What determines psychological well-being among Iranian female adolescents? Perceived stress may overshadow all determinants

Introduction

Mental health problems, as one of the most neglected issues among adolescents,¹ are common during adolescence and emerging adulthood.² The prevalence rate of major depressive disorders in Iran is reported to be 4.1%.³ Previous studies in Iran have reported the prevalence of mental disorders to be from 11.9% to 23.8%.^4,5 Globally, mental disorders and mental health problems seem to have been considerably increased among adolescents in the past decades. It is also a growing public health concern among children and adolescents of developing countries.^6,7 An increase in self-reported stress-related and mental health problems among girls and young women is shown in several nationwide surveys. A systematic review on Iranian studies has shown a wide range for the prevalence rates of mental disorders among high school students and has thus suggested more studies with improved quality in this field.⁸

Among the adolescents, mental health may be related to health behaviors such as smoking, alcohol use and physical activity. Female adolescents are in particular need for effective programs to develop healthy lifestyle behaviors.⁹ Thus, it is important to consider both health behavior and mental health while exploring the independent contributions of these factors. In the domain of healthy lifestyle and prudent health behaviors, previous studies have reported significant associations between happiness and regular physical activity¹⁰ or higher levels of physical activity,¹¹ not smoking or less cigarette use¹² and healthy diet.¹² Therefore, there is less likelihood for happy individuals to engage in damaging and unhealthy behaviors.

Among adolescents, academic pressures and social isolation may be risk factors for the development of mental health problems,¹³ as well. To maintain their mental health, friendship is particularly important.¹⁴ The results of studies performed on the importance of friendships for mental health among college students, the styles of teenagers’ relations, and the formation of friendships during interpersonal stress, have indicated that friendship and interpersonal relations are very important to protect mental health among adolescents.¹⁵

A previous study in Iran reported that 61.7% of the adolescent female students in Tehran had some degree of anxiety.¹⁶ In another Iranian study, a majority of the students was reported to be with mental health problems.¹⁷ In developing countries, there is a lack of research on the self-reported wellbeing among female adolescents.¹⁸ Also, few researches have focused on comparing subjective wellbeing among different adolescent groups (e.g. age, economic status, ethnicity, parental education).¹⁹ On the other hand, few studies in developing countries have considered how perception on facts in daily living (such as perception on the economic status of family, religion, and healthy lifestyles) among female adolescents may be associated with psychological wellbeing at the presence of psychological constructs (like happiness, hopefulness and stress). Thus, the aim of the present study was to investigate the determinants of psychological wellbeing among female adolescents in Tabriz, Iran. The following questions guided our study: (1) How is psychological wellbeing among female adolescents in a developing country, like Iran?, (2) How the Iranian female adolescents perceive the facts of daily living?, and (3) Does perceptions on facts in daily living predict psychological wellbeing, at the presence of psychological constructs (like happiness, perceived self-efficacy and stress)?

Materials and Methods

Results

Of the 300 students who were selected as the sample size, 289 were enrolled in the study, and 11 were excluded due to transfer to other areas. The socio-demographic characteristics of the participants along with their social relationship, having a healthy lifestyle, perceptions on daily facts and commitment to healthy action plan are displayed in Table 1 and 2. About more than half of the students (51.6%) reported to have/had boyfriend. The majority had a good to fair social relationship, religious belief, economic situation and commitment to a healthy action plan (Table 2). Mean (standard deviation) for psychological well-being was 31.04 (15.33) (Table 3).

Mean, standard deviations, mean percent, number of items, possible range and Cronbach α for the psychological constructs as well as their correlation coefficients with psychological wellbeing are presented in Table 3. The Cronbach α for the most of constructs was 0.7 and higher showing an acceptable to excellent internal consistency. The exception was hopefulness (α = 0.53). The level of scores for almost all variables was more than average, which means that the respondents acquired more than one half of the maximum possible score in almost all variables except for psychological wellbeing (mean percent = 36.9%). The lowest scores were found to be for stress (53.87%) and self-efficacy (64.37%). Applying Pearson correlation coefficient test, psychological well-being was found to have statistically significant positive correlations with all psychological constructs except for stress which was negatively associated with psychological well-being (r = -0.689) (Table 3).

