SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA PREVALENCE AND FACTORS ASSOCIATED WITH DEPRESSION AMONG STUDENTS IN THE AKWAPIM SOUTH DISTRICT BY ADWOA ANUONYAM ABBOTSI (STUDENT ID- 10933724) A DISSERTATION PROPOSAL SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE APRIL, 2023 University of Ghana http://ugspace.ug.edu.gh i. DECLARATION I, Adwoa Anuonyam Abbotsi, declare that this research work is my own work done under supervision. All resource persons have been duly acknowledged and referenced. This thesis in whole or part has not been submitted anywhere else for the award of a degree. Adwoa Anuonyam Abbotsi (Student) Date: 27th April, 2023 Signature: Prof. Emilia Udofia (Academic Supervisor) Date: 27th April, 2023 Signature: University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT “But thanks be to God, who gives us the victory, through our Lord Jesus Christ”. I give all the glory and honour to the Almighty God for His Grace and mercies throughout this study. I would like say a big thank you to my Supervisor, Prof. Emilia Udofia for her guidance and support during my study. To Mrs Jennifer Darfoor, Mr. Andrews Asamoah, Miss Siako and the data collection team, I say God bless you for being a there for me and seeing to the successful completion of my work. Your contributions to my success story have been overwhelming. My sincere appreciation also goes to the Ghana Education service directorate of the Akwapim south Municipal, as well as the staff and students at the sampled schools. This study would not have been possible without your co-operation. Finally, to my wonderful Husband and children, I am grateful for your Love, Prayers and understanding. The healthy environment you gave me has brought me this far. University of Ghana http://ugspace.ug.edu.gh iv TABLE OF CONTENT DECLARATION ....................................................................................................................... ii ACKNOWLEDGEMENT ........................................................................................................ iii TABLE OF CONTENT ............................................................................................................ iv LIST OF TABLES ................................................................................................................... vii LIST OF FIGURES .............................................................................................................. viii LIST OF ABBREVIATIONS ................................................................................................... ix ABSTRACT .............................................................................................................................. x CHAPTER ONE ........................................................................................................................ 1 INTRODUCTION ..................................................................................................................... 1 1.0 Background ................................................................................................................. 1 1.1 Problem Statement ...................................................................................................... 3 1.2 Research Objective ...................................................................................................... 6 1.2.1 General Objective ................................................................................................ 6 1.2.2 Specific Objectives .............................................................................................. 7 1.3 Research Questions ..................................................................................................... 7 1.4 Justification of the Study .................................................................................................. 8 1.5 Chapter summary and dissertation outline ....................................................................... 8 CHAPTER TWO ..................................................................................................................... 10 LITERATURE REVIEW ........................................................................................................ 10 2.0 Introduction .................................................................................................................... 10 2.1 Depression in Adolescent: Concept and definition ........................................................ 10 2.2 Prevalence of Depressive Symptoms among Adolescents ............................................. 13 2.2.1 Prevalence of Depressive Symptoms among Adolescents within Global Context . 14 2.2.2 Prevalence of Depressive Symptoms among Adolescents within Africa ................ 16 2.2.3 Prevalence of Depressive Symptoms among Adolescents in Ghana ...................... 17 2.3 Common Depressive Symptoms among Adolescents .................................................... 19 University of Ghana http://ugspace.ug.edu.gh v 2.4 Factors Associated with Depression Symptoms among Adolescents ............................ 21 2.5 Conceptual Framework ............................................................................................. 26 2.6 The Patient Health Questionnaire (PHQ-9) .............................................................. 29 2.7 Chapter summary and outstanding knowledge gaps ................................................. 30 CHAPTER THREE ................................................................................................................. 31 METHODS .............................................................................................................................. 31 3.0 Introduction .................................................................................................................... 31 3.1 Study Design .................................................................................................................. 31 3.2 Study Area ...................................................................................................................... 31 3.3 Study Population ............................................................................................................ 33 3.3.1 Inclusion Criteria ......................................................................................................... 33 3.3.1 Exclusion Criteria ........................................................................................................ 34 3.4 Sample size estimation ................................................................................................... 34 3.5 Sampling methods .......................................................................................................... 35 3.6 Data Collection Method ................................................................................................. 35 3.7 Data Collection Instrument ............................................................................................ 36 3.8 Quality Assurance Measures .......................................................................................... 36 3.9 Data Processing and Management ................................................................................. 37 3.10 Variables....................................................................................................................... 37 3.10.1 Dependent Variables ................................................................................................. 37 3.10.2 Independent Variables ............................................................................................... 37 3.11 Data Analysis ............................................................................................................... 39 3.12 Ethical Consideration ................................................................................................... 39 CHAPTER FOUR .................................................................... Error! Bookmark not defined. RESULTS ................................................................................ Error! Bookmark not defined. 4.2 Socio-demographic characteristics of respondents ........ Error! Bookmark not defined. 4.3 Common depressive symptoms and the prevalence of depressionError! Bookmark not defined. University of Ghana http://ugspace.ug.edu.gh vi 4.4 The prevalence of depression ......................................... Error! Bookmark not defined. 4.5 Behavioural factors of the adolescents ........................... Error! Bookmark not defined. 4.6 Environmental factors (school and home) ..................... Error! Bookmark not defined. 4.7 Socio-demographic factors associated with depression among in-school adolescents .............................................................................................. Error! Bookmark not defined. 4.8 Behavioural factors associated with depression among in-school adolescents .......Error! Bookmark not defined. 4.9 School and home environment factors associated with depression among in-school adolescents ........................................................................... Error! Bookmark not defined. 4.10 Multivariate analysis of factors associated with depression among in-school adolescents .............................................................................................. Error! Bookmark not defined. 4.11 Chapter Summary ......................................................... Error! Bookmark not defined. CHAPTER FIVE ..................................................................... Error! Bookmark not defined. DISCUSSIONS ........................................................................ Error! Bookmark not defined. 5.1 Introduction .................................................................... Error! Bookmark not defined. 5.2 Prevalence of depression among in-school adolescents . Error! Bookmark not defined. 5.3 Most common symptoms that adolescents exhibit during depressionError! Bookmark not defined. 5.4 Socio-demographic factors associated with depression among adolescents ...........Error! Bookmark not defined. 5.5 Other related factors associated with depression among adolescentsError! Bookmark not defined. 5.6 Strengths and Limitation of the Study ........................... Error! Bookmark not defined. 5.5 Summary of the Chapter ................................................ Error! Bookmark not defined. CHAPTER SIX ........................................................................ Error! Bookmark not defined. SUMMARY, CONCLUSION AND RECOMMENDATION Error! Bookmark not defined. 6. 1 summary of major findings ........................................... Error! Bookmark not defined. 6.3 Recommendations .......................................................... Error! Bookmark not defined. Reference ................................................................................................................................. 73 University of Ghana http://ugspace.ug.edu.gh vii APPENDIX I: PARTICIPANT INFORMATION SHEET ................................................ 83 APPENDIX II: CONSENT FORM FOR ADOLESCENT (18-19) YEARS ...................... 86 APPENDIX III: ASSENT FORM FOR ADOLESCENT (10-17) YEARS ........................ 86 APPENDIX IV: PTA CONSENT FORM .......................................................................... 87 APPENDIX IV: DATA COLLECTION TOOL ................................................................. 90 LIST OF TABLES Table 2.1: PHQ-9 Model for measurement of depression ....................................................... 29 Table 3:1: Dependent and Independent Variables for the Study ............................................. 