Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11931 Factors associated with anxiety and depressive symptoms among Indonesian adolescents during the COVID-19 pandemic: a cross-sectional study Rika Sarfika,1 I Made Moh. Yanuar Saifudin,2 Hema Malini,3 Dewi Eka Putri,1 Anggi Lukman Wicaksana,4 Mahathir Mahathir,1 Dwi Novrianda5 1Department of Mental Health and Community, Faculty of Nursing, Universitas Andalas, Padang; 2Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta; 3Department of Medical Surgical, Faculty of Nursing, Universitas Andalas, Padang; 4Department of Medical Surgical Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta; 5Department of Child and Maternity, Faculty of Nursing, Universitas Andalas, Padang, Indonesia Abstract Despite the conclusion of the pandemic, addressing mental health concerns during disasters remains crucial. Examining the impact of mental health issues in such contexts yields valuable insights for preventing future crises. This study aimed to examine the factors linked to anxiety and depression symptoms among Indonesian adolescents during the COVID-19 pandemic. This was a cross-sectional study. The study utilized an online survey collected from 738 participants from 34 provinces in Indonesia. The participants were asked to provide information on their demographics, social media exposure, self-rated health, GAD-7 scores, and the WHO-5 well-being index. The associations between participant characteristics and depression and anxiety were investigated using independent t-tests, ANOVA tests, and ordinal logistic regression. The majority of the participants were late adolescents, aged 18-21 years old (95%), and female (79.1%). Factors such as gender, self-rated health, and social media exposure were significantly associated with depression and anxiety among adolescents during the COVID-19 pandemic. Male adolescents had a higher risk of depression (OR=0.657, 95% CI=0.476-0.908), while infrequent social media exposure was linked to lower anxiety levels (OR=0.401, 95% CI=0.190-0.847). The study revealed that younger age, female sex, suspected COVID-19 infection, and excessive social media exposure were associated with higher levels of depression and anxiety. To manage depression and anxiety during and after pandemics, it is crucial to provide valid and reliable information and healthcare services, foster social connections, and create supportive environments in households and workplaces. Introduction On March 11, 2020, the World Health Organization (WHO) formally classified COVID-19 as a pandemic, leading to the global implementation of various social interventions, such as stay-at- home orders, quarantines, and social distancing guideline.1,2 The COVID-19 virus, first detected in Wuhan, China, on December 31, 20191, has become a global health challenge, persisting in causing both health emergencies and mental health crises around the world. The pandemic had a greater impact on the most vulnerable groups, including youth, the elderly, low-income individuals, and people with comorbidities. Perhimpunan Dokter Spesialis Kedokteran Jiwa Indonesia (PDSKJI) found that the age groups experiencing the most psychological problems during the pandemic in Indonesia Correspondence: Rika Sarfika, Department of Mental Health and Community, Faculty of Nursing, Universitas Andalas. Padang, Indonesia. E-mail: rikasarfika@nrs.unand.ac.id Key words: adolescent, anxiety, COVID-19, depression, Indonesia. Contributions: RS, study conception and design, data collection, litera- ture review/analysis, manuscript writing, critical revisions for important intellectual content; IMMYS, study conception and design, data collec- tion, literature review/analysis, manuscript writing; HM, data collection, literature review/analysis, manuscript writing; DEP, manuscript writing, critical revisions for important intellectual content; ALW, manuscript writing, critical revisions for important intellectual content; MM, manu- script writing, critical revisions for important intellectual content; DN, critical revisions for important intellectual content. All the authors approved the final version to be published. Competing of interest: the authors declare no potential conflict of interest. Funding: this work is funded by the Faculty of Nursing, Universitas Andalas, Indonesia (grant number 0666/UN1.13.D./XIII/KPT/2020). Ethical approval and concent tp participate: ethical approval