As there is shown in Table 4, demographic characteristics of the respondents explained only 6.2% of the observed variance in psychological well-being (P < 0.001). In the subsequent blocks, significant effects were found on psychological well-being by Perceptions on daily facts (P < 0.001) (R² = 0.152), healthy lifestyle (R² = 0.212, P < 0.001), commitment to a healthy action plan/take care about health (R² = 0.211, P < 0.001), perception on social relations (R² = 0.279, P < 0.001) and the psychological variables (R² = 0.595, P < 0.001).

In the final model (step 6), satisfaction with family lifestyle (β = 0.168, P < 0.001) and physical activity (β = 0.140, P < 0.001) were significant positive predictors for psychological well-being. Also, willingness to create happy times (β = -0.084, P < 0.040) and stress (β = -0.470, P < 0.001) were significant negative predictors for the outcome variable (R² = 0.595, P < 0.001).

Considering the significant role of perceived stress in the final model, the hierarchical regression analysis was run once again to find the predictors of perceived stress (Table 5). In the first model, demographic characteristics explained only 3% of the observed variance in perceived stress (P < 0.05). In the second model (step 6), physical activity (β = -0.109, P < 0.019), have/had boyfriend (β = 0.237, P < 0.001), hopefulness (β = -0.130, P < 0.05) and happiness (-β = 0.387, P < 0.001) were significant predictors for perceived stress (R² = 0.453, P < 0.001).

Discussion

This study was conducted to investigate the determinants of psychological wellbeing among female adolescents in Tabriz, Iran. Understanding the psychological wellbeing status and identifying its influential factors among female adolescents may be helpful in addressing the issue through mental health promotion interventions.

In the current study, all the psychological constructs, except for perceived stress, were not significant predictors for mental health. In other words, at the presence of all underlying factors, perceived stress was the most significant negative predictor for psychological wellbeing among the female adolescents. This finding highlights the role of stress in determining psychological wellbeing of female adolescents. As there were several other variables in the present study that could potentially predict psychological wellbeing, it seems that perceived stress has overshadowed the influence of a majority of other variables. For instance, self-efficacy as a perception that determines an individual’s resilience to adversity and his/her vulnerability to depression,⁴⁰ has been shown as an important influencing factor on human behavior and mental health.^41-43 However, its association with psychological wellbeing in our study was not significant. We presume that such associations between the independent variables and outcome variable of our study are affected by perceived stress, considering the high impact of this variable in the final model of the present study as well as the high level of stress among Iranian female adolescents, as reported in the literature.^16,44 Uncontrolled stress may have a detrimental impact on the physical and mental well-being of adolescent and may lead to various disorders such as depression.^36,37 Based on our findings, training skills to create daily happy time events, like listening to music, dancing, and watching movie may increase self-efficacy and decrease the level of stress as steps toward achieving female adolescent’s psychological wellbeing in a country like Iran with specific religious socio-cultural limitations for women.

In the present study, economic status was one of the predictors for psychological wellbeing, in a way that the students with a better perception on the economic status of their families had a better status in their psychological wellbeing. This finding is consistent with those of Ho et al, who associated income disparities to psychological well-being among children.²⁹ It has been well documented that poverty is negatively associated to physical and psychological well-being among adolescents and children.^38,39 Mental disorders and stress among girls in developing countries are common and a public concern,⁴⁵ as well. The World Health Organization (WHO) has focused on building evidence for the prevalence and causes of mental health, promoting health policies and enhancing competence of primary health care providers in such countries. But, this problem may be due to the cultural context and economic status of those countries, which urges the need for developing and applying comprehensive context-based social and community-based strategies with the hope to promote psychological well-being for female adolescents.

