Adolescence (10–19 years) is among the age group which highly experiences several factors in their day-to-day activities [
Child or adolescent abuse is an issue concerning millions of youths and their families worldwide. Maltreatment of youths can be defined as an act of omission or commission by others who are caregivers that may have danger, possibility of danger, or threats of danger to adolescents [
The burden of psychiatric disorders on youths is enormous and covers a great number of people in all types of societies. The majority of psychiatric disorders begin at an early age (12–24), even though they are supposed to be experienced in older individuals later in life. Depression is the most common and severe psychiatric disorder that leads to magnifying problems in an adolescent’s capacity to take care of his or her everyday responsibilities and functionalities. Depressive disorders in adolescents result in a horrible consequences even to other healthy components. It may lead to educational impairment, comorbid psychoactive substance abuse, behavioral difficulties, and risky reproductive and sexual practices [
A mental health service for adolescents’ mental health problems is not adequate yet, even in the developed world. Age-related stigma is among the major contributory factors for unmet mental health needs in youths [
Some statistics indicate that depression is as frequent as 20% common in adolescents [
A school-based cross-sectional survey was conducted in South India to estimate the prevalence of depression among school-going adolescents. In this, a total of 2432 school-going adolescents were included in the study and 25% of them have been found to have depression [
Though depression is one of the major diseases that cause failure to socialize among youths, it is often neglected and has not been given adequate attention it needs. The scarcity services to emotional and other mental problems of children and adolescents make this study necessary for strong emphasis to be given for the support of mental health in Ethiopia for the sake of mental and behavioral welfare of growing children and adolescents [
We conducted a facility-based cross-sectional study from January 1 to 30/2019. The study targeted adolescents at Aksum town high schools. Aksum is located in the Tigray region which is 1024 km far from Addis Ababa. There are three high schools in Aksum town currently named Aksum secondary school, Atse/Kaleb secondary school, and Kedamay Minilik secondary school, and there are a total of 2579 grade nine and 2241 grade ten students in the three high schools.
We calculated the sample size using a single population proportion formula, and we took the following assumptions: 95% confidence interval and 4% marginal error. The proportion of depression is 39.3% from the previous study [
Data was collected by face-to-face interview. Initially, screening tools and other developed structured questionnaire in English language were translated to Amharic and Tigrigna and back to English by independent person to check for consistency and understandability of the tool. Data was collected by six bachelor degree holder health professionals. The data collection process was supervised by the principal investigators. Training was given for data collectors for two days by the principal investigator regarding the process and techniques of data collection.
PHQ-9 was used to assess depression which is a multipurpose instrument for screening, diagnosing, monitoring, and measuring the severity of depression. PHQ 9 score of greater than or equal to 10 has sensitivity and a specificity of 88% and Cronbach’s alpha reliability of 0.77 for major depression. Adverse Childhood Experience Questionnaire (ACEQ) which is a 10-item screening tool was used to access parental neglect. ACEQ includes questions that assess emotional abuse and neglect, physical abuse and neglect, educational and medical neglect, and sexual abuse [
