by Malik et al. and Jayanthi et al.[12,13] Most of the participants, in this study, who screened positive for anxiety and/or depression were studying in either standard 10th or 12th. Both these classes are termed “board classes” as they take examinations conducted by certified boards in India, which shape their career and hence a higher percentage of anxiety among adolescents in these classes is conspicuous, which is similar to the findings by Bisla et al.[6]
In the present study, factors of perception of self, such as possessing qualities that they are ashamed of, body image dissatisfaction, getting suicidal thoughts in times of difficulties, and being optimistic about future, were found to be significantly associated with both anxiety and depression. Räty LK et al.,[4] in their study conducted in Sweden, showed that compared with males, adolescent females scored less favorably on self-esteem, showed a lower sense of coherence, and reported more behavioral problems. Guo C et al.,[14] in their study, showed that the strongest effect was seen for satisfaction of self-appearance with an odds ratio of 2.75, with regards to positive mental health of young adolescents. Beattie TS et al.,[15] in their study, showed that 2.1%girls reported thinking they would be better off dead or of hurting themselves in some way in the past two weeks and that more than one-third of girls (35.1%) reported having no hope for the future, both of which were significantly associated with mood disorders. Further strengthening the inference that a positive perception of self among adolescent girls is crucial for their mental well-being.
The study was conducted among 200 school-going adolescent girls studying in government secondary schools. Inclusion of private schools, co-ed schools, schools from rural areas, and a greater sample size could have given a more wholesome picture. Personal interview of the participants assured a more reliable data. Two-stage random sampling technique was used to combat confounders in the study.
Conclusion
A fair number of adolescent girls had severe anxiety and major depression of severe severity. Therefore, adolescents must be screened for mental disorders from time to time and those at high risk must be identified. Early identification of adolescents at risk of developing mental health disorders is pivotal for the development of preventive strategies. Also, development of life skills such as self-awareness, confidence, coping in difficult situations, optimism, etc., is crucial in the stage of adolescence. Regular sessions for life skills development conducted in the schools, by trained professionals, are the need of the hour. Further such studies are worthy, in order to generate quality evidence for cost-effective, preventive, promotive, curative, and rehabilitative strategies for mental health disorders among adolescents.
Financial support and sponsorship
I would like to thank MAMTA Health Institute for Mother and Child, for believing in and funding the research study.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
I would like to acknowledge the principals and teachers of both the schools for their cooperation. I would also thank and acknowledge all the beautiful adolescent girls who were a part of this study.
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