It seems that identifying of the students with low socioeconomic status as a vulnerable group during health promotion interventions in schools may be necessary to provide them with some facilities and supportive environments as well as financial aid with the hope to promote their level of mental health. Such students may be encouraged to participate more in the health promotion activities by providing them with gift cards, as a good incentive and financial assistance for mental health promotion.

One of the surprising results of our study was the negative contribution of willingness to create happy moments to psychological well-being, which means that the students with lower level of psychological wellbeing had more willingness to create happy moments. Moreover, our findings and previous studies have suggested links between happiness and psychological wellbeing.¹⁷ In other words, the students may feel the lack of happiness as a cause for their low level of psychological wellbeing, and therefore tend to find situations for more happy moments. Also, willingness to listening to music was one of the positive predictors of psychological well-being according to the findings of the present study. There is a large body of literature that has demonstrated the positive effects of music on improving the symptoms and reducing the severity of mental diseases like depression and schizophrenia.^46,47 Schools could play a major role in promoting mental health programs and students’ mental health.⁴⁸ Socio-cultural and political factors in Iran have resulted in the lack of hours for teaching music in schools which may be a contributing factor to the current mental health status of the students. Revising school curriculums to include music-related lessons like lawful anthemion, hymning, and chanting for female students in schools seems to be helpful in mental health promotion of the students. Also, creating supportive environments and activities such as designing and implementation of happy music-based programs in schools during official ceremonies and the recreation breaks and sports times may be useful, as well.

Having the history of smoking in previous year was a significant negative predictor for psychological well-being of the female adolescents in the present study. Smoking has strongly been associated to mental disorders. About one out of 3 adult smokers in the United States and Australia has been found to be with at least one disorder based on DSMIV and ICD-10,⁴⁹ and as a comparison, only 15% of the current non-smoker adults were with a diagnosable mental disorder. A majority of adult smokers begin smoking in their adolescence years.⁵⁰ Considering the increasing rate of beginning to smoke among women at younger ages,⁵¹ as well as the significance of peers and teachers as role models for the adolescents, establishing school-based campaigns on smoking prevention within which peer and teacher support are considered as the main strategies may be recommended. Such school-based campaigns may be also developed to the community and nation-wide levels with focus on strategies like awareness rising on the hazards of tobacco, developing life-skills training in kindergartens and elementary schools, and training parenting skills (like promoting family bonding and taught resistance skills).

Limitations

There may be some limitations for our study. The first limitation is the self-report nature of the study which may has resulted in recall bias. Another limitation may be the correlational design of the research. Therefore, causal inferences are warranted. We had limitations in asking questions on some culturally sensitive questions, like alcohol consumption and having sexual relationships. We propose further researches with more focus on the associations of such factors with psychological wellbeing among female adolescents.

Conclusion

Our finding highlights the role of perceived stress in determining psychological wellbeing of female adolescents. As there were several other determinants in the present study that could potentially predict psychological wellbeing, it seems that perceived stress has overshadowed the influence of a majority of the other factors. Further longitudinal and filed trial researches are suggested to investigate these associations among female adolescents in different communities. School health policymakers and school nurses should consider these findings while designing mental health promotion policies and programs for adolescents, particularly when addressing the issues that may be associated to the role of families, friends, peers and communities in maintaining and promoting adolescents’ mental health.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval was provided by Student Research Committee in Tabriz University of Medical Sciences. Also, Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

HN and HH conceptualized and designed the study, assisted in data collection, carried out the analyses, made substantial contributions to interpretation of data and drafted the initial manuscript, reviewed and revised the final manuscript. Both the authors read and approved the final manuscript.

Acknowledgements

Authors thank all the students participated in the study.

