Socio-demographic characteristics
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 fourth of participants 494 (79.2%) were orthodox Christian religion followers. (Table 1)
Table 1- Distribution of Socio-demographic factors in high school students at Aksum town (n=624)
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
|
grade9
|
328
|
52.6
|
grade10
|
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
|
1-4thgrade
|
162
|
26.0
|
5-8thgrade
|
143
|
22.9
|
9-12thgrade
|
112
|
17.9
|
Certificate & Above
|
124
|
19.9
|
Mother’s educational status
|
Illiterate
|
176
|
28.2
|
1-4thgrade
|
136
|
21.8
|
5-8thgrade
|
124
|
19.9
|
9-12thgrade
|
117
|
18.8
|
Certificate & Above
|
71
|
11.4
|
Social support related variables
Among participants, the level of social support was measured. Based on the result of this study majority of 256 (41%) students have been found to have poor social support followed by moderate social support 217 (34.8%) and only 151 (24.2%) of students were under good social support. (Figure 1)
Figure 1: - Distribution of the level of social support among high school students at Aksum town, 2019 (n=624)
Substance-related variables
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%) of students chewed khat within the last 3 months. 247 (39.6%) of participants reported alcohol drinking in their lifetime while only 138 (22.1%) of students drunk 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. (Figure 2)
Figure 2: -Distribution of substance-related factors among high school students at Aksum town, 2019 (n=624)
Parental neglect related variables
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%) of the 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. (Table 2)
Table 2:- Distribution of Adverse Childhood Experience questionnaire by sex and educational level among adolescents in the sampled governmental high schools in Aksum town, Ethiopia, 2019 (n=624)
Variables
|
|
Male (n, %)
|
Female (n, %)
|
Grade 9(n, %)
|
Grade 10(n, %)
|
Total (n, %)
|
Physically Hurt
|
Yes
|
74 (11.9)
|
116 (18.6)
|
98 (51.6)
|
92 (48.4)
|
190 (30.5)
|
No
|
211 (33.8)
|
223 (35.7)
|
230 (53)
|
204 (47)
|
434 (69.5)
|
Hit you Marks of Injury
|
Yes
|
34 (5.5)
|
58 (9.3)
|
48 (52.2)
|
44 (47.8)
|
92 (14.7)
|
No
|
251 (40.2)
|
281 (45)
|
280 (52.6)
|
252 (47.4)
|
532 (85.3)
|
Sexual Abuse
|
Yes
|
26 (4.2)
|
45 (7.2)
|
41 (57.7)
|
30 (42.3)
|
71 (11.4)
|
No
|
259 (41.5)
|
294 (47.1)
|
287 (51.9)
|
286 (48.1)
|
553 (88.6)
|
No Love
|
Yes
|
41 (6.6)
|
67 (10.7)
|
51(47.2)
|
57 (52.8)
|
108 (17.3)
|
No
|
244 (39.1)
|
272 (43.6)
|
277 (53.7)
|
237 (46.3)
|
516 (82.7)
|
Not Enough Food or Protection
|
Yes
|
35 (5.6)
|
44 (7)
|
43 (54.4)
|
36 (45.6)
|
79 (12.6)
|
No
|
250 (40.1)
|
295 (47.3)
|
285 (52.3)
|
260 (47.7)
|
545 (87.4)
|
Divorced Parents
|
Yes
|
31 (5)
|
49 (7.9)
|
41 (51.3)
|
39 (48.7)
|
80 (12.8)
|
No
|
254 (40.7)
|
290 (46.5)
|
287(52.8)
|
257(47.2)
|
544 (87.2)
|
Abuse with Gun or Knife
|
Yes
|
20 (3.2)
|
29 (4.6)
|
28 (57.1)
|
21 (42.9)
|
49 (7.8)
|
No
|
265 (42.6)
|
310 (49.6)
|
300 (52.2)
|
275 (47.8)
|
575 (92.2)
|
Live With Alcoholic or Drug User
|
Yes
|
29 (4.6)
|
42 (6.7)
|
40 (56.3)
|
31 (43.7)
|
71 (11.3)
|
No
|
256 (41)
|
297 (47.6)
|
288 (52.1)
|
265 (47.9)
|
553 (88.7)
|
Depressed or Attempted Suicide HH Member
|
Yes
|
19 (3)
|
28 (4.5)
|
31 (66)
|
16 (34)
|
47 (7.5)
|
No
|
266 (42.5)
|
311 (49.8)
|
297 (51.5)
|
280 (48.5)
|
577 (92.5)
|
Household Member in Prison
|
Yes
|
41 (6.6)
|
46 (7.4)
|
50 (57.5)
|
37 (42.5)
|
87 (14)
|
No
|
244 (39.1)
|
293 (47)
|
278 (51.8)
|
259 (48.2)
|
537 (86)
|
Parental neglect
|
Yes
|
144 (23.1)
|
190 (30.4)
|
175(52.4)
|
159(47.6)
|
334 (53.5)
|
No
|
141 (22.6)
|
149 (23.9)
|
153(52.8)
|
137(47.2)
|
290 (46.5)
|
Prevalence of depression
