The Reliability and Applicability of the Physical and Mental Health Promotion Model for Adolescent in Different Social Contexts

doi:10.21203/rs.3.rs-4718618/v1

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The Reliability and Applicability of the Physical and Mental Health Promotion Model for Adolescent in Different Social Contexts

https://doi.org/10.21203/rs.3.rs-4718618/v1

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To examine Physical and Mental Health Promotion Model for Adolescent in Different Social Contexts, 1073 sets of survey data per year were randomly selected from databases during the period of the normalization prevention and control, the outbreak of COVID-19, and the lifting of social controls for COVID-19. The average score of sleep duration(SD) for adolescents was 440.15, 430.14, and 441.80 minutes/day respectively (F = 9.62, p < 0.001), physical activity level(PAL) was 2.54, 2.35, and 2.46 respectively (F = 18.87, p < 0.001), general self-efficacy (GSE) was 2.65, 2.36, and 2.71 respectively (F = 74.53, p < 0.001), and mental health (MH) was 1.54, 1.86, and 1.57 respectively (F = 87.31, < 0.001); ANOVA results showed significant differences. There were significantly correlated with each other among average score of PAL, SD, GSE and MH. The total effects of the model were − .196, − .338, and − .221, respectively, all with P < 0.001; the direct effects were − .089, − .230, and − .117, respectively, all with P < 0.001; the total indirect effects were − .107, − .107, and − .104, respectively; with PAL→SD→MH was − .077, − .051, and − .063, and PAL→GSE→MH was − .031, − .057, and − .041, all with a significant meaning in the Bias-Corrected 95%CI test. However, during the COVID-19 outbreak, few fit indices of the model did not reach ideal values. SD and GSE play multiple mediating roles in Physical and Mental Health Promotion Model for Adolescent, which is effective. However, in critical social situations, more attention should be paid to the direct effect of PAL on MH.

Social environment

Model

Physical activity

Mental health

Self-efficacy

Sleep duration

According to WHO statistics, 1 in every 8 people in the world live with a mental disorder, including 58 million children and adolescents were living with an anxiety disorder, 23 million children and adolescents were living with depression [1], more than 80% of adolescents and 27% of adults do not meet WHO’s recommended PAL[2]. In modern society, short sleep duration is becoming a global problem[3]. The primary and secondary school students had an average sleep duration of only 7.74 hours per night in China [4]. Compelling evidence has demonstrated that physical activity and exercise can also prevent common mental disorders, such as depression and anxiety disorders, and have multiple beneficial effects on the physical and mental health of people with a wide range of mental disorders[5]. So, based on the relationships each other between PAL, GSE, SD, and MH in adolescents, a model was constructed to promote physical and mental health for adolescents. This model has been proven to be valid, indicating that PAL in adolescents can promote their MH, with SD and GSE playing partial mediating roles[6]. The proposal of this model provides an integrated solution for issues related to physical inactivity and mental health problems in adolescents who have heavy academic workloads and limited leisure time. The main purpose of this study is to examine the effectiveness and applicability of the model under different social environments.

2.1. Data Sources

A total of 1073 samples per year were randomly selected from the survey databases on adolescent PAL, GSE, SD, and MH conducted by our research team in 2021, 2022, and 2023. The number of samples per grade was kept consistent each year. The data in these databases were obtained through convenience sampling surveys, with all participants came from Guiyang City. The average age of the participants in this study was 14.74 ± 1.71 years old; males accounted for 49.55%, and females made up 50.45% of the sample. For more details on the sample (see Table 1).

Table 1

Overview of Survey Participants
Time	Junior high school students			Senior high school students			Gender		Subtotal	Ages
Time	7 Grade	8 Grade	9 Grade	10 Grade	11 Grade	12 Grade	Male	Female	Subtotal	Mean	Std. D
2021	170	240	199	152	194	118	546	527	1073	15.13	1.77
2022	170	240	199	152	194	118	521	552	1073	14.55	1.70
2023	170	240	199	152	194	118	528	545	1073	14.53	1.67

2.2 Survey Tools

2.2.1 The Physical Activity Questionnaire for Children (PAQ-CN)

The survey on PAL among middle school students employed the Physical Activity Questionnaire for Children (PAQ-CN) [7]. This questionnaire evolved from The Physical Activity Questionnaire for Older Children (PAQ-C) and Adolescents (PAQ-A) [8]. It does not require detailed recall of exercise duration and intensity, features clear and easy-to-understand questions, is quick to fill out, reducing recall bias, and can be completed in just 8 to 10 minutes[9]; it also boasts good reliability and validity[7, 9]. Higher average scores on the questionnaire indicate higher PAL among adolescents. The internal consistency reliability coefficient was Cronbach’s alpha = 0.802, and the structural validity coefficient was a KMO score = 0.872.

