|Year : 2023 | Volume
| Issue : 1 | Page : 14-20
Depression and associated factors among in-school adolescents in Nigeria
Ezioma Anne Alinnor1, Chukwuma Ugochukwu Okeafor2
1 Department of Paediatrics, University of Port Harcourt Teaching Hospital, Rivers, Nigeria
2 Department of Mental Health/Neuropsychiatry, University of Port Harcourt Teaching Hospital, Rivers, Nigeria
|Date of Submission||07-Oct-2022|
|Date of Decision||14-Dec-2022|
|Date of Acceptance||13-Jan-2023|
|Date of Web Publication||10-Feb-2023|
Chukwuma Ugochukwu Okeafor
Department of Mental Health/Neuropsychiatry, University of Port Harcourt Teaching Hospital, Rivers
Source of Support: None, Conflict of Interest: None
Introduction: Depression is projected to become the leading cause of disability as well as the leading contributor to the global burden of disease by 2030. Depression in adolescents is a public health concern as it increases the risk of substance abuse, relationship difficulties, suicide, and poor academic performance. This study aimed to determine the prevalence of depression and its associated risk factors among adolescents. Methods: This was a school-based cross-sectional study involving 1428 adolescents aged 10–19 years in secondary schools in the Port Harcourt metropolis, Rivers State, Nigeria. Adolescents were selected using multistage sampling technique. Data on sociodemographic and family structure were obtained using a self-administered pretested semi-structured questionnaire. The presence of depression was determined using the Beck Depression Inventory (BDI). Adolescents with BDI scores of ≥18 were categorized as depressed. Bivariate and multivariate analyses were performed at P < 0.05. Results: Of the 1428 adolescents recruited, 563 (39.4%) were males. The mean age was 14.30 ± 2.04 years. The prevalence of depression was 21.9% (n = 313). Significantly higher odds of depression were reported among females (adjusted odds ratio (AOR): 1.447; 95% confidence interval (CI): 1.107–1.891; P = 0.007), low socioeconomic status (AOR: 1.409; 95% CI: 1.064–1.865; P = 0.017), and family structures that were not monogamous (AOR: 1.586;95% CI: 1.152–2.183; P = 0.005). Conclusion: Depression is not uncommon among in-school adolescents in Nigeria. In addition to the inclusion of screening for depression in the school health program, measures to reduce the burden are advocated, especially among female adolescents and adolescents from low socioeconomic backgrounds.
Keywords: Adolescence, depression, mental health
|How to cite this article:|
Alinnor EA, Okeafor CU. Depression and associated factors among in-school adolescents in Nigeria. Asian J Soc Health Behav 2023;6:14-20
| Introduction|| |
The adolescent period is a transitional stage of physical and psychological human development that generally occurs during the period from puberty to legal adulthood. Adolescence is marked by hormonal changes with resultant physical maturation, body changes, and exposure to varying levels of stress. This has been linked to mood disorders such as depression, which is a common mental health problem for young people worldwide. However, they have been neglected as a distinct group and overridden by the promotion of family, women, and child health needs, despite glaring evidence of their special health-related vulnerabilities.
Depression is a mental disorder characterized by loss of interest or pleasure in daily activities, low mood and aversion to activity, feelings of worthlessness or low sense of well-being, irritability, significant weight loss or gain, loss of appetite, insomnia or hypersomnia, loss of energy and inability to concentrate. It is a mood disorder that is marked by feelings of sadness, worthlessness, or hopelessness as well as problems with concentrating and remembering details. Depression is projected to become the leading cause of disability and also the leading contributor to the global burden of disease by the year 2030.
Identifying depression in adolescence may be challenging due to the attitude of the adolescent, who may not be aware of a problem or seek help for this problem. Furthermore, the low perception of parents/caregivers, teachers, and doctors who observe mainly the external behavioral disturbances, without placing attention to the depressive emotions of the adolescent, obstruct the need to seek medical attention. Another factor that makes depression so difficult to diagnose in adolescents is the common behavioral changes that are associated with this period. Despite the high prevalence and the substantial impact of depression, detection, and treatment have been suboptimal. It has also been shown that most adults who experience recurrent episodes of depression had an initial depressive episode as teenagers, suggesting that adolescence is an important developmental period in which to intervene. Depressed adolescents are at increased risk of poor school performance, substance abuse, relationship difficulties, attempted or actual suicide, and an increased risk of recurrence of depression in adulthood.
