The role of mental health, academic stress, academic achievement, and physical activity on self-rated health among adolescents in Iran: A multilevel analysis
Zahra Hosseinkhani1, Hamid-Reza Hassanabadi2, Mahboubeh Parsaeian3, Saharnaz Nedjat4, Zohre Foroozanfar3
1 Metabolic Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin, University of Medical Sciences, Qazvin, Iran
2 Department of Educational Psychology, Kharazmi University, Tehran, Iran
3 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
4 Department of Epidemiology and Biostatistics, Knowledge Utilization Research Center, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
|Date of Submission||19-Feb-2020|
|Date of Acceptance||11-Mar-2020|
|Date of Web Publication||28-Jul-2020|
Dr. Saharnaz Nedjat
Department of Epidemiology .and Biostatistics, Knowledge Utilization Research Center, School of Public Health, Tehran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
BACKGROUND: Health promotion of adolescents requires appropriate evidences of its determinants. The aim of this study was to investigate predictors of self-rated health (SRH) among adolescents in Qazvin, Iran.
MATERIALS AND METHODS: In this descriptive cross-sectional study, with a multistage sampling method, we recruited 1740 adolescents aged 12–19 years from 53 schools in Qazvin, Iran (2018). We used the Strengths and Difficulties Questionnaire and Adolescents' Academic Stress Questionnaire for data collection. The analysis was conducted using a multilevel logistic regression model. Gender, educational period, and socioeconomic status were considered as confounders.
RESULTS: Almost 21% of the adolescents reported their SRH suboptimal. Suboptimal SRH was higher in girls and older adolescents. Mental health disorders and academic stress had a positive association with SRH. However, this association was negative for academic achievement and physical activity. The interaction between mental health disorders and academic stress with SRH had a significant association in a crud regression model.
CONCLUSION: Mental health, academic stress, academic achievement, and physical activity were important predictors for SRH. Interventions that focus on promoting mental health, academic stress, academic achievement, and physical activity such as physical activity for 1 h and each day for 3 days per week can improve SRH in adolescents. Hence, policymakers should pay more attention to this issue in health promotion programs of adolescents.
Keywords: Academic achievement, academic stress, adolescents, Iran, mental health, physical activity, self-rated health
|How to cite this article:|
Hosseinkhani Z, Hassanabadi HR, Parsaeian M, Nedjat S, Foroozanfar Z. The role of mental health, academic stress, academic achievement, and physical activity on self-rated health among adolescents in Iran: A multilevel analysis. J Edu Health Promot 2020;9:182
|How to cite this URL:|
Hosseinkhani Z, Hassanabadi HR, Parsaeian M, Nedjat S, Foroozanfar Z. The role of mental health, academic stress, academic achievement, and physical activity on self-rated health among adolescents in Iran: A multilevel analysis. J Edu Health Promot [serial online] 2020 [cited 2020 Oct 20];9:182. Available from: https://www.jehp.net/text.asp?2020/9/1/182/290930
| Introduction|| |
The United Nations defines adolescence the age of 10–19 years., In this period, physical and psychological changes happen for transition from childhood to adulthood. Hence, many factors can affect adolescents' health. According to the WHO reports, mental health disorders in half of the people start at 14 years. However, the early detection of this disorder is important not only for effective treatment but also in their future life achievements, which is not much more attention. As in spite of adolescents, vulnerability is not considered in policy and planning. This is especially more evident in low-income and middle-income countries., In these countries, financial problems are a major obstacle for considering to adolescents' health.
Self-rated health (SRH) is a global measure of people's health that reflects their daily health status. This measure is widely used in social sciences and public health researches. It covers different dimensions of social and personal health. It is associated with mortality and general health status.,, By using SRH in investigates can predict health outcomes affordably, so, at the moment, this measure very used in health researches. The reliability and validity of this measure have been confirmed in previous studies.,
The evidences show that adolescents with healthy lifestyle have good SRH.,, Previous studies have been investigated the association between SRH and many factors such as social and behavioral factors,, gender,,,,,,, high-risk behaviors,,,, mental health-related factors,,, age,,, socioeconomic status (SES),,,, academic stress, and academic achievement.,
To our knowledge, there are few studies on SRH which have been done in this field in Iran. Available documents more investigated the inequality of SES and neighborhood role on SRH in adults. Since the unpleasant experiences in childhood period have a strong association with suboptimal SRH in different stages in adulthood, this can adversely affect health status and economic burden in society. Therefore, it is necessary to pay more attention to adolescents' health status. The current study aims to investigate the association between SRH and determinant factors in Iranian adolescents in Qazvin city.