References

1. Patel V, Ramasundarahettige C, Vijayakumar L, Thakur JS, Gajalakshmi V, Gururaj G, et al. Suicide mortality in India: a nationally representative survey. Lancet 2012;379:2343-51. doi: 10.1016/S0140-6736(12)60606-0. [Crossref]
2. Patton G, Coffey C, Cappa C, Currie D, Riley L, Gore F, et al. Health of the world’s adolescents: a synthesis of internationally comparable data. Lancet 2012;379:1665-75. doi: 10.1016/S0140-6736(12)60203-7. [Crossref]
3. Khatibi Moghaddam HM, Rahmani Fard A, Khadem Rezaiyan M. Epidemiology of psychiatric disorders: The situation of Mashhad city during 2010-2016. Journal of Fundamentals of Mental Health 2017;19(6):451-60.
4. Noorbala A, Bagheri Yazdi S, Yasamy M, Mohammad K. Mental health survey of the adult population in Iran. Br J Psychiatry 2004;184:70-3.
5. Pouretemad HR, Naghavi KR, Malekafzali H, Noorbala AA, Davidian H, Ghanizadeh A, et al. Prevalence of mood disorders in Iran. Iran J Psychiatry 2006;1(2):59-64.
6. Patel V, Prince M. Global Mental Health: a new global health field comes of age. JAMA 2010; 303(19):1976-7. doi: 10.1001/jama.2010.616. [Crossref]
7. Bor W, Dean AJ, Najman J, Hayatbakhsh R. Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Aust N Z J Psychiatry 2014;48:606-16. doi: 10.1177/0004867414533834. [Crossref]
8. Basirnia A, Sharifi V, Mansouri N, Mesgarpour B, Mohammadi M, Amini H. Prevalence of mental disorders among high-school students in Iran: a systematic review. Iran J Psychiatry 2009;4(1):1-6.
9. Neumark-Sztainer D, Story M, Hannan PJ, Rex J. New Moves: a school-based obesity prevention program for adolescent girls. Prev Med 2003;37:41-51.
10. Stubbe JH, de Moor MH, Boomsma DI, de Geus EJ. The association between exercise participation and well-being: a co-twin study. Prev Med 2007;44(2):148-52. doi: 10.1016/j.ypmed.2006.09.002. [Crossref]
11. Bloodworth A, McNamee M. Conceptions of well-being in psychology and exercise psychology research: a philosophical critique. Health Care Anal 2007;15:107-21. doi: 10.1007/s10728-007-0048-6. [Crossref]
12. Kawada T, Kuratomi Y, Kanai T. Lifestyle determinants of depressive feeling and a feeling of unhappiness among workers: a study in Japan. Work 2009;33:255-60. doi: 10.3233/WOR-2009-0873. [Crossref]
13. Truth Hurts: Report of the National Inquiry into Self-Harm Among Young People. Mental Health Foundation; 2006. Available from: https://www.mentalhealth.org.uk/file/1248/download?token=r23RZDZJ. Accessed 31 December 2017.
14. Okada M, Suzue T, Jitsunari F. Association between interpersonal relationship among high-school students and mental health. Environ Health Prev Med 2010;15:57-62. doi: 10.1007/s12199-009-0108-7. [Crossref]
15. Frankel KA. Girls’ perceptions of peer relationship support and stress. J Early Adolesc 1990;10(1):69-88. Doi: 10.1177/0272431690101005. [Crossref]
16. Kheirkhah M, Mokarie H, Nisani Samani L, Hosseini A. Relationship between anxiety and self-concept in female adolescents. Iran Journal of Nursing 2013;26:19-26.
17. Hezomi H, Allahverdipour H, Mohammad AJ. Happiness and its relation on psychological well-being of adolescents. Asian J Psychiatry 2015;16:55-60. doi: 10.1016/j.ajp.2015.05.037. [Crossref]
18. Currie C, Zanotti C, Morgan A, Currie D, Looze MD, Roberts C, et al. Social determinants of health and well-being among young people, health behaviour in school-aged children (HSBC) study. World Health Organization; 2009-2010. Available from: http://www.euro.who.int/__data/assets/pdf_file/0003/163857/Social-determinants-of-health-and-well-being-among-young-people.pdf. Access 31 December 2017.