38 Table 4.1: Socio-demographic characteristics of the adolescentsError! Bookmark not defined. Table 4.2: Depression status and common symptoms ............. Error! Bookmark not defined. Table 4 3: Behavioural factors of the adolescents ................... Error! Bookmark not defined. Table 4 4: Environmental factors (school and home) .............. Error! Bookmark not defined. Table 4 5: Bivariate analysis of socio-demographic factors associated with adolescent depression ................................................................................ Error! Bookmark not defined. Table 4.6: Bivariate analysis of behavioural factors associated with depression among in- school adolescents .................................................................... Error! Bookmark not defined. Table 4.7: Bivariate analysis of environmental factors associated with adolescent depression.21 .................................................................................................. Error! Bookmark not defined. Table 4.8: Multivariate regression analysis of factors associated with depression among in- school adolescents .................................................................... Error! Bookmark not defined. University of Ghana http://ugspace.ug.edu.gh viii University of Ghana http://ugspace.ug.edu.gh ix LIST OF FIGURES Figure 2.1: Conceptual framework showing factors that could influence the prevalence of depressive symptoms among adolescents (concept deduced from various literature and its application to this study) .......................................................................................................... 27 Figure 3.1: District map of Akwapim South District in Eastern Region of Ghana ................. 33 Figure 4.1: Depression conditions among the adolescents ...... Error! Bookmark not defined. University of Ghana http://ugspace.ug.edu.gh x LIST OF ABBREVIATIONS CRC - Convention of the Rights of the Child PHQ-9 - Patient Health Questionnaire SCL - Symptoms Check Lisy UN - United Nations UNICEF - United Nations International Children’s Emergency Fund WHO - World Health Organization University of Ghana http://ugspace.ug.edu.gh xi ABSTRACT Background: Cases of depression and its resultant effect have been reported in different times at different levels. For instance, in early 2022, graphiconline.com reported a case of a depressed man who committed suicide for fear of the future which is unknown. Similar cases of depression and its consequences have been reported from different parts of the Eastern Region with a few in Akwapim South. Unfortunately, detail assessment of the prevailing situation in the region and specifically in Akwapim South has not been done to estimate the prevalence of depression among in-school adolescents. Aim: The main objective of the study is to determine the factors that are associated with depression among in-school adolescents in Akwapim South district. Method: The study employed a cross-sectional in-school survey as the main study design. Adolescents who were aged 10-24 years and were in Junior and Senior High Schools comprised the study participants. Simple random sampling method was employed to select adolescents at different levels. Regression analysis to determine association between factors and depression was conducted using STATA version 17.0. The results were obtained at 95% confidence level. Results: The mean age of the in-school adolescents was 16.4 years (± 2.0 SD). Of the study participants, 57.3% had minimal depression, 30.9% had mild depression, 6.3% moderately depressed, 4.0% had moderately severe depression while 1.5% had severe depression. The prevalence of depression among the adolescents was therefore computed to be 11.8%. After controlling for all significant variables, age (AOR = 7.13, 95% CI: 1.58, 32.23), sex (AOR = 3.65, 95% CI: 1.38, 9.63), smoking (AOR = 4.44, 95% CI: 1.30, 15.15), access to learning materials (AOR = 2.7, 95% CI: 1.27, 5.87), family history of depression (AOR = 2.45, 95% CI: 1.08, 5.58) and marital abuse (AOR = 2.05, 95% CI: 1.03, 4.08) were factors that influenced the rate of depression among the adolescents. Conclusion: The study observed relatively lower rate of depression among in-school adolescents. There were however some of the adolescents who had either severe or moderately University of Ghana http://ugspace.ug.edu.gh xii severe depressive condition. Factors such as socio-demographic, environmental and behavioural conditions contributed to the outcome of the adolescent depressive conditions. Strengthening counselling units at the various schools by the District Directorate of Education of Akwapim South is critical in addressing challenges of depression among in-school adolescents. The school and the home environment play significant influence in the life of an adolescent. Adolescents at their early formative stage needs a conducive environment to grow and develop. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0 Background Depression has been identified as a common mental disorder in recent times. According to American Psychological Association, (2021), depression, which is also called major depressive disorder, is a major illness that affects the way a person feels, acts or thinks negatively. In most cases, depression causes someone to lose interest in activities or things that they previously enjoyed. Similarly, depression is noted to likely cause someone to continuously feel sad even in an environment where there is much happiness. The World Health Organization, (2017) further reiterates that depression most often leads to different forms of physical and emotional problems which may reduce one’s ability to perform an assigned task effectively. Evans-Lacko et al., (2018) in their study noted that sometimes people confuse depression with mood fluctuations and short- lived emotional reaction to problems and challenges. Evans-Lacko et al., (2018) explained that depression goes beyond these daily fluctuations, however, when it is not well managed, it may result into severe health conditions when the the level of intensity increases. Kendler, (2020) explains that depression is an old age problem which has been with man over centuries. However, it was until 1880s that appropriate diagnosis formulation of melancholia was developed to give way for further development and research. Despite the available treatment options and management processes globally, it is estimated that more than 75% of all people who get depressive disorders do not receive effective and appropriate treatment (WHO, 2021). Different factors have been linked to reasons why depressive disorder patients do not get the appropriate care. Lack of resources has been identified as a major barrier to University of Ghana http://ugspace.ug.edu.gh 2 the provision of effective treatment for depressive disorders. Resource constraints have affected the procurement of appropriate logistics and the establishment of rehabilitation centres for dealing with excessive depression especially among the aged and the youth (WHO, 2021). Evans-Lacko et al., (2018) also noted that inadequate trained health-care providers coupled with high levels of stigma within the society has increasingly denied people with depressive disorder to receive appropriate treatment. Chekroud et al., (2018) in a discussion on treatment barriers noted that the cost of treatment, distance to treatment centres coupled with cost of transportation were the main reasons why depression patients do not receive appropriate treatment. Bryant et al., (2013) also indicated that barriers to treatment of depression have two forms: internal and external factors. Internally, patient’s personal business, mind-set, denial and put on a front have been affecting their ability to seek treatment. External factors were described to include spiritual beliefs, lack of medical resources, lack of education/awareness on depression and stigma. It is estimated that, globally, at least 5% of all people are depressed while 5.7% of people aged 60 years and above are also depressed. It is further estimated that nearly 280 million people worldwide have depression (WHO, 2021). The inability of patients with depression to seek care and support have resulted in several problems globally. May et al., (2012) in a 10-year longitudinal study among high school adolescents observed that more than half of people who are depressed either contemplate on committing suicide, try to commit suicide or end up in committing suicide. It is further estimated that more than 700 000 people commit suicide every year as a result of the inability to treat depression cases (WHO, 2021). Ahmed et al., (2017) in a global estimate of depression and suicide in WHO South-East Asia Region noted that the region accounts for about 39% of cases. However, in sub-Saharan Africa, it is estimated that about 34 000 people who are in depressed condition commit suicide every year, culminating into a 3.2 deaths per 100 000 University of Ghana http://ugspace.ug.edu.gh 3 population (Gbadamosi et al., 2022). Additionally, suicide has been established to be three times higher among men compared to women. Gbadamosi et al., (2022) explains that the proportion of men with depression is significnatly higher than depression in women and this has contributed to the higher suicidal cases among men. Among adolescents, cases of depression has been increasing over the years. It has been established that adolescents most often are prone to depression when they are physically and emotionally abuse and are exposed to poverty or violence within their environment (WHO, 2021). The 2021 WHO fact and figures report shows that depression is one of the leading causes of adolescent illness and disability in recent times resulting in frequent suicide cases among adolescents. Suicide among adolescents is the fourth leading causes of death especially among 15-19 years old. The consequences of the failure of stakeholders to address depression among adolescents has resulted in protracted physical and mental health problems into adulthood. These adolescents are expected to take over leadership mantles in future or serve as source of labour force in the near future. It is therefore important that in-dept assessment is done to ascertain the prevailing conditions to help curtail the emerging trend. 