Previous studies on depression among adolescents have reported varying prevalence rates of 4.0%–43.6% due to differences in geographical distribution and screening tools adopted.,,, Most of these studies were focused on depression prevalence rates by age and sex characteristics. However, the index study sought to enrich the body of literature by the inclusion of other demographic and family-related variables in determining associated factors of depression. Furthermore, the findings of the study could provide evidence-based information required to inform policies targeted at promoting adolescent health and optimizing the school health program. Therefore, the purpose of this study was to determine the prevalence and factors associated with depression among adolescents.
| Methods|| |
The study was conducted in Port-Harcourt metropolis, Rivers State in Nigeria, West Africa. Based on data from the 2006 census, Rivers State has a population of about 5,198,716 people. Port Harcourt Metropolis consists of Port Harcourt and Obio-Akpor Local Government Areas (LGAs), which have 61 and 43 secondary schools, respectively. The mean age of adolescents in Nigeria is 14.27 years, with a male-to-female ratio of approximately 1:1.
Study design and study population
This was a school-based cross-sectional study. The study population comprised male and female adolescent students aged 10–19 years.
Sample size calculation
The minimum sample size was calculated using the formula for cross-sectional design.
n = minimum sample size, Z = standard normal deviate of 95% confidence level = 1.96
p = prevalence of depression among adolescents = 6.9% (based on a study by Adewuya et al).
q = 100 − p (100–6.9 = 93.1)
d = level of precision = 1.5%
Minimum sample size (n) =1100
After adjustment for 20% nonresponse, an approximate sample size of 1428 was attained.
Multi-stage sampling method was employed in this study. This involved four stages; the list of Public and Government-approved Private schools in Port Harcourt LGA and Obio-Akpor LGA, as obtained from the Rivers State Ministry of Education, acted as the sampling frame.
Stage 1 (stratification into school districts)
The 61 secondary schools in Port Harcourt LGA were stratified into the three school districts of Diobu with 15 secondary schools, Township with 20 secondary schools, and Trans-Amadi with 26 secondary schools. The 43 secondary schools in Obio-Akpor LGA were stratified into the four school districts of Akpor with seven secondary schools, Apara with 16 secondary schools, Evo with 13 secondary schools, and Rumueme with seven secondary schools.
Stage 2 (stratification into public and private schools)
The schools within each district were stratified according to their various proprietorship into Public and Private Schools. Diobu has five public and ten private schools (1:2), Township has six public and 14 private schools (1:2), Trans-Amadi has seven public and 19 private schools (1:3), Akpor has three public and four private schools (1:1), Apara has ten public and six private schools (2:1), Evo has nine public and four private schools (2:1), and Rumueme has three public and four private schools (1:1). Based on the ratio of public and private schools in each district, the schools were selected in the same ratio as they occurred above. Simple random sampling via ballots was then employed to select six schools (two public and four private) from Diobu; six schools (two public and four private) from Township; eight schools (two public and six private) from Trans-Amadi; four schools (two public and two private) from Akpor; six schools (four public and two private) from Apara; six schools (four public and two private) from Evo and four schools (two public and two private) from Rumueme. Thus, making a total selection of 40 schools, with 20 schools from Port Harcourt LGA and 20 schools from Obio-Akpor LGA.
Stage 3 (stratification into classes and arms)
The 40 selected schools were stratified by class into six regular classes, namely JSS 1, JSS 2, JSS 3, SS 1, SS2, and SS 3, giving a total of 240 classes. From each of the classes, one arm was selected by simple random sampling via the ballot method. Where there was only one arm in a class, that arm was selected, making a total of 240 arms.
Stage 4 (selection of students)
From each of the arms, six students were selected by simple random via ballots using the class register as the sampling frame to ensure the calculated sample size for the study was reached.
Data were collected over a 6-week period within a school term, from May 16 to June 30, 2017. Data collection was done using a self-administered pretested semi-structured tool comprising of sociodemographic questionnaire and the Beck Depression Inventory (BDI). The sociodemographic questionnaire included the students' age, sex, religion, family structure, and parents/guardians' level of education and occupation. The family structure consisted of monogamous, polygamous, single parent/divorced parents, living with the guardian, and orphanage setting. The educational attainment and occupations of parents/guardians were used to determine the Socioeconomic Index Score of the subjects using the Oyedeji classification for social class. The BDI was utilized to identify the presence of depression. It is a valid and reliable self-administered tool for depression. The English BDI adopted in this study has been previously validated in Nigeria among the adolescent population. A score of 18 and above in the BDI was considered depression in this study.