| Materials and Methods|| |
This cross-sectional study conducted on adolescents in high schools of Qazvin city in northwestern Iran in 2018. The participants were selected using multistage sampling. The schools in Iran are divided into three types: governmental, private, and spatial (with entrance exam). We considered each type of schools as strata. Proportional to the population size of each type of schools, 53 high schools out of 221 were randomly selected. From each of the included schools, 30 students randomly selected based on students' list of all grades (between the ages of 7 and 12) from both educational periods ( first and second). The inclusion criterion was willingness to participate in the study. The exclusion criterion was disability to answer questions solely. The questionnaires were completed with a self-administrated method. Overall, 1740 students included in this study. Oral and written informed consent was obtained from all participants and their parents.
We measured SRH using a single question: “How would you rate your general health status?” It has been suggested by the WHO and was a five-point Likert scale, ranging from 1 to 5 (very bad, bad, moderate, good, and very good). The participants who marked their health status as “good” or “very good” were assigned to the optimal group and others were classified as a suboptimal group.,
Mental health disorders were assessed using the Strengths and Difficulties Questionnaire. The validity of the Persian version of this questionnaire was reported in a previous study, and internal consistency was 0.628.
Academic stress was assessed using “Iranian Adolescents' Academic Stress Questionnaire.” To measure academic stress, a five-point Likert scale from “not at all/very little” to “very much/always” has been used. The Cronbach's alpha value for the domains of the questionnaire and intraclass correlation were 0.58–0.85 and 0.80 (95% confidence interval: 0.66–0.90), respectively.
For evaluating the economic status of the family, we asked about their assets and some possibilities such as microwave, dishwashing machine, freezer, liquid crystal display-light-emitting diode television, play station, private laptop for student, owner private room for student, number of car in the family, the participation in additional classes (sports, art, etc.), and number of going to cinema, concert, and trips.
Based on the participant's response to the SRH question, we classified them into two groups of optimal and suboptimal. The ratio of the percentage of the students with optimal and suboptimal SRH was calculated based on different independent variables including age, gender, educational period, family SES, and school type. The association between SRH and key independent variables including mental health disorders, physical activity, academic stress, and academic achievement was examined in regression models separately. Gender, educational period, and SES entered the models as potential confounders and adjusted their effects. SRH was dichotomized as optimal and suboptimal groups. Hence, we used a logistic regression model for determining the association between SRH, the dependent variable, and independent variables. Because of the students were nested in schools, and multilevel nature of the data, we used multilevel model analysis. Before conducting each analysis, we tested the effect of hierarchical structure of data with ANOVA test. The association between SRH and some factors consist of: mental health, academic stress, academic achievement, physical activity were examined in separated models, also interaction between factors was analyzed. Gender, educational period, and SES were considered as confounders. The analysis was conducted using STATA version 14.0 (StataCorp. LP).
The study was approved in Tehran University of Medical Sciences (IR.TUMS.VCR.REC.1396.4610).
| Results|| |
A total of 1724 adolescents out of 53 schools completed the questionnaires. The mean (standard deviation) age of the adolescents was 15 (1.7) years (range: 12–19). 50.12% were girls, and 52.3% were in the first educational period of high schools. The proportion of participants within each of the categories of economic status was equal approximately. Almost, the academic achievement score of all the participants was good or grate. 52.2% of them had more than 2-h physical activity in a week. About less than a quarter (16.2%) of them had mental health disorders. A total of 1348 (78.88%) of the adolescents reported their SRH optimal as “good or very good.”
The background characteristics of the participants are presented in [Table 1].
|Table 1: The background characteristics of the adolescents in Qazvin city, Iran, in 2018 (n=1724)|
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Overall, the proportion with gender (P = 0.024), educational period (P = 0.002), and age (P < 0.001) was significantly different between the two groups of optimal and suboptimal SRH.