2.2.2 The Mental Health Inventory of Middle School Students

The survey on mental health among middle school students utilized the Mental Health Inventory of Middle School Students (MMHI-60), consisting of 60 items that cover ten psychological factors including obsessive-compulsive symptoms, paranoia, hostility, interpersonal sensitivity, depression, anxiety, academic stress, maladjustment, emotional instability, and psychological imbalance. It employs a Likert 5-point scoring system; an overall or factor-specific average score of ≧ 2 indicates mild symptoms, with the total average score reflecting the overall mental health status. Higher scores suggest poorer mental health and more severe related psychological issues among adolescents. This inventory possesses good reliability and validity[10].The internal consistency reliability coefficient was Cronbach’s alpha = 0.970, and the structural validity coefficient was the Kaiser–Meyer–Olkin (KMO) score = 0.980.

2.2.3. General Self-Efficacy Scale

The GSE Scale, developed by German psychologist Schwarzer, employs a 4-point Likert scale. The Chinese version exhibits good reliability and validity. The higher the total mean score of the questionnaire, the higher the individual's self-efficacy[11]. The internal consistency reliability coefficient was Cronbach’s alpha = 0.890, and the structural validity coefficient was KMO score = 0.923.

The self-produced questionnaire included basic information such as the respondents' gender, grade, age, wake-up and bed-time each day, and lunch breaks.

2.2.3. Investigation Implementation

After obtaining approval from the Academic Ethics Committee of the School of Physical Education at Guizhou Normal University, and with the verbal consent of the middle school principals, recruitment of volunteers through oral communication. "Parental Consent Form" was distributed to students who verbally agreed to participate in the survey, which needed to be taken home and signed by a parent; only those who returned the form with parental consent and signature within a week could participate in the survey. Investigators conducted the survey by gathering students in classrooms during rainy days when outdoor physical education classes were not possible, using on-site distribution and collection methods. The surveys were implemented at the end of October in 2021 (the normalized prevention and control period of COVID-19), 2022 (the outbreak of COVID-19), and 2023 (after the lifting of social prevention and control measures for COVID-19), respectively.

2.3. Statistical Methods

The model fit indices were tested using IBM SPSS AMOS 26, descriptive statistics such as frequency, mean, and correlation were performed using IBM SPSS 26; the IBM SPSS plugin PROCESS 4.1 Written by Andrew F. Hayes was used to analyze mediation and moderation effects, to compare the significance of differences of the mediation effects between SD and GSE, etc.

3.1. Mean Values and each other Correlations between PAL, GSE, SD, and MH among Adolescents in Different Social Situations

Compared to period of the normalization prevention and control of COVID-19 (2021) and the lifting of epidemic prevention and control (2023), adolescents had the lowest scores for SD and PAL, GSE, while their MH scores were the highest during the outbreak of COVID-19 (2022). After the lifting of epidemic prevention and control, adolescents had the highest scores for SD and GSE, but their PAL scores were lower than those during the period of epidemic normalization prevention and control, and their MH scores were higher. ANOVA results showed that there were significant differences between the scores of PAL, SD, GSE, and MH among adolescents at different periods (PAL: F = 18.87, p < 0.001; SD: F = 9.62, p < 0.001; GSE: F = 74.53, p < 0.001; MH: F = 87.31, < 0.001) (see Table 2).

Table 2

Description statistics of SD, PAL, GSE and MH of adolescents
Correlation of Pearson					Mean	95% CI for Mean
		SD	PAL	GSE	Mean	Lower	Upper
2021	SD	1			440.15	436.12	444.18
	PAL	.361**	1		2.54	2.50	2.58
	GSE	.174**	.321**	1	2.65	2.61	2.69
	MH	− .333**	− .250**	− .205**	1.54	1.51	1.57
2022	SD	1			430.14	426.32	433.96
	PAL	.357**	1		2.35	2.31	2.40
	GSE	.298**	.399**	1	2.36	2.32	2.41
	MH	− .267**	− .337**	− .276**	1.86	1.82	1.91
2023	SD	1			441.80	437.68	445.92
	PAL	.287**	1		2.46	2.42	2.50
	GSE	.130**	.328**	1	2.71	2.66	2.75
	MH	− .327**	− .268**	− .233**	1.57	1.54	1.61