1.1 Problem Statement The United Nations in 2011 estimated that children and adolescents who are between the ages of 5-17 years constitutes about a quarter of the world population (United Nations, 2011). However, in 2015, a different global assessment on world population further reiterated that children and adolescent between the ages of 5-17 years form about 30% of the global population and approximately 37% of African’s population are expected to be within this age by 2050 (UNICEF, 2014). It has been predicted that nearly half of the population in Africa would be those below 18 University of Ghana http://ugspace.ug.edu.gh 4 years by the end of the 21st century. The increasing trends in children and adolescent population has consequent effect on the demand for specific adolescent healthcare services. Unfortunately, there are challenges with access to appropriate healthcare services to adolescents especially between the ages of 10-19 years. One of such health challenge is the provision of mental health needs of adolescents (Erskine et al., 2017). Even though higher records of depression have reported among middle aged and older population, recent updates and studies have shown increasing cases of depression among the adolescent in developing countries including Ghana (Thapa & Hauff, 2012; Thapa et al., 2015; World Health Organization, 2021). Elsabe, (2021) in an article on “High Mental Health Burden for African Youth” described young people in Africa as people who are at a higher risk of having severe mental disorders due to increasing cases that are reported everyday in health facilities. Despite the increasing reported cases of depression among adolescent, data on the prevalence of mental disorder especially among in-school adolescents have been limited. Elsabe, (2021) have reiterated that global focus on depression have centred on adult population and the systems that can provide adequate treatment to the adult. With the increasing population of the adolescent in Africa, it would have been appropriate to ascertain adequate data on the prevalence of depression and its related mental disorder to inform decision making on the allocation of resources for health service provision. Jorns-Presentati et al., (2021) postulated that research works that have been done on adolescent mental health have largely been done in high-income countries. Interventions that have been carried out to prevent and address challenges on depression continue to be in high- income countries. Erskine et al., (2015) in the discussion on the impact of depression mentioned that lack of empirical evidence has affected health providers on mental health by reducing the level University of Ghana http://ugspace.ug.edu.gh 5 of visibility of mental disorder among adolescents thereby denying them with appropriate treatment. Moukaddam et al., (2019) maintained that adolescent stage is critical period for the development of the brain and therefore any slight problem with it affects the general cognitive development of the adolescent. Moukaddam et al., (2019) indicated that depression among adolescent has been increasing steadily but with limited response to addressing the issue. Consequently, the impact on the adolescent is becoming dire and causing many deaths and other chronic diseases including suicide. Nonetheless, the risk factors associated with the steadily increasing cases of depression among in-school adolescents are not widely known especially in sub-Saharan Africa. A recent WHO report on mental health status in Ghana shows that about a tenth of Ghanaians are living with mental health problems, with the youth as the affected majority (WHO, 2022). The World Health Organization (WHO) estimates that, out of 32 million Ghanaians, around 2.3 million people live with a mental health condition requiring mental health care. Depression constitutes more than a fourth of all mental health problems in the country (WHO, 2022). In Ghana, the burden of depression until recently was mostly linked to the aged with the neglect of the adolescent and the youth who are in-school. The general perception had been that only the aged were linked to severe depression. However, recent reports suggests otherwise (WHO, 2021, Nakua et al., 2023). Despite the increasing rise in depressive conditions among in-school adolescents and the youth, it has not received commensurate attention. University of Ghana http://ugspace.ug.edu.gh 6 Cases of depression in the Eastern Region and its resultant effects have been reported in different times especially through the media space. For instance, in early 2022, graphiconline.com reported a case of a depressed man who committed suicide for fear of the future which is unknown. Similar cases of depression and its consequences have been reported from different parts of the region with a few in Akwapim South. Unfortunately, a detailed assessment has not been done to estimate the prevalence of depression among in-school adolescents in Akwapim South District. In the study district, reported cases of mental health issues among the youth is increasing over time. In 2021, more than half of all mental issues that were reported in the health facilities were attributed to the adolescents who were largely in the schools. Increasingly, adolescents in Junior High Schools are reporting cases of mental distress and depression, resulting in hospitalisation of these adolescents in the district hospital (Ghana Health Service, Akuapem South District, 2022). The fundamental factors that contribute to the increasing cases in the district and the region has equally not been established. It is therefore important to assess the prevailing mental health conditions in the form of depression among in-school adolescents. This study therefore proposes to determine the associated factors of depression among in-school adolescents in the region. 1.2 Research Objective 1.2.1 General Objective The main objective of the study is to estimate the prevalence and the factors associated with depression among in-school adolescents in Akwapim South district. University of Ghana http://ugspace.ug.edu.gh 7 1.2.2 Specific Objectives The specific objectives of the study are to: a. To estimate the prevalence of depression among in-school adolescents in Akwapim South district. b. To identify the most common symptoms that adolescents exhibit during depression. c. To determine socio-demographic factors that are associated with adolescent depression among in-school adolescents d. To determine any other-related factors that are associated with depression among in-school adolescent in Akwapim South district 1.3 Research Questions To achieve the objectives of this study, the following research questions will be investigated: a. What is the prevalence of depression among in-school adolescents in Akwapim South district? b. What are the common symptoms that in-school adolescents exhibit during depression? c. What are the socio-demographic factors that are associated with depression among in- school adolescents? d. What are the other-related factors that are associated with depression among in-school adolescent in Akwapim South district? University of Ghana http://ugspace.ug.edu.gh 8 1.4 Justification of the Study Despite the global response to the fight against depression, there has been steady increase in cases of depression among adolescents in Ghana and across the sub-Saharan African region. Adu et al., (2021) has confirmed the challenges with the emerging depression trend in Ghana among adolescents. This study would therefore determine the level of depression among in-school adolescents which would help policy makers to determine the extent of the condition and how best to develop interventions that can best address the challenges. This study will identify key factors that contribute to the prevalence of depression among in-school adolescents. The results will also provide some evidence to guide in the development of relevant interventions. The study also seeks to identify the common symptoms that are associated with depression among adolescents. Knowledge about these symptoms is critical and provides the first step to addressing the challenges. The outcome of the study would enhance the capacity of the District Health Directorate to understand the prevailing situation and integrate mental healthcare services to offer effective healthcare within a primary health care approach. This study will thus form the basis for further studies on mental health in the district. 1.5 Chapter summary and dissertation outline The chapter has outlined the key problem that has necessitated this study. The research objectives and questions have also been outlined in the chapter. The rest of the dissertation will be organised as follows. Chapter two reviews various literatures that are related to the study objectives. The methods of the study would be presented in chapter three while the results of the study would be University of Ghana http://ugspace.ug.edu.gh 9 presented in chapter four. Chapter five will discuss the findings of the study, while chapter six concludes with relevant recommendations. University of Ghana http://ugspace.ug.edu.gh 10 CHAPTER TWO LITERATURE REVIEW 2.0 Introduction The chapter discusses the various concepts and models that better explains depression among adolescents within global, regional and national context. The concept of depression is discussed as length to unearth the underpinning factors that contributes to its prevalence among adolescents. The chapter thus therefore been categorised into four main sections; concept and definition of depression, prevalence of depression, common depressive symptoms and factors that influence the prevalence of depressive symptoms or conditions among adolescents. The discourse on adolescents is much concentrated on in-school adolescents largely at high school. The chapter is however concluded by presenting a model that predicts depressive condition among adolescent and it’s conceptual framework. Various studies on adolescent depression were reviewed through an analysis of key findings of each study/article and its relevant to this research topic. In most cases, articles of different studies were retrieved from sources such as Google Scholar, PubMed, Wiley, etc. References were also made from other reports of corporate organizations as well as conference papers that have been published in books. For each review, details assessment was done to ascertain key areas that supports the argument for this study while analysing the methods that were adopted in the various studies to understand their significance and possible application in this study. 2.1 Depression in Adolescent: Concept and definition According to the World Health Organization, (2012), depression is classified as a common mental disorder that is mostly experienced in different forms by different people at different times. It is University of Ghana http://ugspace.ug.edu.gh 11 explained that depression which is noted as mental health condition is most often linked directly to sadness, the act of feeling guilty or low self-esteem and sometimes loss of appetite. In some conditions, depression may be classified and explained a distressed sleep condition while others feeling tired as often as possible. (WHO, 2012). The American Psychological Association, (2021) defined depression a mental disorder which negatively affects someone’s ability to reason or think, to act and how to feel. The ability to think is borne from the fact that depression is directly linked to the brain and is described as retarding the functionality of the brain/mind at the point of the defect. It further explained that depression can lead to variety of emotional as well as physical problems and this consequently affects the affected person’s capacity to perform any activity. Globally, it is estimated that over 350 million people have been affected by depression and this further increased by 4.1% in 2020 (World Health Organization, 2021). Depression constitutes about 11% of the global burden of mental illness. However, when the condition recurs in an individual, the effect is noted to be severe and may have dire consequences to the social capabilities of the person affected (World Health Organization, 2012). In recent times, the rate of depression among the youth is increasing. Wartberg et al., (2018) explains that, among adolescents, unipolar depressive disorder remains the major mental health disorders which is more apparent during the later stages in adolescence. Mokdad et al., (2016) further reiterated that the widespread of depression among adolescent has consequently affected their well-being and this has increased the risk of suicidal cases in recent times. The risk of suicide among those who are depressed has been established to be significantly higher in the youth compared to those in adult population (Mehler- Wex & Kölch, 2008). Biological, psychological and social factors have consistently influenced or University of Ghana http://ugspace.ug.edu.gh 12 determined depressive symptoms or conditions among adolescents, however, psychosocial factors have dominated in most of the identified cases (Naab et al., 2015). While discussing the concept of depression among adolescents, it is important to understand the context within which adolescents are described. Adolescence is a period of transition from childhood to adulthood. The World Health Organization defines adolescence as the phase of life of transition from childhood to adulthood, which falls between