for the study was granted by the Research Ethics Committee of the Faculty of Medicine at Andalas University, Padang, Indonesia (Approval number: 280/KEP/FK/2020). All participants provided informed consent. Informed consent: all patients participating in this study signed a written informed consent form for participate in this study. Availability of data and material: the data is not accessible to the public as it contains information that might compromise the confidentiality of the research participants. Data can be made available upon a reasonable request. Acknowledgments: the authors acknowledge the contribution of all respondents who participated in this study. Received: 8 October 2023. Accepted: 17 November 2023. Early access: 14 December 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11931 doi:10.4081/hls.2023.11931 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 64] [Healthcare in Low-resource Settings 2024;12:11931] Non -co mmerc ial us e o nly included individuals aged 17–29 years and those over 60 years.3–5 These measures have had a profound impact on the daily lives and routines of people of all ages, including adolescents, who are especially vulnerable during public health emergencies.6 Adolescents are susceptible to mental health conditions, including internalizing disorders such as depression and anxiety, which can have enduring impacts on their physical and mental health and overall quality of life.7 The COVID-19 pandemic has led to significant changes in circumstances that are known to influence mental health, such as daily routines, household finances, and social interactions. Regulatory laws and sudden changes have turned people’s lives upside down, leaving them in shock.8 These changes have presented increased difficulties for teenagers in establishing positive social connections beyond their immediate family.9–11 During the initial stage of the pandemic in Indonesia, a research study found that adolescents faced a higher likelihood of experiencing mental health issues.12–14 Furthermore, similar results from studies conducted in China have documented elevated levels of symptoms associated with anxiety and depression relative to rates reported prior to the pandemic,15–17 while a longitudinal study of Australian adolescents found an increase in depression and anxiety symptoms during the pandemic18. On the other hand, a study conducted in Britain observed a rise in depressive symptoms among adolescents but did not report any significant changes in anxiety symptoms during the pandemic.19 Nevertheless, some other studies have found no significant changes in internalizing symptoms or even a reduction in the risk of anxiety among early adolescents during the pandemic.20 There is a possibility that individual-level factors, such as age and race/ethnicity, may contribute to the alterations in adolescent mental health from pre-pandemic to during the pandemic. It is, therefore, crucial to examine these factors as moderators to determine who is at the highest risk and in need of support.21 Although initial cross-sectional studies suggested that older adolescents had higher levels of anxiety and depression symptoms compared to younger adolescents at the outset of the pandemic, it does not necessarily imply that older adolescents experienced greater changes in mental health symptoms during the pandemic than their younger counterparts.15,16 It is possible that older adolescents had distinct experiences during the pandemic compared to younger adolescents, given that they tend to spend more time with their peers, which may have been complicated by pandemic-related restrictions. Furthermore, they may have had greater needs for autonomy and independence, which could have been affected by pandemic-related disruptions.22,23 Depression and anxiety symptoms are prevalent during public health crises and periods of social isolation, as evidenced by both the SARS and COVID-19 pandemics. Research has demonstrated that a substantial number of people experience such symptoms, including COVID-19 patients, frontline healthcare workers, and the general population. For adolescents, depressive and anxiety symptoms are linked to greater frailty and reduced well-being, potentially increasing their vulnerability to COVID-19. However, there is a lack of consensus regarding the prevalence of these symptoms among adolescents during the pandemic, with estimates varying widely.24–26 Although