The Oslo 3 Social Support Scale was applied to know the level of social support towards adolescents. The scale divides the level of social support into three as poor social support (3-8), moderate social support (3-14), and strong social support (12-14) (reliability of Cronbach’s
After the questionnaire was checked for cleanliness, data was entered using EpiData 3.1 and exported to IBM SPSS version 22 statistical software for analysis. Sociodemographic characteristics of respondents were analyzed by descriptive statistics and presented in percentage, mean, and standard deviations. Bivariate analysis was used to see the association between outcome and independent variables. Multivariate logistic regression was done for those variables whose
A total of 624 participants with a response rate of 99.05% were included in the study. Among this, 339 (54.3%) were females. The age of the majority of students (246 (39.4%)) were known to be 15 years followed by 16 years of age (217 (34.8%)), and more than half (328 (52.6%)) were grade 9 students. More than three-fourths of participants (494 (79.2%)) were Orthodox Christian religion followers (see Table
Distribution of sociodemographic factors in high school students at Aksum town (
Variable | Frequency | Percent (%) |
---|---|---|
Sex | ||
Male | 285 | 45.7 |
Female | 339 | 54.3 |
Age | ||
15 | 246 | 39.4 |
16 | 217 | 34.8 |
17 | 78 | 12.5 |
18 | 63 | 10.1 |
19 | 20 | 3.2 |
Grade | ||
Grade 9 | 328 | 52.6 |
Grade 10 | 296 | 47.4 |
Religion | ||
Orthodox | 494 | 79.2 |
Muslim | 101 | 16.2 |
Protestant | 24 | 3.8 |
Other | 5 | .8 |
Family size | ||
1-5 | 372 | 59.6 |
>5 | 252 | 40.4 |
Residence | ||
Urban | 422 | 67.6 |
Rural | 202 | 32.4 |
Father’s occupation | ||
Farmer | 220 | 35.3 |
Labor work | 32 | 5.1 |
Merchant | 112 | 17.9 |
Government employee | 158 | 25.3 |
Private employee | 102 | 16.3 |
Mother’s occupation | ||
Farmer | 175 | 28.0 |
Labor work | 38 | 6.1 |
Merchant | 76 | 12.2 |
Government employee | 107 | 17.1 |
Private employee | 93 | 14.9 |
Housewife | 135 | 21.6 |
Father’s educational status | ||
Illiterate | 83 | 13.3 |
1-4th grade | 162 | 26.0 |
5-8th grade | 143 | 22.9 |
9-12thgrade | 112 | 17.9 |
Certificate & above | 124 | 19.9 |
Mother’s educational status | ||
Illiterate | 176 | 28.2 |
1st-4th grade | 136 | 21.8 |
5th-8th grade | 124 | 19.9 |
9th-12th grade | 117 | 18.8 |
Certificate & above | 71 | 11.4 |
Among participants, the level of social support was measured. Based on the result of this study, majority of students (256 (41%)) have been found to have poor social support followed by moderate social support (217 (34.8%)) and only 151 (24.2%) students were under good social support (see Figure
Distribution of the level of social support among high school students at Aksum town, 2019 (
Regarding substance use among high school students at Aksum town, only 22 (3.5%) have chewed khat within their lifetime whereas only 14 (2.2%) students chewed khat within the last 3 months. 247 (39.6%) participants reported alcohol drinking in their lifetime while only 138 (22.1%) students drank alcohol within the last 3 months. Regarding cigarette smoking, 26 (4.2%) of the total participants smoke within their lifetime and 20 (3.2%) smoke cigarettes within the last 3 months (see Figure
Distribution of substance-related factors among high school students at Aksum town, 2019 (
Parental neglect among adolescents was assessed using the Adverse Childhood Experience Questionnaire in which the neglected part assessed physical and emotional neglect. Among the 624 adolescents who participated in this study, 334 (53.5%) participants answered yes to one or more questions among the total 10 items of the Adverse Childhood Experience Questionnaire and females account 190 (56.9%) of the total response. Among this figure of students experiencing parental neglect, more than half (175 (52.4%)) of them were grade 9 students (see Table
Distribution of Adverse Childhood Experience Questionnaire by sex and educational level among adolescents in the sampled governmental high schools in Aksum town, Ethiopia, 2019 (
Variables | Male ( |
Female ( |
Grade 9 ( |
Grade 10 ( |
Total ( |
---|---|---|---|---|---|