Summary measures of mean and standard deviation were used for numerical variables, while frequencies and proportions were used for categorical variables. Depression categorized as Yes/No was the dependent variable, while the independent variables comprised age, sex, religion, socioeconomic class, and family structure. Bivariate analysis was performed at a 0.05 significant level using Chi-square statistics or Fisher's exact test. Fisher's exact test was used only when the expected cell value was below five in at least twenty percent of the crosstab cells. Variables with P < 0.05 from the bivariate analysis were entered into the logistic regression model to identify predictors of depression. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were determined as measures of the strength of the association. Statistical Package for the Social Sciences (SPSS), version 20 (IBM, New York, USA).
Ethical clearance was obtained from the Research and Ethics Committee of the University of Port Harcourt Teaching Hospital (UPTH) before the commencement of the study, with reference number: UPTH/ADM/90/S. II/VOL. X/631. Permission to carry out the study was obtained from the Rivers State Universal Basic Education Board and the Rivers State Senior Secondary Schools Board. A written informed consent was obtained from the parents of selected adolescents, while assent was obtained from the adolescents. Information retrieved were treated with the utmost confidentiality. The voluntary withdrawal was upheld in the study. Study participants who were found to be depressed were referred to UPTH for further evaluation and management.
| Results|| |
A total of 1428 adolescents were involved in the study. There were 563 males and 865 females, giving a male:female ratio of 1:1.5. The mean age was 14.30 ± 2.04 years. The median age of the adolescents was 15 years, with an age range of 10–19 years.
Sociodemographic and family structure characteristics
[Table 1] shows the sociodemographic and family structure findings of the adolescents in the study. Almost three-quarters of the participants belonged to the high socioeconomic class (74.2%; n = 1060). Majority (98.1%) were Christians. Concerning family structure, the highest proportion of the students was from monogamous family settings (83.8%), while polygamous and living with guardian settings revealed proportions of 5.0% and 6.7%, respectively.
|Table 1: Distribution of sociodemographic and family structure characteristics of adolescents|
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Depression prevalence among the adolescents
A total of 313 of 1428 adolescents in the study had depression, giving a prevalence of 21.9%.
[Table 2] shows the bivariate analysis of sociodemographic and family structure characteristics by depression. Adolescents aged 18–19 years had the highest prevalence of depression (38.7%), while the least prevalence was reported among those aged 10–14 years (18.9%). This difference was statistically significant (P = 0.0001). Concerning depression prevalence by sex, females had a higher prevalence than males (24.5% vs. 17.9%; P = 0.003). There was no significant difference between religion and depression among adolescents (P = 0.368).
|Table 2: Bivariate analysis of the relationship between depression and sociodemographic and family structure characteristics among adolescents|
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Depression prevalence was highest among adolescents who belonged to the low socioeconomic class (31.4%) and lowest among those in the high socioeconomic class (19.9%). This difference was statistically significant (P = 0.005). Adolescents in the monogamous family structure had the lowest prevalence of depression (20.2%), while those from orphanages and single/divorced families had higher prevalence rates of 100% and 34.9%, respectively.
Predictors of depression among adolescents
[Table 3] shows the logistic regression analysis of predictors of depression. The study found that sex, socioeconomic class, and family structure were significantly associated with depression. Females were about 1.4 times more likely to experience depression than males (AOR: 1.447; 95% CI: 1.107–1.891; P = 0.007). Furthermore, adolescents belonging to the low socioeconomic class were about 1.4 times more likely than those from the middle/high socioeconomic class (AOR: 1.409; 95% CI: 1.064–1.865; P = 0.017). Other family structures that were not monogamous had higher odds of depression than monogamous family (AOR: 1.586; 95% CI: 1.152–2.183; P = 0.005). After controlling for sex, socioeconomic class and family structure, age of the adolescent showed no significant relationship with depression.