the pandemic has come to an end, the significance of addressing mental health concerns during times of disaster remains crucial. Examining and understanding the impact of mental health issues in such contexts can provide valuable insights that contribute to the prevention of future crises. Therefore, the aim of this study was to examine factors related to anxiety and depression symptoms among Indonesian adolescents during the COVID-19 pandemic. Research question What factors are related to anxiety and depression symptoms among Indonesian adolescents during the COVID-19 pandemic, and how do these factors contribute to our understanding of addressing mental health concerns during times of disaster and preventing future crises? Materials and Methods Study design The current study utilized a cross-sectional online survey design and recruited participants through snowball sampling, which involved distributing an online questionnaire to students who then shared it with their peers. This approach allowed for the collection of a varied and diverse sample for analysis. Samples The study population consisted of Indonesian adolescents aged between 11 and 21 years, who were willing to participate. Individuals with a history of mental health problems or diagnoses were excluded from the sample. The exclusion criteria allowed researchers to better isolate the potential impact of the COVID-19 pandemic on mental health symptoms, focusing their investigation on individuals without prior conditions. The optimal sample size was determined using G*Power 3.1, based on a correlation (p H1) of 0.15, an α error of 0.01, and a power of 0.95, minimizing the risk of errors22. As a result, the minimum sample size required was 693, but ultimately, 738 individuals completed the survey and provided comprehensive responses to all questions. Instruments Sociodemographic Previous research has suggested that demographic factors, including gender, age, education, marital status, occupation, area of residence (urban or rural), and self-rated health status, can impact mental health outcomes. However, the relationship between these factors and mental health outcomes can differ depending on the individual’s place of residence.27 To account for the potential impact of demographic factors on mental health outcomes, this study collected information on various sociodemographic variables, including age, gender, and education level. Additionally, the study assessed the participants’ exposure to COVID-19-related information on social media (less, sometimes, frequently), self- rated health status (healthy or good, unwell or sick, or not good), and history of exposure to COVID-19 patients (categorized as “ever” and “never”). It is worth noting that all sociodemographic questionnaires were provided in the Indonesian language. Anxiety The Generalized Anxiety Disorder Scale (GAD-7) was used to assess the anxiety level of the adolescents.28,29 The researchers obtained permission to use the GAD-7 instrument for non- commercial data collection purposes in this study. The Indonesian version of GAD-7 was translated previously.30 The GAD-7 is a tool that individuals can use themselves to assess the severity of their generalized anxiety symptoms. It consists of seven questions that assess different aspects of anxiety, including excessive worry, restlessness, irritability, and physical symptoms like sleep disturbances and fatigue. Respondents rated each item on a scale of 0 to 3, with higher scores indicating more severe symptoms. The Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11931] [page 65] Non -co mmerc ial us e o nly GAD-7 has established cut-off scores for mild, moderate, and severe anxiety symptoms. Studies have shown that it is a reliable and valid measure, with high sensitivity and specificity at a cut-off score of 10. The scale’s internal consistency is also high, indicating that it consistently measures anxiety symptoms. Depression The assessment of depression in this study was conducted using the WHO-5 Well-Being Index, which comprises five items featuring positive language that indicates the presence or absence of well-being rather than depression symptoms.24 The WHO-5 Well-Being Index is a self-administered questionnaire that measures well-being in individuals. The Indonesian version of the index was developed with the help of the Language Center of Universitas Andalas and was reviewed by an expert panel prior