Physically hurt | |||||
Yes | 74 (11.9) | 116 (18.6) | 98 (15.7) | 92 (14.7) | 190 (30.4) |
No | 211 (33.8) | 223 (35.7) | 230 (36.9) | 204 (32.7) | 434 (69.6) |
Hit you marks of injury | |||||
Yes | 34 (5.5) | 58 (9.3) | 48 (7.7) | 44 (7) | 92 (14.7) |
No | 251 (40.2) | 281 (45) | 280 (44.9) | 252 (40.4) | 532 (85.3) |
Sexual abuse | |||||
Yes | 26 (4.2) | 45 (7.2) | 41 (6.6) | 30 (4.8) | 71 (11.4) |
No | 259 (41.5) | 294 (47.1) | 287 (46) | 266 (42.6) | 553 (88.6) |
No love | |||||
Yes | 41 (6.6) | 67 (10.7) | 51 (8.2) | 57 (9.1) | 108 (17.3) |
No | 244 (39.1) | 272 (43.6) | 277 (44.4) | 239 (38.3) | 516 (82.7) |
Not enough food or protection | |||||
Yes | 35 (5.6) | 44 (7) | 43 (6.9) | 36 (5.8) | 79 (12.7) |
No | 250 (40.1) | 295 (47.3) | 285 (45.7) | 260 (41.7) | 545 (87.4) |
Divorced parents | |||||
Yes | 31 (5) | 49 (7.8) | 41 (6.6) | 39 (6.2) | 80 (12.8) |
No | 254 (40.7) | 290 (46.5) | 287 (46) | 257 (41.2) | 544 (87.2) |
Abuse with gun or knife | |||||
Yes | 20 (3.2) | 29 (4.6) | 28 (4.5) | 21 (3.4) | 49 (7.9) |
No | 265 (42.5) | 310 (49.7) | 300 (48.1) | 275 (44) | 575 (92.1) |
Live with alcoholic or drug user | |||||
Yes | 29 (4.6) | 42 (6.7) | 40 (6.4) | 31 (5) | 71 (11.4) |
No | 256 (41.1) | 297 (47.6) | 288 (46.1) | 265 (42.5) | 553 (88.6) |
Depressed or attempted suicide household member | |||||
Yes | 19 (3) | 28 (4.5) | 31 (5) | 16 (2.6) | 47 (7.6) |
No | 266 (42.6) | 311 (49.9) | 297 (47.6) | 280 (44.8) | 577 (92.4) |
Household member in prison | |||||
Yes | 41 (6.6) | 46 (7.4) | 50 (8) | 37 (6) | 87 (14) |
No | 244 (39) | 293 (47) | 278 (44.5) | 259 (41.5) | 537 (86) |
Parental neglect | |||||
Yes | 144 (23.1) | 190 (30.4) | 175 (28) | 159 (25.5) | 334 (53.5) |
No | 141 (22.6) | 149 (23.9) | 153 (24.5) | 137 (22) | 290 (46.5) |
The study showed that the prevalence of depression was 226 (36.2%) with 95% CI (32.3, 40.2). The prevalence rate was higher among grade 10 students since 110/296 (37.2%) of them met the screening criteria for depression which is higher when compared to 116/328 (35.4%) of them who met the screening criteria for depression in the study. According to the PHQ-9 severity classification from the total students under depression, 133 (21.3%) students lie in the mild depression category whereas 74 (11.4%), 15 (2.4%), and 7 (1.1%) students were found to have moderate, moderately severe, and severe depression, respectively (see Figure
Characterization of depression severity among adolescents in governmental high schools at Aksum town, 2019 (
Adverse Childhood Experience Questionnaire which assesses physical neglect, educational neglect, emotional neglect, and medical neglect was used to assess the main independent variable. Physical neglect refers to parents’ negligence to provide adequately nutritious meals consistently, or it might mean that parents have abandoned their child. Educational neglect is a failure to provide a child with adequate education in the form of enrolling them in school or providing adequate homeschooling. Emotional neglect is consistently ignoring, rejecting, verbally abusing, teasing, withholding love, isolating, or terrorizing a child. Medical neglect is, in turn, the failure to provide appropriate health care for a child (although financially able to do so) [
The adverse childhood experience questionnaire was checked for colinearity between each item using the Pearson correlation coefficient at the
In addition to parental neglect, bivariate analysis was done for other explanatory variables for depression and the result revealed that explanatory variables, sex, family size, father’s education, mother’s education, social support, and current use of alcohol, were found to have a
Bivariate and multivariate logistic analysis of factors associated with depression among adolescents in the sampled governmental high schools in Aksum town, Ethiopia, 2019 (
Variable | Category | Depression | COR (95% CI) | AOR (95% CI) | ||
---|---|---|---|---|---|---|
Yes | No | |||||
Sex | Male | 83 | 202 | 1 | 1 | |
Female | 226 | 113 | 4.86 (1.82, 5.22) | 1.48 (1.03, 2.13) | 0.034 | |