Mental health disorders and academic stress had a positive association with suboptimal SRH. The association between academic achievement and physical activity with suboptimal SRH was negative. Only the interaction between mental health disorders and academic stress with suboptimal SRH had a significant association in crud regression multilevel analysis. The result of the association between different determinants and suboptimal SRH in multilevel logistic regression analysis is presented in [Table 2].
|Table 2: Multi-level logistic regression models representing the association between different determinants|
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The effect of gender, age, and SES was adjusted because of their confounding role in models.
| Discussion|| |
This study showed that the minority of the adolescents have perceived their SRH suboptimal as poor and fair (21.12%). The association between mental health disorders and academic stress with suboptimal SRH was positive, whereas this association for academic achievement and physical activity was negative. Furthermore, the interaction between mental health disorders and academic stress had a significant association with suboptimal SRH in crud regression analysis.
Because of forming adolescents' health knowledge in this period of the life and its role in their health promotion and healthy behaviors, so should pay more attention to adolescents SRH. In this study, the percentage of optimal SRH in adolescents was desirable that was concordance with the result of studies in other countries.,,,,,,,
Suboptimal SRH in girls was higher than boys. SRH in girls and boys is affected by social aspects, so it is necessary to know how they interpret their SRH. Therefore, age and gender are important factors that should be considered. In other studies, similar ours, such as Peru, Sweden, Finland, SRH in boys were better than girls and and in some studies the association between SRH and gender was significant.,,,,
Although, in this study, the association between SES and SRH was not significant, in many studies, SES has been associated with SRH., Among African American adolescents, the odds of poor SRH have been significantly higher in low SES families. Even interventions for improving the economic status of people have been a positive effect on their SRH. However, no significant association was observed in few studies.
The result of the present study shows that the percentage of suboptimal SRH was more among older adolescents. Adolescents in the second educational period had higher suboptimal SRH than of those in the first period, as well as with increasing the age of the adolescents, their suboptimal SRH have been increased. In other studies, optimal SRH has been less reported in older adolescents. In Iran, likely, the adolescent's health is affected with academic stress. Because adolescents have to accepted in the competing national entrance exam (KONKOUR) for studying in the top universities in Iran.
Furthermore, in this study, academic stress had a positive association with suboptimal SRH. The studies conducted in other countries confirm this result and consider the effect of adolescents' perceived stress and SRH., One of the main factors that should be considered in adolescents' stress is an academic achievement that in the present study had a negative association with suboptimal SRH. As regards, adolescents in Iran spend most of the times at school and doing homework at home, so their amount of assignments and academic achievement can have an important role in their academic stress and even their sleep that “this issue” can affect their SRH.,,, The social position among peers is another factor that associates with adolescents' health and affects their stress and consequently SRH.,
We found an association between mental health and SRH, and other studies reported similar findings. Moreover, other studies have been mentioned the association between SRH and some constructs such as life satisfaction, self-esteem, self-concept, and healthy spirituality that have a relationship with mental health.,,,,, However, difficult childhood experiences have an association with a risk of chronic diseases and suboptimal SRH in adulthood, but adolescents' health and mental health is neglected in both middle-income countries and low-income countries.,
Since the people's lifestyle is one of the most important factors in their SRH, in this study, physical activity as one of the lifestyle factors was investigated. According to the result, in adolescents like adults, physical activity had a negative association with suboptimal SRH. This finding was concordance with the findings of other studies in Iran and other parts of the world.,,,,,
First, the limitation of this study was temporality in the association between SRH and predictors because of the cross-sectional design of the study. Second, since there is a difference in adolescents' perceived subjective health and their honesty, likely, the reply of the participants to question of SRH was not precise, so should consider this information bias in this study.
| Conclusion|| |
This study shows that the majority of the adolescents have optimal SRH. Gender, educational period, and age were associated with SRH. Mental health disorders and academic stress had a positive association with suboptimal SRH, whereas suboptimal SRH was lower in adolescents with physical activity and academic achievements. This issue demonstrates that school-related factors and mental health status are the most important constructs that should be considered in adolescence period.
Considering programs to reduce academic stress, including consulting with adolescents and their parents as well as extracurricular activities to increase adolescents' physical activity, can help improve SRH.
We would like to thank the students who participated in this study. This study was the part of the Ph.D thesis of Zahra Hosseinkhani (proposal number 96-20-10, 240.1309) at Tehran University of Medical Sciences.
Financial support and sponsorship
Tehran University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jodkowska M, Oblacińska A, Dzielska A, Nałęcz H, Fijałkowska A. Behavioural factors as predictors of self-rated health among polish adolescent girls. Dev Period Med 2019;23:109-16.