to the study. To test the validity and reliability of the index, it was administered to a group of 30 individuals who had the same criteria as the study participants. The index demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.864. Participants were asked to report positive feelings they experienced in the past two weeks using a 6-point scale. The severity of depression is indicated by the score generated, with higher scores indicating higher depression. The total score ranges from 0 to 25. The scale was modified to categorize the responses as never, rarely, sometimes, often, and always. Since no established cut-off score exists, the possible range of scores was divided into percentiles to provide categories of severe, moderate, mild, and minimal or no depression. A score of ≤11 indicates severe depression, 12-13 indicates moderate depression, 14-15 indicates mild depression, and ≥16 indicates minimal or no depression. Data collection The research study was conducted over a period of three months, from February to April 2020. To collect research data, the present study employed snowballing technique with online questionnaires distributed through popular social media platforms, such as WhatsApp, Facebook, and Instagram. This approach was chosen since it provides access to hard-to-reach populations, leverages existing social networks, is convenient and cost-effective for online surveys, and can explore hidden or understudied groups. In this context, it allows the research to tap into a diverse sample of Indonesian adolescents who may have experienced mental health issues during the COVID-19 pandemic, making it a practical and efficient choice for the study. The survey was initially disseminated through student groups, and participants were encouraged to share it with their social media networks. The study followed ethical guidelines by obtaining informed consent from participants before they filled out the online questionnaire on the Google form. Those aged between 11 and 21 years were eligible if they obtained parental consent and agreed to the terms on the consent page. The study’s objectives, procedures, and administrative aspects were clearly explained to all participants. A total of 738 participants from 34 Indonesian provinces willingly participated and provided information on their demographics, social media exposure, self-rated health, GAD-7 scores, and the WHO-5 well-being index. Participants had the right to withdraw from the study at any time without providing a reason. Data analysis The data collected in this study underwent statistical analysis using IBM SPSS Statistics software version 22.0 (IBM Corp., Armonk, N.Y., USA). The normality assumption of continuous variables was confirmed through the Kolmogorov-Smirnov test, indicating that the data followed a normal distribution. To summarize the data, descriptive statistics, including frequencies, percentages, means, medians, minimum and maximum values (min-max), and standard deviations (SD), were employed. Furthermore, the relationship between participants’ characteristics and depression and anxiety was examined using independent t- tests and ANOVA tests. Subsequently, a stepwise ordinal logistic regression analysis was conducted to identify the variables that influenced depression and anxiety. The Brant test was used to assess the proportionality assumption, and the model’s performance was evaluated using the Hosmer test for goodness of fit. The statistical significance level was set at p<0.05. Ethical consideration Informed consent was obtained from all adult human participants and their parents or legal guardians. Additionally, informed assent was obtained from the adolescents, ensuring their understanding and agreement to participate. The Research Ethics Committee of the Faculty of Medicine, Universitas Andalas (Approval number: 280/KEP/FK/2020), has approved this research. Results Characteristics of the participants The study involved 738 participants. The majority of the participants were late adolescents aged 18-21 years old (n=701, 95%). Additionally, most of the participants were female (n=584, 79.1%) and had a high school background (n=720, 97.6%). The researchers also collected data on the participants’ exposure to COVID-19. The majority of the participants reported having a good self-rated health status (n=707, 95.8%), frequently being exposed to COVID-19-related information on social media (n=407, 