Family size | ≤5 | 143 | 229 | 1 | 1 | |
>5 | 83 | 169 | 0.79 (0.56, 1.10) | 0.77 (0.53, 1.10) | 0.150 | |
Social support | Poor | 107 | 149 | 1.86 (1.21, 2.88) | 1.69 (1.07, 2.69) | 0.026 |
Moderate | 77 | 140 | 1.43 (0.91, 2.24) | 1.56 (0.97, 2.52) | 0.067 | |
Good | 42 | 109 | 1 | 1 | ||
Current alcohol | Yes | 98 | 149 | 1.28 (0.918, 1.784) | 0.73 (.51, 1.06) | 0.100 |
No | 128 | 249 | 1 | 1 | ||
Mother’s education | Illiterate | 75 | 99 | 2.07 (1.13, 3.80) | 2.21 (1.09, 4.49) | 0.028 |
1-4 | 49 | 86 | 1.56 (0.83, 2.93) | 1.45 (0.70, 3.01) | 0.317 | |
5-8 | 47 | 79 | 1.63 (0.861, 3.08) | 1.67 (0.83, 3.35) | 0.153 | |
9-12 | 36 | 82 | 1.20 (0.62, 2.31) | 1.27 (.64, 2.56) | 0.496 | |
College and above | 19 | 52 | 1 | 1 | ||
Father’s education | Illiterate | 35 | 46 | 1.81 (1.01, 3.24) | 1.11(.56, 2.20) | 0.768 |
1-4 | 62 | 101 | 1.46 (0.89, 2.40) | 0.92(.495, 1.706) | 0.789 | |
5-8 | 56 | 87 | 1.53 (0.92, 2.55) | 1.11 (0.61, 2.03) | 0.730 | |
9-12 | 36 | 76 | 1.13 (0.65, 1.96) | 1.00(.55, 1.83) | 0.997 | |
College and above | 37 | 88 | 1 | 1 | ||
Parental neglect | Yes | 156 | 178 | 2.75 (1.95, 3.89) | 2.61 (1.83, 3.72) | 0.000 |
No | 70 | 220 | 1 | 1 |
The study revealed that the prevalence of depression was 36.2%. This result was in line with studies conducted in Addis Ababa (39.3%) among adolescents in governmental high schools [
However, the current finding for the study on depression was higher than that for the studies conducted among adolescents at Korea (20.6%) [
On the other hand, the finding of this study on the prevalence of depression was lower than that of a study conducted in Can Tho City, Vietnam (41.1%) [
The above difference might also be due to differences in screening tools used to determine depression in which the Center for Epidemiology Studies Depression Scale (CES-D) was used in a study conducted in Can Tho City, Vietnam [
Regarding the severity of depression, the prevalence of mild depression was in line with a study conducted in Egypt which was 21.5%. However, the result of this study for moderate and severe depression is higher than that of a study conducted in Egypt which was 7.1% and 0%, respectively [
The result of this study on mild depression is also found to be lower than that of a study conducted in Iran among high school and preuniversity adolescents which was 28% [
Furthermore, the result of this study revealed the prevalence of parental neglect among adolescents to be 53.5%. This result has been found consistent with the study conducted in Addis Ababa preparatory school which was 53.1% [
Parental neglect which is the main independent variable is found to be statistically associated with depression at a
Students who were experiencing parental neglect were 2.61 times more likely to develop depression than those who did not experience parental neglect. This study is in line with a study conducted in Addis Ababa (
In more tremendous cases, breakdown to succeed can also influence children over their entire existence course by really destructing their cognitive progress and their immune system due to inadequate calorie intake or lack of therapeutic consideration, making the child lose developmental milestones to a great extent and a great extent prone to poor health even after adulthood and give way to depression [
It might also be because a preponderance of neglected kids displays attachment disorder manifestations and finally forms timid connections even to their close families. This disturbed attachment to their primary caregiver alters their upcoming interaction with peers by making them emotional and physically isolated from others, and this in turn reduces the possibility of forming true relations. Moreover, as a result of their precedent abuse, neglected children experience that forming close relationships with others loses their control in life and exposes them by raising their susceptibility [
Neglectful parents and caregivers give poor interaction and positivity for their belongings which is linked to increased levels of shame called shame-proneness [