19. The United Nations Children’s Fund (UNICEF). Adolescence. A Time that Matters. In: The State of the World’s Children. Washington DC: UNICEF’ 2002. p. 75-7. Available from: https://www.unicef.org/publications/index_4266.html. Access 31 December 2017.
20. Moeini B, Shafii F, Hidarnia A, Babaii GR, Birashk B, Allahverdipour H. Perceived stress, self-efficacy and its relations to psychological well-being status in Iranian male high school students. Soc Behav Personality 2008;36:257-66.
21. Alipoor A, Noorbala AA. A Preliminary Evaluation of the Validity and Reliability of the Oxford Happiness Questionnaire in Students in the Universities of Tehran. Iranian Journal of Psychiatry and Clinical Psychology 1999;5(1 and 2) :55-66. [Persian].
22. Charkhabi M, Azizi Abarghuei M, Hayati D. The association of academic burnout with self-efficacy and quality of learning experience among Iranian students. Springerplus 2013;2:677. doi: 10.1186/2193-1801-2-677. [Crossref]
23. Maroufizadeh S, Zareiyan A, Sigari N. Reliability and validity of Persian version of perceived stress scale (PSS-10) in adults with asthma. Arch Iran Med 2014;17(5):361-5.
24. Cohen S, Kessler RC, Gordon LU, editors. Measuring stress: A guide for health and social scientists. New York: Oxford University Press; 1997.
25. Kariman N, Simbar M, Ahmadi F, Vedadhir AA. Socioeconomic and emotional predictors of decision making for timing motherhood among Iranian women in 2013. Iran Red Crescent Med J 2014;16(2):e13629. doi: 10.5812/ircmj.13629. [Crossref]
26. Snyder CR, Sympson SC, Ybasco FC, Borders TF, Babyak MA, Higgins RL. Development and validation of the State Hope Scale. J Pers Soc Psychol 1996;70(2):321.
27. Joshanloo M, Afshari S. Big five personality traits and self-esteem as predictors of life satisfaction in Iranian Muslim university students. J Happiness Stud 2011;12:105-13.
28. Diener ED, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess 1985;49(1):71-5.doi: 10.1207/s15327752jpa4901_13. [Crossref]
29. Ho KY, Li WH, Chan SS. The effect of poverty and income disparity on the psychological well‐being of Hong Kong children. Public Health Nurs 2015;32:212-21. doi: 10.1111/phn.12147. [Crossref]
30. Fancourt D, Perkins R, Ascenso S, Atkins L, Kilfeather S, Carvalho L, et al. Group drumming modulates cytokine response in mental health services users: a preliminary study. Psychother Psychosom 2016;85(1):53-5. doi: 10.1159/000431257. [Crossref]
31. Gálvez CA, Rosa GA, Garcia-Canto E, Rodríguez GP, Perez-Soto JJ, Tarraga ML, et al. Nutritional status and health-related life quality in school children from the southeast of Spain. Nutr Hosp 2015;31(2):737-43. doi: 10.3305/nh.2015.31.2.8468. [Crossref]
32. Giletta M, Scholte RH, Prinstein MJ, Engels RC, Rabaglietti E, Burk WJ. Friendship context matters: examining the domain specificity of alcohol and depression socialization among adolescents. J Abnorm Child Psychol 2012;40(7):1027-43. doi: 10.1007/s10802-012-9625-8. [Crossref]
33. Dark-Freudeman A, West RL. Possible selves and self-regulatory beliefs: exploring the relationship between health selves, health efficacy, and psychological well-being. Int J Aging Hum Dev 2016;82(2-3):139-65. doi: 10.1177/0091415015627666. [Crossref]
34. Rawdin B, Evans C, Rabow MW. The relationships among hope, pain, psychological distress, and spiritual well-being in oncology outpatients. J Palliat Med 2013;16(2):167-72.doi: 10.1089/jpm.2012.0223. [Crossref]