Adolescent Mental Health [cited 2019 July 20]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health.
Kapungu C, Petroni S, Allen NB, Brumana L, Collins PY, De Silva M, et al
. Gendered influences on adolescent mental health in low-income and middle-income countries: Recommendations from an expert convening. Lancet Child Adolesc Health 2018;2:85-6.
Dowd JB, Zajacova A. Does the predictive power of self-rated health for subsequent mortality risk vary by socioeconomic status in the US? Int J Epidemiol 2007;36:1214-21.
Waldhauer J, Kuntz B, Mauz E, Lampert T. Intergenerational educational pathways and self-rated health in adolescence and young adulthood: Results of the German KiGGS cohort. Int J Environ Res Public Health 2019;16:684
Nedjat S. Is self-rated health a good indicator for assessment of population health? A review article. Iranian J Epidemiol 2015;10:89-96.
Chandola T, Jenkinson C. Validating self-rated health in different ethnic groups. Ethn Health 2000;5:151-9.
Burström B, Fredlund P. Self rated health: Is it as good a predictor of subsequent mortality among adults in lower as well as in higher social classes? J Epidemiol Community Health 2001;55:836-40.
Marques A, Peralta M, Santos T, Martins J, Gaspar de Matos M. Self-rated health and health-related quality of life are related with adolescents' healthy lifestyle. Public Health 2019;170:89-94.
Yeo SC, Jos AM, Erwin C, Lee SM, Lee XK, Lo JC, et al
. Associations of sleep duration on school nights with self-rated health, overweight, and depression symptoms in adolescents: Problems and possible solutions. Sleep Med 2019;60:96-108.
Joffer J, Flacking R, Bergström E, Randell E, Jerdén L. Self-rated health, subjective social status in school and socioeconomic status in adolescents: A cross-sectional study. BMC Public Health 2019;19:785.
Ghalichi L, Nedjat S, Majdzadeh R, Hoseini M, Pournik O, Mohammad K. Determinants of self-rated health in Tehran, from individual characteristics towards community-level attributes. Arch Iran Med 2015;18:266-71.
Shakya HB, Domingue B, Nagata JM, Cislaghi B, Weber A, Darmstadt GL. Adolescent gender norms and adult health outcomes in the USA: A prospective cohort study. Lancet Child Adolesc Health 2019;3:529-38.
Malta DC, Oliveira MM, Machado IE, Prado RR, Stopa SR, Crespo CD, et al
. Characteristics associated to a poor self-rated health in Brazilian adolescents, National Adolescent School-based Health Survey, 2015. Rev Bras Epidemiol 2018;21:e180018.
Aho H, Koivisto AM, Paavilainen E, Joronen K. The relationship between peer relations, self-rated health and smoking behaviour in secondary vocational schools. Nurs Open 2019;6:754-64.
Joffer J, Jerdén L, Öhman A, Flacking R. Exploring self-rated health among adolescents: A think-aloud study. BMC Public Health 2016;16:156.
Abdollahpour I, Nedjat S, Noroozian M, Salimi Y, Majdzadeh R. Positive Aspects of Caregiving Questionnaire. J Geriatr Psychiatry Neurol 2017;30:77-83.
Kjeldsen MZ, Stapelfeldt CM, Lindholdt L, Lund T, Labriola M. Reading and writing difficulties and self-rated health among Danish adolescents: Cross-sectional study from the FOCA cohort. BMC Public Health 2019;19:537.
Abdollahpour I, Nedjat S, Noroozian M, Salimi Y, Majdzadeh R. Caregiver burden: The strongest predictor of self-rated health in caregivers of patients with dementia. J Geriatr Psychiatry Neurol 2014;27:172-80.
Baigi V, Nedjat S, Hosseinpoor AR, Sartipi M, Salimi Y, Fotouhi A. Socioeconomic inequality in health domains in Tehran: A population-based cross-sectional study. BMJ Open 2018;8:018298.
Elgar FJ, Pförtner TK, Moor I, De Clercq B, Stevens GW, Currie C. Socioeconomic inequalities in adolescent health 2002-2010: A time-series analysis of 34 countries participating in the health behaviour in school-aged children study. Lancet 2015;385:2088-95.