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 grade 10 students met the screening criteria for depression which is higher when compared to 116/328(35.4%) of grade 9 students 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%) of students lie in mild depression category whereas 74 (11.4%), 15 (2.4%) and 7 (1.1%) of students were found to have moderate, moderately severe and severe depression respectively. (Figure 3)
Figure 3:- characterization of depression severity among adolescents in governmental high schools at Aksum town, 2019 (n=624)
Association between depression and parental neglect
Adverse childhood 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 a parent has 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) (20).
The adverse childhood experience questionnaire was checked for co-linearity between each item using the Pearson correlation coefficient at the p-value of <0.05. As a result, there was no co-linearity found between each item of the screening tool. A reliability test was conducted among the 10 items and it has been found to have high reliability (Cronbach's alpha=0.83). After it is checked for co-linearity it was entered into logistic regression analysis and it is found to have a p-value of <0.25 on bivariate analysis crude odd ratio (COR=2.75, 95% CI (1.95, 3.89), p-value=0.000).
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 education, mother education, social support and current use of alcohol were found to have p-value <0.2 (Table 3).
These factors were entered into multivariate logistic regression for further analysis to control confounding effects. As a result being female, poor social support, mother educational status and parental neglect are found to be statistically significant for depression at p-value <0.05.
The odds of developing depression among those who had parental neglect were 2.61 times higher as compared to those who haven't parental neglect (AOR=2.61, 95% CI: (1.83,3.72)). (Table 3)
Table 3:- bivariate and multivariate logistic analysis of factors associated with depression among adolescents in the sampled governmental high schools in Aksum town, Ethiopia, 2019 (n=624)
Variable
|
Category
|
Depression
|
COR (95% CI)
|
AOR (95% CI)
|
p-value
|
yes
|
No
|
Sex
|
Male
|
83
|
202
|
1
|
1
|
|
Female
|
226
|
398
|
1.78(1.27, 2.48)
|
1.48(1.03, 2.13)
|
.034*
|
Family size
|
<=5
|
143
|
229
|
1
|
1
|
|
>5
|
83
|
169
|
0.79(0.56,1.10)
|
0.77 (0.53,1.10)
|
.150
|
Social support
|
Poor
|
107
|
149
|
1.86(1.21,2.88)
|
1.69(1.07,2.69)
|
.026*
|
Moderate
|
77
|
140
|
1.43(0.91,2.24)
|
1.56(0.97,2.52)
|
.067
|
Good
|
42
|
109
|
1
|
1
|
|
Current alcohol
|
Yes
|
98
|
149
|
1.28(0.918,1.784)
|
0.73 (.51,1.06)
|
.100
|
No
|
128
|
249
|
1
|
1
|
|
Mother education
|
Illiterate
|
75
|
99
|
2.07(1.13, 3.80)
|
2.21 (1.09,4.49)
|
.028*
|
1-4
|
49
|
86
|
1.56(0.83,2.93)
|
1.45 (0.70, 3.01)
|
.317
|
5-8
|
47
|
79
|
1.63(0.861,3.08)
|
1.67(0.83,3.35)
|
.153
|
9-12
|
36
|
82
|
1.20(0.62,2.31)
|
1.27 (.64,2.56)
|
.496
|
College and above
|
19
|
52
|
1
|
1
|
|
Father education
|
Illiterate
|
35
|
46
|
1.81(1.01,3.24)
|
1.11(.56,2.20)
|
.768
|
1-4
|
62
|
101
|
1.46(0.89, 2.40)
|
0.92(.495, 1.706)
|
.789
|
5-8
|
56
|
87
|
1.53 (0.92,2.55)
|
1.11 (0.61,2.03)
|
.730
|
9-12
|
36
|
76
|
1.13(0.65,1.96)
|
1.00(.55,1.83)
|
.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)
|
.000***
|
No
|
70
|
220
|
1
|
1
|
|
a = 0.05 * P-value<0.05 ** P-value< 0.01 *** P-value<0.001
Discussion on the prevalence of depression
The study revealed that the prevalence of depression was 36.2%. This result was in line with studies conducted at Addis Ababa (39.3%) among adolescents in governmental high schools (16) and Northern Iran 34% among high school and pre-university adolescents using Beck's questionnaire (21).