the ages of 10 to 19 years (WHO, 2017). Situating the World Health Organization’s definition within context of childhood definition connotes that majority of the adolescents are within the childhood bracket of less than 18 years as clearly defined in the Convention of the Rights of a Child (CRC) (United Nations, 1989). Sawyer et al., (2012) in discussing the concept of adolescence expanded the scope to capture both the WHO and the UN definitions to integrate it into young people between the ages of 10 – 24 years. At age 18 years, although a girl or boy at 18 is considered as an adolescent, the CRC describes such a person as an adult and therefore may be treated differently within different context. Children between the ages of 10-14 years have been categorised as those within early adolescents stage while middle adolescents describes children who are between the ages of 15-17 years. The later adolescent stage has been identified as young adults who are largely between the ages of 18- 19 years, and expanded to 24 years in the context of young people. Young adults or later adolescents have passed the age of childhood and are characterised with diverse behaviours and practices. For each developmental stage, there are unique characteristics that are equally linked to the health needs of the adolescent. The adolescent within the three phases go through both physical/biological, cognitive, and psychosocial development. The development for each stage, University of Ghana http://ugspace.ug.edu.gh 13 whether biological, cognitive, or physical differ from each other. However, it must be emphasised that not all adolescents may get through the same process at different stages as per the age criteria. Laski, (2015) in discussing adolescent health described adolescent stage as a critical stage of human development which is characterised by rapid biological, emotional and social development. It is also mentioned that it is the stage where specific health and other developmental needs and rights of every human being is required (WHO, 2014). In essence, the time in every human beings life to develop knowledge and skills and to learn how to manage emotions is significantly high during the adolescent stage. However, the failure of some adolescents to manage their emotions and other psychosocial challenges during that period has greatly influenced the condition of depression within that stage. Sawyer et al., (2012) has maintained that when the cognitive growth of an adolescent is affected, there are severe consequences that may require urgent medical attention. Adolescent stage has also been described as a healthy stage, however, other negative issues including death and injury have been associated with the stage. While some of these negative tendencies are preventable, there are some that have lacked the support to help them move out of their condition. 2.2 Prevalence of depression The discussion on depressive symptom prevalence has been situated within global and national context. Assessment of the conditions at different levels helped to appreciate the context within which this study can be linked to. University of Ghana http://ugspace.ug.edu.gh 14 2.2.1 Prevalence of Depression among Adolescents within Global Context Globally, it is estimated that one in seven people (approximately 14.3%) of adolescents who are aged 10-19 years experienced depression in the form of mental disorder, constituting about 13% of all global burden of disease among adolescents (World Health Organization, 2021). It is further estimated that at least 1.1% of adolescents aged 10-14 years are likely to experience some form of depression. Racine et al., (2021) conducted a meta-analysis of various studies that had been conducted globally from different WHO regions. The study was to estimate the prevalence of depression among children and adolescents during COVID-19 period. The results of the meta- analysis which had about 80,879 participants observed a pooled prevalence of 25.2% for depression while prevalence of anxiety symptoms was 20.5%. The prevalence in this study was comparatively higher than the global prevalence as reported by WHO (WHO, 2021). Erskine et al., (2017) also estimated the global prevalence of mental disorders in children and adolescents. The global analysis of the mental disorder used data from 63 countries which had reliable data. The estimate showed a prevalence of 6.2% among children 5-17 years. Studies from other countries from different WHO regions have also been reviewed to ascertain the disparities that exist in these countries with reference to adolescent depression. In Asia, different studies have provided some perspectives of depression symptoms among adolescents. Singh et al., (2017) in an earlier study in Chandigarh, India among school-going adolescents in both private and public schools. The study adopted the Indian Patient Health Questionnaire-9 (PHQ-9) tool for assessing the levels of depression among the in-school adolescents of ages between 13-18 years old. The study, which was a cross-sectional design, recruited 542 participants. Adolescent depression was observed among 40% of the study participants. There were however some University of Ghana http://ugspace.ug.edu.gh 15 disparities in measuring the severity of depression. It was noted that 7.6% of the adolescents had major depressive disorders while 32.5% had other forms depressive disorder. The rate of severity was further assessed. The result showed that 29.7% of the adolescents had mild depression while 3.7% had moderately severe depression. About 1% of the participants had severe depression. Bharati et al., (2022) also in a later study in Patna in Eastern India determined the prevalence of adolescent depression. The study was conducted among 838 adolescents who were aged between 11-19 years in 15 selected urban schools. Similar to the earlier study by Singh et al., (2017), this study also adopted the Patient Health Questionnaire-9 (PHQ-9) tool. The results of the study showed that 51.2% of the adolescents had some level of depression at the time of study. The study noted that 32.2% of the adolescents had mild depression while 14.3%, 3.9% and 0.6% had moderate condition, moderately severe and severe depression conditions respectively. Vashisht et al., (2014) had earlier conducted a similar study in Haryana city, India to determine the prevalence of depression among school going adolescents. The study which adopted a cross-sectional design recruited 1,632 adolescents between the ages of 13-19years in both rural and urban communities. Unlike the studies by Singh et al., (2017) and Bharati et al., (2022) which adopted the PHQ-9 tool, Vashisht et al., (2014) in their study adopted the depression subscale of Symptom Check List 80 (SCL-80) to estimate the prevalence of depression among adolescents. The study observed a prevalence of 29.9%. further analysis showed that 22.9% of the adolescents were experiencing mild depression while the remaining 7% had moderate category of depression. In Bangladesh, Anjum & Hossain, (2019) in a cross-sectional pilot study investigated the prevalence of depressive symptoms among adolescents in semi-urban schools. A total of 311 University of Ghana http://ugspace.ug.edu.gh 16 adolescents in graces 8-10 participated in the study. The prevalence of depressive symptoms among the adolescents was 36.6%, however, disaggregation of the prevalence according to sex showed that adolescent girls had higher prevalence of 42.9% compared to adolescent boys (25.7%). Moeini et al., (2019) also conducted a study to determine the prevalence of depression among female adolescents in some selected secondary schools in Iran. The study which adopted a cross-sectional design recruited 670 adolescent females between the ages of 15-18 years. For this study, the Persian version of Centre for Epidemiologic Studies Depression Scale (CES-D) was adopted to determine the prevalence of depression. Significantly, the study observed a higher depression rate of 52.6% among the females. The concentration of the study in only secondary schools as well as limiting the participants to only females might have influenced the outcome. In the United States, an analysis of trend of the prevalence of depression among adolescents showed a steady increase from 8.1% in 2009 to 15.8% in 2019 (Daly, 2022). However, among girls, the rate of depression increased from 6.4% to 14.8% within the same period. It was evident that the trend of depression had being increasing over time. 2.2.2 Prevalence of Depression among Adolescents within Africa The situation in Africa has been relatively lower, though there are cases of higher reported prevalence. Jorns-Presentati et al., (2021) conducted a systematic review of various studies that had been conducted in Sub-Saharan Africa on depression and other mental health problems. A pooled prevalence of 26.9% was observed among 9 different studies. However, when high-risk population studies were pooled together, depression prevalence rate of 29.0% was observed. In Nigeria, Fatiregun & Kumapayi, (2014) conducted a study on the prevalence of depressive symptoms among in-school adolescents in some rural communities. The study which also adopted University of Ghana http://ugspace.ug.edu.gh 17 the PHQ-9 tool recruited 1,713 adolescents to ascertain the real prevalence within communities and observed a prevalence of 21.2%. More than 5% of the adolescents had moderately severe to severe depression. Two different studies (Nalugya-Sserunjogi et al., 2016 & Nabunya et al., 2020) which were conducted in Uganda showed relatively higher prevalence of depression among adolescents. The study by Nalugya-Sserunjogi et al., (2016) focused on in-school adolescents in Central Uganda among 519 adolescents. The study noted that about 21% of the adolescents had significant depressive symptoms while severe depression disorders was estimated at 2.9%. Nabunya et al., (2020) however observed depression prevalence 45.9%, a result that is noted to be extremely high especially within the African context. The study however concentrated on only adolescent girls who were between the ages of 14-17 years and were in secondary schools. As the age of the adolescent increased, the prevalence for depression also increased. Girma et al., (2021) also did a study in Southeast Ethiopia to determine prevalence of depression among adolescents in Jimma southeast Ethiopia. With the help of the PHQ-9 tool, 546 adolescents were assessed, and the result showed that 28% of the adolescent had some form of depression. However, further assessment showed that 18.5% and 8.2% of the adolescents had moderate and/or moderate to severe depression. 