| Discussion|| |
This school-based study focused on depression and associated factors among adolescents and found that depression is not uncommon among the study population. The prevalence of depression of 21.9% reported among adolescents in this study is in tandem with other studies in Nigeria., Similar high prevalence of depression was reported among adolescents in Kenya and India. Yet, this finding that 1 in 5 adolescents experience depression is a public health concern because of the consequences of depression, such as suicidal thoughts, suicide, substance abuse, and poor academic performance. A much earlier Nigerian study revealed a depression rate of 6.9%, which, in the light of the index study, reveals the possibility of an upward trend in the prevalence of depression among adolescents in Nigeria. However, a study in Uganda reported a depression prevalence of 7.6%, which is much lower than the index study. This disparity could be due to the adoption of diagnostic interviews in identifying depression in the study in Uganda, whereas the index study utilized a self-administered screening tool. The use of diagnostic interviews in detecting depression increases specificity and reduces the number of false positives. However, depression screening tools remain a valid means of rapidly identifying positive cases so that further evaluation can be undertaken.
Although several studies,,, have noted a significant relationship between age and depression, with older aged adolescents reporting higher prevalence rates, the index study's findings did not have sufficient evidence to support such observations. After controlling for other demographic and family structure factors, the age of the adolescents showed no significant relationship with depression in the present study, implying that the risk of depression was similar in both early and late adolescents. This finding infers that interventions targeted at curtailing depression should be carried out across all adolescents, irrespective of their ages. In keeping with the index study, some similar studies have also reported no significant difference between depression and the ages of adolescents.,
There was a significantly higher prevalence of depression among female adolescents compared to males in this study, which is consistent with other studies.,, Possible explanations for the higher prevalence in females are the effect of puberty and the hormonal changes that occur. In addition, females are more emotional, more vulnerable to difficulties in social relations and tend to dwell more on interpersonal and body image events than males. Males, on the other hand, in trying to conform to traditional norms of masculinity, may not express their emotions so as not to be seen as weak, and this may affect their response while filling out the screening tool.
The prevalence of depression was significantly higher in study participants whose parents belonged to the low socioeconomic class, which is consistent with the studies by Kinyanda et al., and Joinson et al. Families with low socioeconomic status are more likely to be affected by stressful life events, as they are faced with economic hardships and lack opportunities for social support compared to families from higher socioeconomic class, thereby increasing their predisposition to depression. However, this differed from the study by Huisman et al., where adolescents from high socioeconomic backgrounds had a higher risk for mental health problems such as depression. The longitudinal nature of the study by Huisman et al., which followed up the subjects from birth to 11 years of age and the measure for classification of socioeconomic status (mothers' highest educational attainment and household income) may have influenced the difference in the findings reported.
Concerning family structure and depression, adolescents with single or divorced parents had significantly higher rates of depression than those from other family settings. This may be attributed to the quality of parenting and the home environment in single-parent settings. A similar high prevalence of depression among adolescents from single homes have been documented in previous research.,, This contrasted with findings by Grinde and Tambs in Norway, which reported no relationship between single parenting and depression. Government support to single parents in developed nations such as Norway may reduce the risk of such adolescents experiencing depression; however, such support is not present in the setting where the current study was carried out. Nonetheless, the present study highlights the role of family structure in depression among adolescents. Therefore, measures to promote positive family relationships as well as emotional support to families could reduce the burden of depression among adolescents.
The findings of the index study reiterate the need for assessment of the mental health of adolescents at regular intervals. Furthermore, the guidance and counseling units of the school health program should be strengthened to provide timely support and appropriate referrals to adolescents with emotional issues such as depressive symptoms. The finding on the reported mean age in the study samples being similar to that of the population mean of adolescents in Nigeria promotes the external validity of the study. The cross-sectional design of the study forestalls causal inference in the identified factors associated with depression. The study being a school-based one may limit the external validity, as inferences may not be extrapolated to out-of-school adolescents. Another possible limitation of the study is social-desirability bias; however, this was minimized by maintaining anonymity and reassurance of confidentiality of information to the adolescents in the study.
| Conclusion|| |
Depression is not uncommon among adolescents in the Port Harcourt metropolis. Predictors of depression among in-school adolescents included female sex, low socio-economic status and being raised in a non-monogamous family setting. The study serves as a basis for modifying school health programs to address depression among adolescents. In addition, the findings reveal that strategies targeted at reducing the burden of depression among adolescents should encompass positive socioeconomic and family relationship measures.
The authors would like to thank Eagles Watch Research Centre for research support services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]