55.1%), and having been exposed to COVID-19 patients (n=730, 98.9%). This information is presented in Table 1. Anxiety description among adolescents during COVID-19 outbreak Table 2 presents the GAD-7 item descriptors. There were 7 questions included in the study to measure the anxiety level of the participants. Item 1 had a mean score of 0.97 (SD=0.52) and indicated that the majority of adolescents felt nervous, anxious, or on edge on several days (77.9%). Item 2 obtained a mean score of 0.80 (SD=0.60) and showed that the majority of adolescents were not able to stop or control worrying for several days (63.7%). Item 3 had a mean score of 0.89 (SD=0.58) and indicated that the majority of adolescents worried too much about different things for several days (67.9%). Item 4 had a mean score of 0.73 (SD=0.65) and indicated that the majority of adolescents experienced difficulty in relaxing for several days (54.9%). Item 5 had a mean score of 0.54 (SD=0.64) and showed that the majority of adolescents did not experience being so restless that it was hard to sit still (52.6%). Item 6 had a mean score of 0.97 (SD=0.70) and indicated that the majority of adolescents became easily annoyed or irritable for several days (60.6%). Lastly, Item 7 had a mean score of 0.99 (SD=0.64) and showed that the majority of adolescents felt afraid, as if something awful might happen for several days (68.4%). Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 66] [Healthcare in Low-resource Settings 2024;12:11931] Non -co mmerc ial us e o nly Depression description among adolescents during COVID-19 outbreak Furthermore, there were 5 questions included in the study to measure depression. Item 1 had a mean score of 2.74 (SD=0.80) and indicated that the majority of adolescents felt cheerful and in good spirits most of the time (45.3%). Item 2 obtained a mean score of 2.72 (SD=0.84) and showed that the majority of adolescents felt cheerful and in good spirits most of the time (45.7%). Item 3 had a mean score of 2.60 (SD=0.83) and indicated that the majority of adolescents sometimes felt active and vigorous (39.6%). Item 4 had a mean score of 2.69 (SD=0.92) and showed that the majority of adolescents woke up feeling fresh and rested most of the time (41.5%). Lastly, item 5 had a mean score of 2.43 (SD=0.92), indicating that the majority of adolescents reported that their daily life had been filled with things that interested them at times (40.2%) (Table 3). Anxiety and depression among adolescents during COVID-19 outbreak Table 4 presents the descriptive statistics for anxiety scores, including the mean and standard deviation. Based on the results, the mean depression score in adolescents was 13.18 (SD 3.45), and the mean anxiety score was 5.88 (SD 3.01). The majority of the respondents (73.6%) reported experiencing depression during the COVID-19 outbreak. Among those respondents, 24.8% reported symptoms of mild depression, 19.4% reported moderate depression, and 29.4% reported severe depression. Additionally, most respondents experienced mild levels of anxiety (47.4%), while 314 (42.5%) respondents did not experience significant anxiety. Related factors of depression and anxiety among adolescents during COVID-19 outbreak Table 5 presents findings that demonstrate a statistically significant link (p<0.05) between anxiety and variables such as age, gender, and exposure to social media. However, no discernible connection was observed between anxiety and other factors like self-rated health, exposure to COVID-19 patients, and education (p>0.05). Moreover, Table 5 reveals a statistically significant correlation (p<0.05) between depression and both gender and social media exposure. Nevertheless, no noticeable relationship Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Description of participant characteristics (n=738). Characteristics f (%) Age, in years 11-14 (early adolescent) 3(0.4) 15-17 (middle adolescent) 34(4.6) 18-21 (late adolescent) 701(95.0) Gender Male 154(20.9) Female 584(79.1) Self-rated health Good 707(95.8) Not good 31(4.2) Exposure to COVID-19 patients Never 8(1.1) Ever 730(98.9) Social media exposure Never 2(0.3) Rarely 32(4.3) Sometimes 146(19.8) Often 407(55.1) Always 151(20.5) Education High school 720(97.6) College 18(2.4) Table 2. Description of anxiety among adolescents during COVID-19 outbreak. Over the last two weeks, Mean ± SD No at all Several days More than half the days Nearly