35. Soltani MA, Karaminia R, Hashemian SA. Prediction of war veteran’s mental health based on spiritual well-being, social support and self-efficacy variables: The mediating role of life satisfaction. J Educ Health Promot 2014;3:57-66. doi: 10.4103/2277-9531.134757. [Crossref]
36. Chandra A, Batada A. Exploring stress and coping among urban African American adolescents: the Shifting the Lens study. Prev Chronic Dis 2006;3(2):A40.
37. Meng XH, Tao FB, Wan YH, Yan HU, Wang RX. Coping as a mechanism linking stressful life events and mental health problems in adolescents. Biomed Environ Sci 2011;24(6):649-55. doi: 10.3967/0895-3988.2011.06.009. [Crossref]
38. Fowler J, Christakis N. Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ 2008;337:a2338. doi: 10.1136/bmj.a2338. [Crossref]
39. Elstad JI, Pedersen AW. The impact of relative poverty on Norwegian adolescents’ subjective health: a causal analysis with propensity score matching. Int J Environ Res Public Health 2012;9:4715-31.
40. Bandura A, Caprara GV, Barbaranelli C, Gerbino M, Pastorelli C. Role of affective self‐regulatory efficacy in diverse spheres of psychosocial functioning. Child Dev 2003;74:769-82.
41. Babazadeh T, Nadrian H, Banayejeddi M, Rezapour B. Determinants of skin cancer preventive behaviors among rural farmers in Iran: an application of protection motivation theory. J Cancer Educ 2017;32(3):604-12. doi: 10.1007/s13187-016-1004-7. [Crossref]
42. Morowatisharifabad MA, Fallahi A, Nadrian H, Haerian A, Babaki BN. Interdental cleaning behaviour and its relationship with psychological constructs based, on the transtheoretical model. Oral Health Prev Dent 2011;9:37-42.
43. Vakili M, Rahaei Z, Nadrian H, Yarmohammadi P. Determinants of oral health behaviors among high school students in Shahrekord, Iran based on Health Promotion Model. J Dent Hyg 2011;85(1):39-48.
44. Ahmadi A, Mohammadi-Sartang M, Nooraliee P, Veisi M, Rasouli J. Prevalence of anxiety and it’s relationship with consumption of snacks in high school students in Shiraz. Journal of Shahrekord University of Medical Sciences 2013;15(1):83-90. [Persian].
45. WHO. Gender disparities and mental health: The Facts. Geneva: World Health Organization; 2017 Available from: http://www.who.int/mental_health/prevention/genderwomen/en/. Accessed 8 February 2017.
46. Erkkilä J, Punkanen M, Fachner J, Ala-Ruona E, Pöntiö I, Tervaniemi M, et al. Individual music therapy for depression: randomised controlled trial. Br J Psychiatry 2011;199:132-9. doi: 10.1192/bjp.bp.110.085431. [Crossref]
47. Talwar N, Crawford MJ, Maratos A, Nur U, McDermott OR, Procter S. Music therapy for in-patients with schizophrenia: exploratory randomised controlled trial. Br J Psychiatry 2006;189:405-9. doi: 10.1192/bjp.bp.105.015073. [Crossref]
48. Weare K, Nind M. Mental health promotion and problem prevention in schools: what does the evidence say. Health Promot Int 2011;26 Suppl 1:i29-69. doi: 10.1093/heapro/dar075. [Crossref]
49. Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health 2009;9:285. doi: 10.1186/1471-2458-9-285. [Crossref]
50. Lawrence D, Considine J, Mitrou F, Zubrick SR. Anxiety disorders and cigarette smoking: results from the Australian Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2010;44:520-7. doi: 10.3109/00048670903571580. [Crossref]
51. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2004.