Moor I, Kuipers MA, Lorant V, Pförtner TK, Kinnunen JM, Rathmann K, et al
. Inequalities in adolescent self-rated health and smoking in Europe: Comparing different indicators of socioeconomic status. J Epidemiol Community Health 2019;73:963-70.
Ghanizadeh A, Izadpanah A. Scale validation of the strengths and difficulties questionnaire in Iranian children. Iran J Psychiatry 2007;2:651-71.
Hosseinkhani Z, Nedjat S, Hassanabadi HR, Parsaeian M, Veysi Hampa F. Designing and psychometric evaluation of Iranian students' academic stress questionnaire (IAASQ). Iran J Public Health 2020;49:701-10.
Zhang F, Zhao L, Feng X, Hu X. An investigation on self-rated health of adolescent students and influencing factors from Sichuan, China. Am J Ther 2016;23:e1143-50.
Srugo SA, de Groh M, Jiang Y, Morrison HI, Hamilton HA, Villeneuve PJ. Assessing the impact of school-based greenness on mental health among adolescent students in Ontario, Canada. Int J Environ Res Public Health 2019;16:4364.
Powell-Young YM. Household income and spiritual well-being but not body mass index as determinants of poor self-rated health among African American adolescents. Res Nurs Health 2012;35:219-30.
Krause L, Lampert T. Relation between overweight/obesity and self-rated health among adolescents in Germany. Do socio-economic status and type of school have an impact on that relation? Int J Environ Res Public Health 2015;12:2262-76.
Breidablik HJ, Meland E, Holmen TL, Lydersen S. Role of parents in adolescent self-rated health: Norwegian nord-trøndelag health study. Adolesc Health Med Ther 2010;1:97-104.
Bertoldi AD, Camargo AL, Silveira MP, Menezes AM, Assunção MC, Gonçalves H, et al
. Self-medication among adolescents aged 18 years: The 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2014;55:175-81.
Sharma B, Nam EW, Kim D, Yoon YM, Kim Y, Kim HY. Role of gender, family, lifestyle and psychological factors in self-rated health among urban adolescents in Peru: A school-based cross-sectional survey. BMJ Open 2016;6:010149.
Spein AR, Pedersen CP, Silviken AC, Melhus M, Kvernmo SE, Bjerregaard P. Self-rated health among Greenlandic Inuit and Norwegian Sami adolescents: Associated risk and protective correlates. Int J Circumpolar Health 2013;72:19793
Ssewamala FM, Han CK, Neilands TB. Asset ownership and health and mental health functioning among AIDS-orphaned adolescents: Findings from a randomized clinical trial in rural Uganda. Soc Sci Med 2009;69:191-8.
Nedjat S, Hosseinpoor AR, Forouzanfar MH, Golestan B, Majdzadeh R. Decomposing socioeconomic inequality in self-rated health in Tehran. J Epidemiol Community Health 2012;66:495-500.
Meireles AL, Xavier CC, de Souza Andrade AC, Proietti FA, Caiaffa WT. Self-rated health among urban adolescents: The roles of age, gender, and their associated factors. PLoS One 2015;10:1-19
Hosseinkhani Z, Nedjat S, Hassanabadi HR, Parsaeian M. Academic stress from the viewpoint of Iranian adolescents: A qualitative study. J Educ Health Promot 2019;8:13.
Conklin AI, Yao CA, Richardson CG. Chronic sleep disturbance, not chronic sleep deprivation, is associated with self-rated health in adolescents. Prev Med 2019;124:11-6.
Jackson DB, Vaughn MG. Adolescent health lifestyles and educational risk: Findings from the monitoring the future study, 2010-2016. Am J Prev Med 2019;57:470-7.
Pranjić N, Brković A, Beganlić A. Discontent with financial situation, self-rated health, and well-being of adolescents in Bosnia and Herzegovina: Cross-sectional study in Tuzla Canton. Croat Med J 2007;48:691-700.
Boardman JD. Self-rated health among U.S. adolescents. J Adolesc Health 2006;38:401-8.
Sonu S, Post S, Feinglass J. Adverse childhood experiences and the onset of chronic disease in young adulthood. Prev Med 2019;123:163-70.
Hosseini M, Maghami M, Kelishadi R, Motlagh ME, Khoshbin S, Amirkhani A, et al
. First report on self-rated health in a nationally-representative sample of Iranian adolescents: The CASPIAN-iii study. Int J Prev Med 2013;4:146-52.
[Table 1], [Table 2]