2.2.3 Prevalence of Depression among Adolescents in Ghana Depression in Ghana has equally gain much attention as other public health issues because of its resultant effect on the individual. Reports and other studies as have been reviewed in this section outlines clearly the prevailing condition in the country. The studies in Ghana have not been limited University of Ghana http://ugspace.ug.edu.gh 18 to the depression but considers the broader spectrum of mental health problems. Nonvignon, (2020) in a report by National Development Planning Commission on benefit-cost analysis of mental health noted that about 13% of the population in Ghana have problems with mental health. Nonetheless, other specific studies have looked at adolescent depression in different context. A total 1342 in-school adolescents who were aged 12-18 years and were in Secondary Schools formed the study participants. The study consequently noted that anxiety-induced sleep disturbance was significantly linked to depression. Oppong et al., (2017) in a study on mental health also analysed the prevalence of suicidal behaviour among in-school adolescents aged 11-18 years who were in Secondary School. The study was carried out among some selected second cycle schools across the country (Ghana). The prevalence of suicidal behaviour among in-school adolescents was observed to be 22.5%. Beyond the national level studies, there are other studies that have been limited to specific geographical locations. In Kumasi, Kusi-Mensah et al., (2019) determined the prevalence and patterns of mental disorder among on-school adolescents between the ages of 11-15 who were in primary schools. Using a pilot cross-sectional design approach, the study recruited 303 pupils who were in grade 3. The assessment of child and adolescent mental disorder among the in-school adolescents was conducted using the Child Behaviour Checklist (CBCL) as well as the Kiddie- Schedule for Affective Disorders and Schizophrenia (K-SADS-PL). The study observed adolescent mental disorder prevalence of 7.25% comprising of 1.3% depressive disorder, 1% of anxiety disorder, 1.6% of attention deficit hyperactivity disorder, 2.0% of conduct disorder, and 1% of intellectual disability. Another study in Kumasi (Anokye et al., 2020) examined the prevalence of attention-deficit/hyperactivity disorder among 1540 primary school University of Ghana http://ugspace.ug.edu.gh 19 children/adolescents. The study observed a prevalence of 27% with 5% displaying higher symptoms of attention disorder. Asante & Andoh-Arthur, (2015) conducted a study among adolescents in some selected universities to determine the prevalence of depressive symptoms. The study recruited 270 students with a mean age of 22 years. The observed overall prevalence of depression among the students was 39.2% which was categorised into severe depression (8.1%) and mild to moderate depression (31.1%). 2.3 Common Depressive Symptoms among Adolescents The World Health Organization (2017) estimates that, among teenagers between ages 15-19 years, depression remains the largest single cause of death among the world’s global burden of disease. Depression is measured through basic symptoms, and some are directly linked to the behaviour exhibited by adolescents. Sadness is one of the major symptoms of depression. It may take different form, from sense emptiness to a perception of hopelessness. If not resolved, this condition may persist for a long time and have dire consequences on the health of the person. Anum et al., (2019) also discussed depressive symptomatology in adolescents in Ghana. The study which adopted a cross-sectional study design discussed the key symptoms that have been identified among adolescents in Ghana with a focus on PHQ-9 model as has been used in depression assessment in many studies. The analysis of depression symptoms using PHQ-9 showed that there was a positive corelation of PHQ-9 and measures of anxiety as well as mental wellbeing. The assessment revealed that suicidal behaviours were common symptoms and practices that were linked with depression in adolescents. In the analysis, it was noted that suicidal attempts have resulted from conditions of sadness and prolong sense of rejection and hopelessness. University of Ghana http://ugspace.ug.edu.gh 20 Rose & Magidson, (2020) discussed major depressive disorder in the book Functional Analysis in Clinical Treatment. In the discussion, Rose & Magidson, citing from the American Psychiatric Association, (2013) explained that major depresive disorder (MDD) has been categorisesd into two main symptoms; i.e., a) loss of interest or pleasure in activities (anhedonia); and b) depreesed mood. Rose et al., (2020) further explain that these two conditions are mostly predominant within two weeks prior to any assessment. By inference, any major depressive disorder can be determined when the condition had been observed for a period of 14 days. Beyond the first two conditions that were explained, the report also showed that there are other secondary symptoms of depression and some of these may include significant loss of weight, consistent decrease in appetite, insomnia or hypersomnia, retardation which may take the form of psychomotor agitation and feeling of hopelessness or worthlessness. Other secondary symptoms may include feeling of guilt which may be excessive for some time, lack of concentration, thoughts of death and/or suicide and fatigue or loss of energy. Wahid et al., (2022) discussed the perspectives of adolescents on depression in relation to the symptoms adolescents commonly experience. The qualitative study which was conducted in Nepal with adolescents with different backgrounds; adolescents with no traits of depression, adolescents with depressive symptoms, parents of the adolescents and teachers, social workers and healthcare providers who manage these adolescents. The study noted that loneliness was the major depressive symptom among adolescents. The study further observed some other symptoms which clustered into 5 groups: 1) low mood and anhedonia; 2) disturbance in sleep and appetite; 3) irritability and anger; 4) negative self-appraisals including hopelessness and self-doubt; and 5) suicidality. These observations made by Wahid et al., (2022) confirms the observed result in the earlier study by University of Ghana http://ugspace.ug.edu.gh 21 Rose et al., (2020). In similar studies (Rice et al., 2019; Vos & Westerhof, 2021) have concluded that depressive symptoms in adolescents can best fit into the five major categories that have been described by Wahid et al., (2022). It is therefore important to situate any discussions on common depressive symptoms among adolescents within this context. 2.4 Factors Associated with Depression Symptoms among Adolescents Depressive symptoms in adolescents may have diverse root causes and related factors. The prevalence as discussed above from global context to national level have shown some different prevalence. The determining factors play a major role in the overall outcome of depression conditions among adolescents. The factors have been discussed in accordance with the observed factors in various studies. Sex of adolescents The sex of an adolescent has been identified as a major determinant of depression in most countries. Surabhi et al., (2014) in a study in Nepal noted that female adolescent were more prone to depression compared to males. In general, the study observed depression prevalence of 38% among adolescents. However, when analysis of depression was further done in relation to sex, it was observed that the prevalence of depression among females was relatively higher (41.8%) compared to males (35%). Nalugya-Sserunjogi et al., (2016) in their study also observed that females were about 1.7times more susceptible to depression compared to male adolescents. Nyundo et al., (2020) also observed that depressive symptoms were common among female adolescents compared to male adolescents. Wartberg et al., (2018) in a study observed depression prevalence of 5.6%, however, when the analysis was only limited to girls, the study observed a higher prevalence of 5.9% compared to boys with a prevalence of 4.5%. Other studies like Bharati University of Ghana http://ugspace.ug.edu.gh 22 et al., (2022), Girma et al., (2021) have established a strong relationship between depressive symptoms and sex of adolescent (females). Age of adolescents Wartberg et al., (2018) in a cross-sectional study noted that adolescents who are aged above 16 years had higher probability of experiencing depressive symptoms compared to adolescents who were relatively younger. Nyundo et al., (2020) in a study across a number of countries in sub- Saharan Africa observed that depression conditions were associated with age of the adolescents. Older adolescents had higher probability of experiencing depressive symptoms compared to adolescents who were younger. Ho et al., (2018) in a trend analysis have identified age as a constant factor that influences or determines the level of depression among adolescents. Bharati et al., (2022) also noted that older adolescents have higher risk of experiencing depressive symptoms compared to younger adolescents. Nabunya et al., (2020) also noted that the severity of depression is prominent among adolescents who were aged 16 years and above. Vashisht et al., (2014) in an assessment of depression conditions noted that the severity of depression increases with increasing age of the adolescent. Residence Girma et al., (2021) noted that residence of adolescents had significant influence on whether the adolescent would experience any symptom of depression. Adolescents who resides in rural communities had significant association with depressive symptoms. Singh et al., (2017) also observed that adolescents who live in rural communities had higher risk of experiencing depressive conditions compared to adolescents who were residing in urban areas. Vashisht et al., (2014) however in their study observed a result that directly opposite of the results observed in other University of Ghana http://ugspace.ug.edu.gh 23 studies. Vashisht et al., (2014) observed that students or adolescents who resides in urban cities were at a higher risk of experiencing depressive symptoms than those in rural communities. School conditions Anjum et al., (2019) identified the grade of adolescent as a factor to depression. In their study, Anjum et al., (2019) observed that adolescents who were in Grade 9 (largely in secondary school) were significantly prove to depression than those in lower grades. Nalugya-Sserunjogi et al., (2016) also observed that the rate of depression is significantly high among adolescents who are in girls’ schools only compared to boys’ school only. There were no significance association between those who were in mixed boarding school or mixed day schools. Bharati et al., (2022) also noted that adolescents who are in Grades 9-11 were more likely to experience depressive symptoms than those who are in lower grades. The study further noted that poor academic results have the tendency to trigger depressive symptoms among adolescents. Girma et al., (2021) also observed results as others where higher-grade adolescents were more susceptible to depressive symptoms. Singh et al., (2017) in their study also noted that adolescents who were in grade 10-12 had more cases of depressive symptoms compared adolescents who were in lower grades. Additionally, Singh et al., (2017) noted that adolescents who were in public schools had higher risk of experiencing depression compared to adolescents who were in private schools. Again, lack of supportive environment in schools, either from teachers or infrastructure and learning materials, had a strong association with depressive symptoms. University of Ghana http://ugspace.ug.edu.gh 24 Alcohol consumption and other substance abuse Nyundo et al., (2020) further analysed why the risk of depression was relatively higher among adolescents across some selected countries in sub-Saharan Africa. The study observed that substance use in different forms have significantly increased among especially among in-school adolescents and this has consequently increased the risk of depression and suicidal ideation among adolescents in Africa. Singh et al., (2017) also observed that depressive symptoms were common among adolescents who were engaged in alcohol consumption. Health conditions of the adolescent Nalugya-Sserunjogi et al., (2016) noted that adolescents with physical illness or deformity have higher probability of becoming depressed compared to the adolescents who do not have any form of deformity. Most often, these children tend to live in low self-esteem and with little mockery from colleagues or peers, the level of depression or its associated risk is exacerbated. Wartberg et al., (2018) have also established a strong relationship between depressive symptoms and negative body image. The negative body image was explained in some defect in the physical body of adolescents. Parental / family or domestic