3.2. Comparison of the Mediating Effects of GSE and SD in Different Social Situation

The results from the AMOS indicate that Physical and Mental Health Promotion Model for Adolescent is valid. However, the direct and indirect effects of physical activity on mental health vary under different social circumstances. During the outbreak of COVID-19, the direct effect of PAL on MH was the greatest, while it was the least after the lifting of social controls; the direct effect of GSE on MH was the least during the outbreak of COVID-19, but it was the greatest after the lifting of social controls; the direct effect of SD on MH was the greatest during the period of normalization control of COVID-19, and which was the least after the lifting of social controls (see Fig. 1).

Model testing revealed that the path coefficients between PA and MH, as well as between SD and GSE, were statistically significant (P < 0.001) in 2021 model, 2022 model and 2023 model, respectively. The higher the MH scores of adolescents, the greater the overall and direct effects of PAL on MH. However, the indirect effects remain almost unchanged.

Under different social contexts, the direct effect, indirect effect, and total indirect effect of adolescent PAL on MH, as well as the indirect effects through SD and GSE on MH, were all significant. During the period of normalization prevention and control of COVID-19 and the lifting of epidemic prevention and control measures, the indirect effect of adolescent PAL on MH through SD is greater than that through GSE; during the outbreak of COVID-19, the indirect effect of adolescent PAL on MH through SD is slightly less than that through GSE; furthermore, during the period of epidemic normalization prevention and control of COVID-19, the indirect effect of PAL on MH through SD is significantly greater than that through GSE.

Table 3

Bootstrap analysis of the significance test for mediation effect
	Total effect	Direct effect	Indirect effect						%
			Pathways	Point Estimation	SE	Z	Bias-Corrected
			Pathways	Point Estimation	SE	Z	95%CI
2021	− .196 P < 0.001	− .089 P < 0.001	Total indirect effects	− .107	.013	-8.231	− .136	− .080
			PAL→SD→MH	− .077	.010	-7.700	− .098	− .058	71.39%
			PAL→GSE→MH	− .031	.010	-3.100	− .051	− .013	28.61%
			SD minus GSE	− .046	.014	-3.286	− .073	− .018
2022	− .338 P < 0.001	− .230 P < 0.001	Total indirect effects	− .107	.017	-6.294	− .143	− .075
			PAL→SD→MH	− .051	.013	-3.923	− .078	− .028	47.30%
			PAL→GSE→MH	− .057	.014	-4.071	− .085	− .030	52.70%
			SD minus GSE	− .006	.021	− .286	− .035	.046
2023	− .221 P < 0.001	− .117 P < 0.001	Total indirect effects	− .104	.013	-8.000	− .133	− .079
			PAL→SD→MH	− .063	.010	-6.300	− .083	− .046	60.65%
			PAL→GSE→MH	− .041	.010	-4.100	− .061	− .024	39.35%
			SD minus GSE	− .022	.014	-1.571	− .049	.004
Note:5000 bootstrap samples; Run MATRIX procedure: PROCESS Procedure for SPSS Version 4.1, Written by Andrew F. Hayes, Ph.D. (Documentation available in Hayes (2022). www.guilford.com/p/hayes3). model 4,CI 95%, Probe interactions of Moderation and conditioning was if p < 0.05.

The bias-corrected nonparametric percentile Bootstrap test revealed that the 95% confidence intervals for the two mediating pathways did not include 0, signifying significant multiple mediating roles of SD and GSE of adolescents on their PAL and MH. Specifically, the mediating pathway for SD was as follows: PAL ➔ SD ➔ MH (β = − .077, P < 0.001 in 2021, β = − .051, P < 0.001 in 2022, and β = − .063, P < 0.001 in 2023); and the mediating pathway for GSE was as follows: PAL ➔ GSE ➔ MH (β = − .031, P < 0.05 in 2021, β = − .057, P < 0.01 in 2022, and β = − .041, P < 0.01 in 2023). Furthermore, PAL had a direct and significant effect on MH (β = − .089, P < 0.001 in 2021, β = − .230, P < 0.001 in 2022, and β = -0.117, P < 0.001 in 2023).