The development of the brain may continue beyond adolescence age group. Therefore, neglectful experiences may impose a lasting effect on the continuing need for optimal conditions for development of some structures concerned with attention and emotional regulation, which contributes to the heightened occurrence of depression in victims [
The increased occurrence of depression in those who are experiencing parental neglect might also be due to the reason that neglected children show trouble in regulating their feeling and appreciating others’ emotional expression and trouble in differentiating emotions which amplify their susceptibility for developing depression. Youths with a history of neglect during their early ages may also have stressful reminders which contributes to their current depressive state by suppressing and leads to deregulation of their emotion [
The higher prevalence of depression may also be a result of the injured hippocampus, as there are elevated levels of stress hormones such as cortisol due to increased stress levels in youths who had experienced neglect. This increased release of stress hormone is assumed to have an injury on the hippocampus, cortical area implicated in diverse brain function, and this, in turn, gives rise to developing depression in youths [
In the current study, the prevalence of depression is found to be high when compared to other populations. A significant and strong association is also determined between parental neglect and depression. During the data collection period, patients with a severe depression category were linked to a hospital and 24 of them got psychiatric evaluation for diagnosis and treatment accordingly. The result of this study has been submitted to stallholders for special consideration to depression and parental maltreatment towards adolescents. It is good if school teachers give emphasis to those students who seem psychologically unwell. It is better if school teachers exercise recommending such students to school psychologists. It is good to conduct a prospective cohort study to investigate the temporal relationship between factors and depression. It is good if Aksum University comprehensive hospital starts a campaign which will teach about the effect of parental neglect on the adolescent’s mental health. Then, it is good to start clinic service for students who are psychologically unwell including consultation service.
All the data included in the manuscript can be accessed from the corresponding author Mengesha Srahbzu upon request through email address of
Ethical clearance was obtained from the ethical review board of the Institute of Health, Aksum University.
Written consent was asked from each selected student after being informed about the nature, purposes, benefits, and adverse effects of the study and invited to participate. Written assent was also obtained from those who are under 18 years old from their parents/guardians/teachers. Confidentiality was ensured. Participants were strictly informed as they have the right to refuse or discontinue participation at any time.
The authors declare that there is no conflict of interest regarding the publication of this paper.
All authors contributed to the study conception and design. Material preparation and data collection and analysis were performed by Enguday Tirfeneh Gebeyehu and Mengesha Srahbzu Biresaw. The first draft of the manuscript was written by Mengesha Srahbzu Biresaw, and all authors commented on the previous version of the manuscript. All authors read and approved the final manuscript.
First, we would like to thank Aksum University for allowing and supporting the research materially. We would like to extend our heartfelt thanks to Aksum University College of Health Science Research Office and ethical review committee for their timely cooperation. We would like also to praise our thanks to the Aksum town education office and each governmental high school head office for their cooperation during the data collection period. Finally, we would like to extend our thanks to the study participants.