environment factors Nalugya-Sserunjogi et al., (2016) have explained that adolescents whose family is centred on single parent system (either living with mother alone or father alone) were about 1.94 times more likely to experience depressive symptoms compared to those who live with a monogamous marriage with both father and mother. The study further observed that children who are orphans have higher risk of depression compared to children whose parents are alive. Wartberg et al., (2018) also noted that adolescents who have good family relations have low tendency to University of Ghana http://ugspace.ug.edu.gh 25 experience depression compared to adolescents who live in abusive family environment. Bharati et al., (2022) also observed that domestic harassment on any of the adolescents or related to any member of the family is a strong trigger to depressive symptoms. Similarly, parental discord had strong association with depressive disorder. Girma et al., (2021) also noted that low social support had significant effect on depressive symptoms. Similarly, depressive symptoms were common among adolescents who had adverse childhood experience. The rate of depression among adolescents was significantly higher among those who had experienced some level of abuse by any of the family members, either at a tender age or during the adolescent stage (Singh et al., 2017). The study further noted that depressive symptoms were also common with adolescents whose parents were into smoking. The observed results was common with adolescent girls. Nabunya et al., (2020) argued that depression among adolescents is predominantly influenced by family relations and the type of social support that is received by the adolescent at all stages of childhood growth. When family relations are poor, adolescents tend to suffer the consequences thereof. Obesity Surabhi et al., (2014) in their study noted that adolescents who are obese are more likely to experience depressive symptoms compared to those who are not obese. While the general depression prevalence stood at 38%, the prevalence of depression among obese adolescents 48.7%. The difference in the prevalence was significantly high when difference in the two variables was further computed in the study. University of Ghana http://ugspace.ug.edu.gh 26 Other factors Food insecurity has been identified as another significant factor that influences the prevalence of depression among adolescents (Nyundo et al., 2020). Wartberg et al., (2018) also noted that the frequent use of social media has negatively influenced adolescents’ attitude towards depressive and suicidal behaviour. Bharati et al., (2022) in their study also established strong relationship between depressive symptoms and factors such as consumption of soft drinks and fast foods. The risk of depression was significantly higher among adolescents who were having boy/girlfriends (Singh et al., 2017). The risk of depression increased when the adolescent is deserted by his/her supposed friend. The study also observed that depressive symptoms was relatively high among adolescents who did not participate in any cultural event or activity. 2.5 Conceptual Framework The concept of depression as discussed in the chapter transcends beyond just the definition but further to the indicators that constitutes depressive conditions. While it is difficult to use only one indicator to describe depressive conditions, Naab et al., (2015) has argued that a number of factors such as biological, psychological and social factors have consistently influenced or determined depressive symptoms or conditions among adolescents. The construct of a conceptual framework for this study therefore is not limited to only condition or factor but a number of factors that have been deduced from the various studies/articles reviewed in this chapter. University of Ghana http://ugspace.ug.edu.gh 27 Figure 2.1: Conceptual framework showing the relationship between factors that influence the prevalence of depressive symptoms among adolescents. Source: Researcher’s construct adapted from previous studies (Bharati et al., 2022; Singh et al., 2017) Demographic Characteristics • Age (in complete years • Residence • Sex • Religion Other related factors • Health conditions of adolescent • Substance use/abuse • Use of social media • Access to food (food security) • Eating habit School Environment • Grade/class • Type of school • Academic performance • Teacher/student relationship • Learning materials • School infrastructure Family/Social system • Parent/adolescent relationship • Type of parenting • Harassment/abuse • Community support • Family support • Peers • Family status (parents, caregiver, etc Depressive symptoms University of Ghana http://ugspace.ug.edu.gh 28 Narrative of the conceptual framework The conceptual framework predicts that the prevalence of depressive symptoms is likely to be influenced by four key factors, demographic, school environmental factors, family and social system and other related factors. For demographic factors, the framework identifies factors such as age the adolescent, place of residence (rural or urban), type of religion and sex of the adolescent (boy/girl). Factors explains the school environment conditions may include the academic performance of the adolescent, his/her grade in school, the type of school he/she is attending (this may either boys or girls’ school; public or private), the relationship that exist between the teachers and the adolescent. Other factors include the availability of learning materials the type of infrastructure the adolescent is using for studies. Other related factors such as health conditions of the adolescent, whether or not the adolescent is into alcohol drinking or use of any other substance, use of social media, access to food and eating habit. Studies from different literature as demonstrated in earlier discussions have shown a strong relationship between the factors outlined in the conceptual framework and its resultant effect of depressive symptoms. It is expected that the outcome variable which is explained in depressive symptoms would be influenced by these factors that have been presented in the framework. The framework further establishes a direct linkage between demographic factors and school environment factors. The age of the child/adolescent is more likely to correspond with the grade/class of the child. Similarly, the location of the child may determine the type of school to attend especially for those in Primary and Junior High schools. In the same vein, the sex of the adolescent will determine the type of school to attend (boys or girls school only). University of Ghana http://ugspace.ug.edu.gh 29 2.6 The Patient Health Questionnaire (PHQ-9) The Patient Health Questionnaire (PHQ-9) is a nine-item version or questions that is used to assess depression conditions of any individual within the previous two weeks preceding the assessment. It is a multiple-choice self-reporting inventory which is mostly used in clinical and other research settings to ascertain whether an individual is in severe or low depressive conditions. It was developed from the initial Primary Care Evaluation of Mental Disorder (PRIME-MD) which was originally developed by Pfizer Inc. in 1990 (Spitzer et al., 1999). The original had several questions that was further revised to be limited to 11 questions that provides more details of depressive conditions within any given period. However, the final validated PHQ-9 which was validated by experts reduced the questions into nine (Kroenke et al., 2010). The PHQ-9 helps to categorise adolescent’s perceived depressive conditions into five depressive severity criteria. For each question, four assessment scale; “not at all = 0”; “several days = 1”; “more than half the days = 2” and “nearly every day = 3”. The result of each question is therefore computed into overall scores of 27. However, to determine the severity of the depressive condition, the scale below is used: Table 2.1: PHQ-9 Model for measurement of Depression Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression Source: Kroenke et al., (2010). University of Ghana http://ugspace.ug.edu.gh 30 2.7 Chapter summary and outstanding knowledge gaps The general review of literature from different geographical perspectives have shown that different studies have been done in relation to the prevalence of depression among adolescents within the global context. Similarly, there are evidence of some new ideas within the African context on depression prevalence. Largely, studies conducted in Ghana on depressive symptoms have focused significantly on adult population. Among adolescents, available studies on adolescents have gone a step further to assess factors that influence suicide rather than focusing on depressive factors that may influence suicidal ideation. The factors that determine depression in adolescent have been established to come from different situations. Some of these factors may not be relevant within the context of Ghana. There is therefore the need to first establish whether in-school adolescents in Ghana experience some level of depressive symptoms and the underlying factors that influences or determines these established conditions. University of Ghana http://ugspace.ug.edu.gh 31 CHAPTER THREE METHODS 3.0 Introduction This chapter discusses the methods that were employed to collect and analyse data to satisfy the objectives of this study. The chapter discusses the study design, study area, study population, sample size and sampling, data collection methods and tools, and data analysis. Ethical issues were also discussed. 3.1 Study Design The study employed a cross-sectional in-school survey as the main study design. In-school survey for the adolescents who are in both high school was conducted. A quantitative method of research approach was used for this study. The quantitative method was employed to help estimate the prevalence of depression among in-school adolescent in the district. Additionally, the quantitative method was used to determine significant factors that were associated with the prevalence of depression among the in-school adolescent. To further help explain and identify the key symptoms of depression among in-school adolescents, quantitative methods were further employed to determine the various symptoms among the adolescents. 3.2 Study Area The study was carried out in Akwapim South District of Eastern Region, Ghana. The Akwapim South District was carved out of the original Akwapim South Municipality in 2012 which originally had Nsawam as the municipal capital. The current Akwapim South District has Aburi as the district capital with a population of 76,922 as per the 2021 Population and Housing Census University of Ghana http://ugspace.ug.edu.gh 32 (Ghana Statistical Service, 2022). The district is predominantly rural with more than 70% of the people residing in rural communities. Females constitute about 51.7% of the total population while adolescent form nearly 27% of the entire population. The main economic activity of the people in the district is agriculture with crops such as maize, cassava, yam and vegetables as the main crops produced. Farmers within the district are small holder farmers who work on subsistence basis. The district is known for its tourism centres with the famous Aburi botanical gardens which attract different category of tourist. The garden receives averagely about 15,000 tourist every year and this has become the main source of income for the district. On education, the district has committed to the infrastructural development of its education through the expansion of educational facilities. The district has over 50 public and 35 private Pre- Schools, 42 public and 38 private Primary Schools as well as 32 public and 18 private Junior High Schools. Additionally, the district privilege with 4 public and 1 private Senior High Schools including the popular Aburi Girls Senior High School. The district equally has 1 College of Education for the training of teachers. University of Ghana http://ugspace.ug.edu.gh 33 Figure 3.1: District map of Akwapim South District in Eastern Region of Ghana 3.3 Study Population The main study participants were adolescents in both Junior and Senior High Schools in the district. Specifically, adolescents who were aged between 10 – 24 years and were attending high school within the district formed the study participants. 