According to the results of PROCESS Procedure for SPSS Version 4.1, the moderating effect value was calculated using the following formula: [(-.107)/(-0.196)] = 0.5459; this value, expressed as a percentage, is approximately 54.59%. Because mediating and direct effects are homogeneous, they are not masking effects. Therefore, in adolescents, both SD and GSE partially mediated the association between PA and MH levels, with the mediating effect accounting for 57.59% of the total effect. This suggests that almost half of the effect of the PAL of adolescents on their MHL was mediated through the combined effects of SD and GSE. Significance tests for mediating effects indicated that SD (71.39%) played a significant larger role than GSE (28.61%) in 2021. The moderating effect value was calculated: [(-.107)/( -0.338)] = 0.3166; this value, expressed as a percentage, is approximately 31.66%. Because mediating and direct effects are homogeneous, they are not masking effects. Therefore, in adolescents, both SD and GSE partially mediated the association between PA and MH levels, with the mediating effect accounting for 31.66% of the total effect. This suggests that more than 1/3 the effect of the PAL of adolescents on their MH was mediated through the combined effects of SD and GSE. Significance tests for mediating effects indicated that SD (47.30%) played a slightly larger role than GSE (52.70%) in 2022. The moderating effect value was calculated: [(-0.104)/(-0.221)] = 0.4706; this value, expressed as a percentage, is approximately 47.06%. Because mediating and direct effects are homogeneous, they are not masking effects. Therefore, in adolescents, both SD and GSE partially mediated the association between PA and MH levels, with the mediating effect accounting for 47.06% of the total effect. This suggests that almost half of the effect of the PA level of adolescents on their MH levels was mediated through the combined effects of SD and GSE. Significance tests for mediating effects indicated that SD (60.65%) played a slightly larger role than GSE (39.35%) in 2023. The results suggesting that both SD and GSE played an incomplete mediating role in adolescents' PA promotion of MH (see Table 3).

3.3. Comparison of Model Fit Indices in Different Social Situations

While the original study only provided absolute model fit indices. There are no consistent standards for what is considered an acceptable model[12]. However, to further demonstrate the accuracy and applicability of the model, this study reports the following fit indices from the CFA test results based on recommendations from scholars (Hooper, D., et al, 2008; Jackson, D. L., et al, 2009; Robin Nunkoo, et al, 2013; Newsom, 2023)[13–16].

During the period of normalization prevention and control and the lifting of epidemic prevention and control, the GFI, AGFI, NFI, IFI, TLI, and CFI of model fit were All greater than 0.90; SRMR was < 0.05, and RMSEA was less than 0.08.

During the outbreak period of COVID-19, the absolute fit indices of Physical and Mental Health Promotion Model for Adolescent showed χ2/df > 10, RMSEA > 0.10, and AGFI, TFI < 0.90 (see Table 4).

Table 4

the Overview of Model Fit Indices
Time	Absolutely Model Fit					Incremental Model Fit
Time	х²/df	GFI	AGFI	SRMR	RMSEA	NFI	IFI	TLI	CFI
2021	4.613	.998	.979	.019	.058	.989	.992	.950	.992
2022	36.05	.984	.837	.050	.181	.934	.936	.612	.935
2023	1.681	.999	.992	.012	.025	.996	.998	.990	.998

In this study, samples were taken from three different social environments: the period of pandemic normalized prevention and control of COVID-19 in 2021, the period of COVID-19 outbreak in 2022, and the lifting of epidemic prevention and control measures in 2023. The sample size for each year exceeded 1000 cases, meeting the requirements for modeling; it also met the conditions for testing the applicability of the model in different social environments. Changes in adolescents’ PAL, SD, GSE, and MH, and their absolute values of correlation coefficients indicate that the COVID-19 pandemic and corresponding social control measures have had a negative impact on adolescent physical activity and MH[17], and this adverse effect is long-term[18]. Different social control measures not only brought different effects on adolescent physical activity, SD, GSE, and MH, but also on the correlation between them each other. Especially during the COVID-19 outbreak, all factors in the model were significantly negatively affected, which could also affect the fit of the model. During different periods, SD and GSE in Physical and Mental Health Promotion Model for Adolescent had significant total effect, direct effect, and indirect total effect as well as the separate indirect effects through SD and GSE pathways, indicating the model is valid, and both SD and GSE only partially play a mediating role. During the COVID-19 outbreak period, the absolute value of the correlation coefficient between PAL and MH, GSE was the largest; the direct effect and total effect of PAL on MH increased, while the indirect effect value remained unchanged, but the proportion of indirect effect decreased. When facing a dangerous social environment, the direct effect of PAL on MH and GSE becomes more prominent. This suggests that when dealing with a critical social environment, in applying the Physical and Mental Health Promotion Model for Adolescent, we should focus on the direct effect of PAL on MH, as well as consider the indirect effects of SD and GSE on MH to maximize the effect of Physical and Mental Health Promotion Model for Adolescent.