However, the current study finding for depression was higher than the studies conducted among adolescents at Korea 20.6% (22), Saudi Arabia 23.8 (23), Egypt 28.6% (24), Malaysia 10.3% (25) and Trinidad 25.3% (26).The reason for the above difference might be due to difference in adolescents age which was only 13-19 in Trinidad (26), study population who were only boys in Korea (22), type of study conducted which was a large survey in Ethiopia (27), screening tool which was BDI II in a study conducted at Saudi Arabia (23) and the children's depression inventory in a study at Malaysia (25) and sample size which was 1373 in Egypt (24).
On the other hand, the finding of this study on the prevalence of depression was lower than a study conducted at Can Tho-City, Vietnam 41.1% (28) and China Hong Kong 50% (29). This difference might be attributed to time point the studies conducted which was a long-term study in Hong Kong (29), difference in study subjects in which only those adolescents who are abused physically and emotionally were studied and difference in sample size in which large sample size was used in Vietnam i.e.1159 students (28).
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 at Can Tho-City, Vietnam (28).
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 a study conducted in Egypt which was 7.1% and 0% in Egypt respectively (24) and Iran 5.7% and 0.3% respectively (21).
The result of this study on mild depression is also found to be lower than a study conducted in Iran among high school and pre-university adolescents which was 28% (21). A possible reason for the difference might be difference screening tools used to determine depression such as CES-D was applied in Iran (21) and sample size which was 1373 in Egypt (24).
Discussion on the association between depression and parental neglect
Parental neglect which is the main independent variable is found to be statistically associated with depression at p-value<0.05. It was tried to analyze the students' parental neglect with other explanatory variables to control for confounding variables. After multivariate analysis, the strength of association between depression and parental neglect doesn't show a significant difference i.e. COR=2.75 and AOR=2.61.
Students who were experiencing parental neglect were 2.61 times more likely to develop depression than those who didn't experience parental neglect. This study is in line with a study conducted at Addis Ababa (AOR=2.9) (16). This may be because among the most common outcomes of neglect is the failure to succeed. Breakdown to succeed is a term that is normally applied to explain kids with a strange prototype of weight gain or weight loss, or experiencing inadequate growth patterns (both mental and physical health) per a kid's age and developmental phase. This situation can occur when a child does not get sufficient diet or necessary medical consideration essential for appropriate bodily development (30); which may later hinder adolescents' overall physical health including mental health and lead them to depression.
In more tremendous cases breakdown to succeed can also influence children over their entire existence course by really destructing his/her cognitive progress and his/her 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 afterward adulthood and give way to depression (30).
It might also be because a preponderance of neglected kids displays attachment disorder manifestations and finally form 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 intern reducing 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 (31).
Neglectful parents and caregivers give poor interaction and positivity for their belongings which is linked to increased levels of shame called shame-proneness (32). Shame-proneness may increase neglected adolescent's risk for depressive symptoms since they try to suppress such an aversive feeling. Shame suppression, in turn, may lead to sadness, social isolation and withdrawal and lastly to depression (33, 34).
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, emotional regulation, which contributes for the heightened occurrence of depression on victims (35).
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, appreciate others' emotional expression and trouble in differentiating emotions which amplify their susceptibility for developing depression. Youth 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 (36).
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 for developing depression in youths (37).