3.3.1 Inclusion Criteria For the purpose of this study, adolescents who qualified to participate in the study included: 1. Adolescents and young persons who were aged between 10-24 years 2. Adolescents who were attending either Junior or Senior High School within the district University of Ghana http://ugspace.ug.edu.gh 34 3.3.1 Exclusion Criteria 1. Adolescents and young persons who met the above criteria but were indisposed. 3.4 Sample size estimation The sample of the study was calculated using the Cochran formula: N = Z²pq * d e² Where: Z = z score for 95% confidence interval, p = estimated prevalence. For this study, the prevalence of depression of 22.5% (Oppong et al., 2017) was used. q = 1 – p d = design effect = 1.65 e = precision (fixed at 5%). Therefore, Z = 1.96, p = 0.252, q = 1 – 0.225 and d = 0.05, then N = 425 Allowing for 15% non-respondents of the sample size, the sample size then becomes: 0.15(425) + 425 = 488.7 The sample size for the study was therefore estimated at 489. University of Ghana http://ugspace.ug.edu.gh 35 3.5 Sampling methods Multiple sampling methods were employed in this study. First, a list of all high schools in the district was taken from the District Directorate of Ghana Education Service, Akwapim South. The list of the schools was grouped according to the five sub-districts. In each sub-district, the high schools were grouped according to Junior High and Senior High. For the purpose of equal representation, one sub-district with only Junior High School was sampled while another sub- district with both Senior and Junior High Schools was selected. In each of the sampled sub- districts, names of the schools were written on sheets of papers and folded. A staff of the Ghana Education Service was asked to randomly select two Junior High schools each in the two-sampled sub-districts. In addition, one Senior School was sampled/selected from the sub-district with the Senior High School. In each school sampled, convenient sampling method was used to select students/adolescents to participate in the study. Any student that was met on campus during the data collection period was approached for interview. Students were interviewed using a structured questionnaire as they exit from their classrooms or school. Proportionate sampling method was used to determine the number of students to be interviewed per school. The population of each school was determined and proportionate to size estimation was done to determine the exact number of students/adolescents to be interviewed. 3.6 Data Collection Method Data collection was done through face-to-face interaction with full adherence to COVID-19 protocols (details of COVID-19 protocols as outlined in the section on Ethical considerations). For University of Ghana http://ugspace.ug.edu.gh 36 each sampled participant, data collection was done using a structured questionnaire. Data collection was led by the principal investigator with support from four (4) research assistants. Each of the research assistant selected to support in data collection possessed a minimum of diploma qualification and had previously been engaged in similar data collection exercise. The principal investigator trained the data collectors on the general study focus, the main questionnaire and data collection ethics. The training of the research assistants lasted for a maximum of two days. During the training of the research assistants, the principal investigator ensured that all the questions in the data collection instruments/tools are translated in Twi and/or English depending on the language of convenience of the study participant. 3.7 Data Collection Instrument The interviews with the students were done through face-to-face using structured questionnaire. The questionnaire was organised in three sections. The first section outlined all the demographic factors described in the conceptual framework. The second section of the questionnaire focused on depression conditions and symptoms in adolescents. The prevalence of depression was determined from the second section. The third and final section of the questionnaire focused on all other relevant factors that might influence the occurrence of depression. All the questions were close-ended questions. 3.8 Quality Assurance Measures The designed data collection tool was tested/piloted in two other schools in Akuapem North District. The principal investigator ensured that the two schools selected for the pilot had the same characteristics as those selected for the main study. Feedback from the data collection tool piloting University of Ghana http://ugspace.ug.edu.gh 37 was used to shape and finalise the data collection tool. Each data collection tool was coded to ensure that proper follow ups are done when data gaps are identified. 3.9 Data Processing and Management Data collected from the field was done using structured questionnaire. A defined MS Excel template based on the questionnaire was designed and used to capture all data. Data validation and verification was done to ensure all data entered into the MS Excel file are complete. The final validated data was stored on hard drive of a computer and the hard copy of the questionnaire kept in a safe until the next two years after the study. Data files on computers and external hard drives have been protected with security codes (password) to prevent easy access by another person. 3.10 Variables For the purpose of this study, the two main variables for consideration were the prevalence of depression among in-school adolescents (dependent variable) and the factors that influence or determine the prevalence of depression (independent variables). For each of main variables, details on specific indicators to be measured have been described in Table 1. 3.10.1 Dependent Variables Dependent variable for this study was the prevalence of depression among in-school adolescent. 3.10.2 Independent Variables Independent variables for this study included demographic factors, behavioural factors and environmental factors (school and home environment). University of Ghana http://ugspace.ug.edu.gh 38 Table 3:1: Dependent and Independent Variables for the Study Variable Operational Definition Source Measurement Dependent Variable Depression among in- school adolescents The proportion of in-school adolescent and young persons who had exhibited had moderate depression, moderately severe depression or severe depression Respondent Numerical Independent Variables Age Age in absolute years Respondent Numerical Gender Sex of the adolescent; male or female Respondent Categorical Current level of education Current level as either in JHS or SHS Respondent Categorical Type of school Private or public Respondent Numerical Residence The place of stay of the adolescent; rural or urban Respondent Categorical Occupation of parents Type of work by the parents the adolescent stay with; either employed, unemployed; If employed, type of employed Respondent Categorical Who adolescents live with The person who the adolescent live with Respondent Categorical Religion Type of religion: Christianity, Islam, Traditional, others Respondent Categorical Symptoms of depression Different types of symptoms that adolescents go through Respondent Categorical Home factors / parental conditions Parents factors including that contribute to depression Respondent Categorical School environment factors Respondent Numerical Lifestyle of adolescent Lifestyle in terms of medication, social life Respondent Numerical Family and medical history History of the adolescent in terms of medication and family; existing records Respondent Categorical University of Ghana http://ugspace.ug.edu.gh 39 3.11 Data Analysis The final data set was imported/uploaded into STATA version 17.0 for analysis. The results of the analysed data were presented in tables and graphs. Descriptive statistics were presented using frequencies and percentages. Bivariate and multiple regression analysis were conducted to ascertain the relationship that exist between dependent variable and independent variables. At bivariate level, results of the regression analysis were reported in chi square and p-values with frequencies and percentages (at row level) for each variable. For multiple regression analysis, results of the analysis were reported in odds ratio at 95% confidence interval and its corresponding p-values. The prevalence of depression among in-school adolescents and young persons was measured with the presence at least, one of the following: with moderate depression, moderately severe depression or severe depression. 3.12 Ethical Consideration Ethical clearance for the study was obtained from Ghana Health Service Ethics Review Committee as requirement for the conduct of this study. Study Approval: A letter of introduction from the School of Public Health (SPH) was obtained and sent to District Directorate of Education, Ghana Education Service in Akwapim South District to seek for approval for the conduct of this study in the sampled schools in the district. In each school, a similar letter and with an authorization note from the District Director of Education was sent to the schools to inform them about the study and seek for their approval and support. University of Ghana http://ugspace.ug.edu.gh 40 CHAPTER FOUR RESULTS 4.1. Introduction The chapter presents the results of the findings of the study. The findings of the study have been grouped according to the study objectives. The output of the descriptive analysis is presented first and followed by the output of inferential statistical analysis on association between the independent variables and the outcome variable. 