Although, if the research purpose is validity verification, the attention to model fit indices is generally low and can be ignored[19]. This study still added a comparison of model fit indices. From the scores of model fit indices, only during the COVID-19 outbreak period did the model's cmin/df, RMSEA, AGFI, and TLI not reach ideal values. However, Hou Jietai et al believed that cmin/df only corrects for the influence of degrees of freedom without eliminating the effect of N, so it is difficult to determine the quality of the model based solely on its magnitude[20]. Chi square is also affected by the size of the correlations in the model: the larger the correlations, the poorer the fit[12]. During the period of COVID-19 outbreak, the correlation between PAL, GSE, and MH increased, which might be one of the main reasons. At the same time, during the period of COVID-19 outbreak, the PAL, SD, and GSE scores were significantly lower than those during the period of pandemic normalized prevention and control and after lifting epidemic prevention and control measures, while MH scores were significantly higher. This fully demonstrates that the COVID-19 outbreak itself and its corresponding social control measures had a significant negative impact on adolescent PAL, SD, GSE, and MH comprehensively, leading to a decrease in adolescent PAL, SD, GSE scores and an increase in MH scores, which inevitably had a certain adverse effect on the fit of the model.

Additionally, the benefits of physical activity and self-efficacy on MH seem to be achieved through the multifactorial impacts on neurobiological and psychosocial development[21]。Self-efficacy is rooted in the core belief that one has the power to effect changes by one’s actions[22]. Self-efficacy has been found to be a consistent predictor of health behaviour adherence in domains of physical activity[23]. The social relationships commonly inherent in physical activity, as well as the mutual support that occurs among individuals involved in exercise, play an important role in the effects of exercise on MH[24]. Self-efficacy plays an important role in influencing achievement outcomes through its dynamic interplay with environmental and behavioural determinants[25], and self-efficacy reflects internal personal beliefs that interact bi-directionally with behavioural and environmental determinants [26]. However, the lockdown management during the outbreak of COVID-19 has reflected people's feelings of helplessness towards external environments, fear of COVID-19, and concerns about family members and friends being infected or isolated. Those may lead to outliers in MH within the sample and other potential variables affecting the model.

In summary, the Physical and Mental Health Promotion Model for Adolescent in different social contexts is established, and SD and GSE play a partial multiple mediating role in it.

Insufficiency and Limitations

The data used in this study were obtained from cross-sectional surveys, and the accuracy of the data may be affected by recall bias in surveys; convenience sampling was adopted, and all samples came from the same city, which may limit the representativeness of the sample; the sample sizes of different grades in the sample are not equal, which may have a certain impact on the research results, etc.

In different social situations, the Physical and Mental Health Promotion Model for Adolescent is effective. Especially when the social environment has a significant adverse effect on adolescents' physical activity and MH, the direct effect of PAL on MH is greater, while the mediating effect of SD and GSE is relatively smaller; but, SD and GSE both play multiple mediating roles in the model of PAL promoting MH for adolescents in different social environments, etc.

Funding

This work was supported by a grant from the National Social Science Foundation of China (No. 17BTY081).

Acknowledgement

None.

Conflict of Interest

The author declares no conflict of interest.

Data Availability

All data can be provided as needed.

Author Contributions

Dou Kai-yun conceived and designed the study. Dong Ru-bao analyzed the data and wrote the manuscript. Huang Jiaben performed the model fit indicatives and mediation path tests. All authors reviewed and approved the final version of the manuscript.

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No competing interests reported.

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The Reliability and Applicability of the Physical and Mental Health Promotion Model for Adolescent in Different Social Contexts

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Abstract

Figures

1. Introduction

2. Data Sources and Tools

2.1. Data Sources

2.2 Survey Tools

2.2.1 The Physical Activity Questionnaire for Children (PAQ-CN)

2.2.2 The Mental Health Inventory of Middle School Students

2.2.3. General Self-Efficacy Scale

2.2.3. Investigation Implementation

2.3. Statistical Methods

3. Results

3.2. Comparison of the Mediating Effects of GSE and SD in Different Social Situation

3.3. Comparison of Model Fit Indices in Different Social Situations

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

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