4.2 Socio-demographic characteristics of respondents Socio-demographic characteristics of respondents is summarized in Table 4.1. A total of 475 adolescents participated in the study given a response rate of 97.1%. The mean age of the in-school adolescents was 16.4 years ± 2.0 SD with observed minimum and maximum ages as 10 and 25 years respectively. The majority (77.9%) of the in-school adolescents were between the ages of 15-19 years. Most (73.4%) of the adolescents were females and Christians (94.1%) Christians. About half (50.3%) of the adolescents were living with both parents with about 15% (n = 73) living with other family members. A little over a third (35.4%) of the adolescents lived in rural communities. More than half (55.4%) of the adolescents indicated that their parents lived together. Less than a fifth (18.3%) of the adolescents indicated that their fathers had completed tertiary education while less than a tenth (9.3%) mentioned that their mothers had completed tertiary education. On employment status of the parents, majority (66.9%) and (84.4%) of the adolescents indicated that their fathers and mothers were self-employed respectively. University of Ghana http://ugspace.ug.edu.gh 41 Majority (78.9%) of the adolescents indicated that they had more than two siblings. For NHIA registration, 16% were not registered under any health insurance package. Nearly two-thirds (64.8%) of the adolescents owned a mobile phone while 61.5% used mobile phones for social media activities. University of Ghana http://ugspace.ug.edu.gh 42 Table 4.1: Socio-demographic characteristics of the adolescents Variables Frequency (n = 475) Percent (%) Age in years (M ± SD) 16.4 + 2.0 10-14 81 17.1 15-19 370 77.9 20+ 24 5.0 Sex Male 126 26.5 Female 349 73.5 Religion Christianity 447 94.1 Islamic 25 5.3 Others 3 0.6 Living with Both parents 239 50.3 Father only 58 12.2 Mother only 105 22.1 Other family members 73 15.4 Residence Rural 168 35.4 Semi-urban 19 4.0 Urban 288 60.6 Marital status of parents Live together 263 55.4 Separated/divorced 174 36.6 Loss both parents 12 2.5 Loss father or mother 21 5.5 Father education status No formal education 35 7.4 Basic 148 31.2 Senior High/Secondary 178 37.5 Tertiary 87 18.3 I don’t know 27 5.7 Mother education status No formal education 57 12.0 Basic 192 40.4 Senior High/Secondary 175 36.8 Tertiary 44 9.3 I don’t know 7 1.5 Father/Guardian employment status Unemployed 11 2.3 Employed (salary worker) 122 25.7 Self employed 318 66.9 I don’t know 24 5.1 Mother/Guardian employment status Unemployed 13 2.8 Employed (salary worker) 51 10.7 Self employed 401 84.4 I don’t know 10 2.1 Number of siblings University of Ghana http://ugspace.ug.edu.gh 43 No sibling 15 3.2 One 28 5.9 Two 57 12.0 More than 2 375 78.9 NHIA registrants Registrants 399 84.0 Non-registrants 76 16.0 Ownership of mobile phone Owns mobile phone 308 64.8 Does not own a mobile phone 167 35.2 Mobile phone usage on social media Uses mobile phone 292 61.5 Does not use mobile phone 183 38.5 Total 475 100.0 4.3 Common depressive symptoms The results of the analysis of common depression symptoms among the in-school adolescent is presented in Table 4.3. The result is based on the 9-model questions of the PHQ-9 model. About 5% (n = 24) of the adolescents indicated that nearly every day, they have little interest or pleasure in doing things while 4.0% (n = 19) mentioned that they nearly every day feel down, depressed or hopeless. About 31% (n = 148) of the adolescents mentioned that on several days they have troubles falling or staying asleep or sleeping too much while 8% (n = 38) also indicated that for more than half the days, they always feel tired or having little energy. More than half (n = 60.8%) of the adolescents indicated that they never have poor appetite or overeat while 66.7% (n = 317) of mentioned that they never feel bad about themselves or that they are a failure or have let themselves or their families down. About 2% (n = 11) of the adolescents indicated that they nearly every day have trouble concentrating on things such as reading the newspapers or watching television. University of Ghana http://ugspace.ug.edu.gh 44 About 25% (n = 118) of the adolescents mentioned that, on several days, they either move or speak slowly such that other people could have noticed or sometimes the opposite being so fidgety or restless that they have been moving around a lot more than usual. About 5% (n = 25) of the adolescents indicated that nearly every day, they have had thoughts that they would be better off dead or of hurting themselves. Table 4.2: Depression status and common symptoms Depression variables Not at all n (%) Several days n (%) More than half the days n (%) Nearly every day n (%) Little interest or pleasure in doing things 179 (37.7) 220 (46.3) 52 (10.9) 24 (5.1) Feeling down, depressed, or hopeless 261 (54.9) 148 (31.2) 47 (9.9) 19 (4.0) Trouble falling or staying asleep, or sleeping too much 279 (58.7) 148 (31.2) 36 (7.6) 12 (2.5) Feeling tired or having little energy 289 (60.8) 139 (29.3) 38 (8.0) 9 (1.9) Poor appetite or overeating 295 (62.1) 139 (29.3) 24 (5.0) 17 (3.6) Feeling bad about yourself or that you are a failure or have let yourself or your family down 317 (66.7) 119 (25.1) 26 (5.5) 13 (2.7) Trouble concentrating on things, such as reading the newspaper or watching television 302 (63.6) 128 (26.9) 34 (7.2) 11 (2.3) Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual 305 (64.2) 118 (24.8) 34 (7.2) 18 (3.8) Thoughts that you would be better off dead, or of hurting yourself 358 (75.4) 64 (13.5) 28 (5.9) 25 (5.3) University of Ghana http://ugspace.ug.edu.gh 45 4.4 The prevalence of depression Categorising the common symptoms into the various levels of depression using the PHQ-9 model, two levels were done. All adolescents who had minimal or mild depression were categorised as “no depression” while adolescents who had moderate, moderately severe and severe depression were categorised as those with depression. Based on this categorization, the results showed that 6.3% (n = 30), 4.0% (n = 19) and 1.5% (n = 7) of the adolescents were experiencing moderate depression, moderately severe depression and severe depression respectively (Figure 4.1). The prevalence of depression among the adolescents was therefore computed to be 11.8%. Figure 4.1: Levels of depression among the adolescents 57.3% 30.9% 6.3% 4.0% 1.5% 0 50 100 150 200 250 300 Minimal depression Mild depression Moderate depression Moderately severe depression Severe depression University of Ghana http://ugspace.ug.edu.gh 46 4.5 Behavioural factors of the adolescents The results of the analysis of behavioural factors are presented in Table 4.3. A little over a tenth (12.0%) of the adolescents indicated that they drink alcohol while 5.7% indicated that they smoke. Less than a third (30.3%) of the adolescents indicated that they were in a relationship with the opposite sex. The majority (51.4%) of the adolescents mentioned that they do some exercise. Almost half (49.6%) of those who exercise indicated that they do their exercise on weekly basis. More than half (58.5%) of the adolescents indicated that they participate in outdoor activities. Less than a fifth (19.8%) of the adolescents had chronic illness while 14.9% of the adolescents were on some medication. Table 4 3: Behavioural factors of the adolescents Variables Frequency (n) Percent (%) Drink alcohol No alcohol 418 88.0 Drinks alcohol 57 12.0 Smoking Does not smoke 448 94.3 Smokes 27 5.7 In a relationship with opposite sex No relationship 331 69.7 In a relationship 144 30.3 Do you exercise No exercise 231 48.6 Yes, exercise is done 244 51.4 How often the exercise is done Weekly 121 25.5% Once every two weeks 20 4.2% Once a month 25 5.3% Not frequent 78 16.4% Do not exercise 231 48.6% Participate in outdoor activities No 197 41.5 Yes 278 58.5 Presence of any chronic illness No 381 80.2 Yes 94 19.8 On any medication No medication 404 85.1 Yes, on medication 71 14.9 Total 475 100.0 University of Ghana http://ugspace.ug.edu.gh 47 4.6 Environmental factors (school and home) The results of the analysis of the environmental factors consisting of the school and home environment is presented in Table 4.4. The majority (62.9%) of the adolescents were in Senior High School. For those in Senior School, more than half (54.2%) were in mixed boarding schools. On academic performance, only 4.8% of the adolescents rated themselves as excellent students with 4.4% having poor academic performance. About half (49.5%) of the adolescents indicated that they have good relationship with their teachers. Similarly, more than half (55.8%) of the adolescents had good relationship with their classmates. About 14% of the adolescents indicated that they did not have adequate learning materials while 39.4% mentioned that their classroom environment was not conducive for their learning. About two-thirds (66.3%) of the adolescents mentioned that their fathers were the heads of the households. More than a quarter (28%) of the adolescents indicated that they are aware of past records of depression in the family. A little over a fifth (21.3%) of the adolescents indicated that their mothers have ever been abused by their fathers while about a fifth (20.6%) mentioned that their mothers have also abused their fathers either verbally or physically. On the part of the adolescents, less than a quarter (23.6%) mentioned that they have ever been abused by their parents while 18.5% mentioned that they had ever been abused by other persons other than their parents. About 18% of the adolescents indicated that one of their parents is into smoking. Almost a quarter (24.2%) of the adolescents indicated that they are unable to discuss their issues with anyone but to keep it to themselves. For those who can discuss their issues, 74.4% discuss their issues with their mothers. About 67% indicated that they were able to spend some time with their parents on vacation. University of Ghana http://ugspace.ug.edu.gh 48 Table 4 4: Environmental factors (school and home) Variables Frequency (n) Percent (%) Level of school Junior High School 176 37.1 Senior High School 299 62.9 Type of school (SHS only) Girls only (boarding) 137 45.8 Boarding mixed 162 54.2 Academic performance Poor 21 4.4 Average 214 45.1 Good 217 45.7 Excellent 23 4.8 Relationship with class teacher(s) Poor 21 4.4 Normal 219 46.1 Good 235 49.5 Relationship with classmates Poor 20 4.2 Normal 190 40.0 Good 265 55.8 Availability of learning materials to the adolescent Inadequate learning material 67 14.1 Adequate learning materials 408 85.9 Classroom environment conducive for learning No 187 39.4 Yes 288 60.6 Head of household Father 315 66.3 Mother 124 26.1 Others* 36 7.6 Family history of depression No depression case in the family 171 36.0 Past cases of depression 133 28.0 Don’t know 171 36.0 Mother ever been abused by father No 364 76.6 Yes 101 21.3 I don’t know 10 2.1 Father ever been abused by mother No 375 78.9 Yes 98 20.6 I don’t know 2 0.4 Ever experienced any abuse from parents/guardian No 363 76.4 Yes 112 23.6 University of Ghana http://ugspace.ug.edu.gh 49 Ever experienced any abuse from someone other than parents No 387 81.5 Yes 88 18.5 Parents are into smoking No 388 81.7 Yes 87 18.3 Ability to discuss any issue with anyone No 115 24.2 Yes 360 75.8 Who do you feel comfortable to discuss the issue with Father 62 17.2 Mother 268 74.4 Siblings 14 3.9 Others** 16 4.5 Having sometime with parents on vacation or weekends No 155 32.6 Yes 320 67.4 * represents grandmother, siblings, uncle/aunt, family member, friends. ** teachers, friends, other family members 4.7 Socio-demographic factors associated with depression among in-school adolescents. The results of the analysis of socio-demographic factors associated with depression among in- school adolescents is presented in Table 4.5. Two socio-demographic factors had significant association with depression among the in-school adolescents. The factors were age of the adolescents (χ2 = 17.78; p-value < 0.001) and sex (χ2 = 6.41; p-value < 0.02). On the age of the adolescents, the rate of depression was relatively higher (37.5%) among those aged 20+ compared to those who were 10-14 years. Similarly, the proportion of adolescents who were depressed was relatively higher in females (14.0%) than in males (5.6%). University of Ghana http://ugspace.ug.edu.gh 50 Table 4 5: Bivariate analysis of socio-demographic factors associated with adolescent depression. Variable Depressive conditions among adolescents n (%) Adolescent without depression n (%) Adolescents with depression Chi-square p- value Age in years 17.78 0.000 10-14 76 (93.8) 5 (6.2) 15-19 328 (88.6) 42 (11.4) 20+ 15 (65.5) 9 (37.5) Sex 6.41 0.011 Male 119 (94.4) 7 (5.6) Female 300 (86.0) 49 (14.0) Religion 0.84 0.658 Christianity 395 (88.4) 52 (11.6) Islamic 21 (84.0) 4 (16.0) Others 3 (100.0) - Living with 2.24 0.523 Both parents 215 (90.0) 24 (10.0) Father only 49 (84.5) 9 (15.5) Mother only 93 (88.6) 12 (11.4) Other family members 62 (84.9) 11 (15.1) Residence 0.95 0.620 Rural 149 (88.7) 19 (11.3) Semi-urban 18 (94.7) 1 (5.3) Urban 252 (87.5) 38 (12.5) Marital status of parents 2.26 0.687 Live together 236 (89.7) 27 (10.3) Separated/divorced 149 (85.6) 25 (14.4) Loss both parents 11 (91.7) 1 (8.3) Loss father or mother 23 (88.5) 3 (11.5) Father education status 3.70 0.448 No formal education 30 (85.7) 5 (14.3) Basic 132 (89.2) 16 (10.8) Senior High/Secondary 161 (90.5) 17 (9.5) Tertiary 72 (82.8) 15 (17.2) I don’t know 24 (88.9) 3 (11.1) Mother