every day how often have you been bothered f (%) f (%) f (%) f (%) f (%) by the following problems? Feeling nervous, anxious, or on edge 0.97±0.52 100 (13.6) 575 (77.9) 49 (6.6) 14 (1.9) Not being able to stop or control worrying 0.80±0.60 214 (29.0) 470 (63.7) 43 (5.8) 11 (1.5) Worrying too much about different things 0.89±0.58 163 (22.1) 501 (67.9) 65 (8.8) 9 (1.2) Trouble relaxing 0.73±0.65 273 (37.0) 405 (54.9) 48 (6.5) 12 (1.6) Being so restless that it is hard to sit still 0.54±0.64 388 (52.6) 308 (41.7) 32 (4.3) 10 (1.4) Becoming easily annoyed or irritable 0.97±0.70 171 (23.2) 447 (60.6) 94 (12.7) 26 (3.5) Feeling afraid, as if something awful might happen 0.99±0.64 134 (18.2) 505 (68.4) 75 (10.2) 24 (3.3) Table 3. Description of depression among adolescents during COVID-19 outbreak. Over the last two weeks, Mean ± SD At no time Rarely Sometimes Most of the time All of the time how often have you been f (%) f (%) f (%) f (%) f (%) f (%) bothered by the following problems? I have felt cheerful and in good spirits 2.74±0.80 2 (0.3) 35 (4.7) 241 (32.7) 334 (45.3) 126 (17.1) I have felt calm and relaxed 2.72±0.84 5 (0.7) 47 (6.4) 223 (30.2) 337 (45.7) 126 (17.1) I have felt active and vigorous 2.60±0.83 3 (0.4) 52 (7.0) 292 (39.6) 281 (38.1) 110 (14.9) I woke up feeling fresh and rested 2.69±0.92 5 (0.7) 76 (10.3) 208 (28.2) 306 (41.5) 143 (19.4) My daily life has been filled with things that interest me 2.43±0.92 10 (1.4) 96 (13.0) 297 (40.2) 238 (32.2) 97 (13.3) [Healthcare in Low-resource Settings 2024;12:11931] [page 67] Non -co mmerc ial us e o nly was found between depression and other variables such as age, self-rated health, exposure to COVID-19 patients, and education (p>0.05). Additionally, Table 6 highlights variations in participant characteristics across different categories of depression, while Table 7 demonstrates differences in participant characteristics across categories of anxiety. According to the results of the multivariable analysis, several factors were found to be significantly associated with depression among adolescents during the COVID-19 pandemic. Specifically, variables such as gender, self-rated health, and social media exposure showed a significant relationship. The analysis revealed that the risk of higher depression was 0.657 times (OR=0.657, 95% CI=0.476-0.908) higher among male adolescents compared to their female counterparts. Conversely, adolescents with good self-rated health were 0.439 times (OR=0.439, 95% CI=0.220-0.876) less Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 5. Personal characteristics and relationships with the anxiety and depression. Characteristics Anxiety t F p Depression t F p Mean±SD Mean±SD Age, in years 3.791 0.023* 0.896 0.409 11-14 (early adolescent) 3.67±2.08 15.67±3.78 15-17 (middle adolescent) 7.12±3.86 13.44±3.16 18-21 (late adolescent) 5.83±2.95 13.15±3.46 Gender -2.315 0.021* 2.232 0.026* Male 5.38±3.36 13.73±3.58 Female 6.01±2.90 13.03±3.40 Self-rated health -1.746 0.081 1.780 0.075 Good 5.84±2.98 13.22±3.45 Not good 6.81±3.49 12.10±3.29 Exposure to COVID-19 patients -0.596 0.551 -1.071 0.284 Never 5.25±3.69 11.88±4.01 Ever 5.89±3.00 13.19±3.44 Social media exposure 3.048 0.017* 4.248 0.002* Never 4.00±5.65 15.00±7.07 Rarely 4.41±2.89 14.78±3.20 Sometimes 6.22±3.01 12.42±3.38 Often 5.78±2.90 13.15±3.32 Always 6.17±3.01 13.60±3.72 Education 0.386 0.700 -0.333 0.739 High school 13.17±3.47 13.17±3.47 College 13.44±2.85 13.44±2.85 t, t-test; F, one-way ANOVA, *Statistically significance (p<0.05). Table 4. Anxiety and depression level among adolescents during COVID-19 outbreak. Variables f (%) Mean (SD) Depression 13.18 (3.45) No depression 195 (26.4) Mild 183 (24.8) Moderate 143 (19.4) Severe 217 (29.4) Anxiety 5.88 (3.01) No anxiety 314 (42.5) Mild 350 (47.4) Moderate 66 (8.9) Severe 8 (1.1) Table 6. Results of ordinal logistic regression on the association between variables of interest and depression of respondents during COVID-19. Variables Categories Depression OR 95% CI for OR p Lower Upper Age Continuous 1.005 0.898 1.126 0.923 Gender (reference: female) Male 0.657 0.476 0.908 0.010* Education (reference: college) High school 1.287 0.573 2.892 0.554 Exposure to COVID-19 Patients (reference: never) Ever 3.223 0.696 14.920 0.134 Self-rated health (reference: not good) Good 0.439 0.220 0.876 0.019* Social media exposure (reference: always) Never 0.479 0.026 8.869 0.621 Rarely 0.711 0.357 1.419 0.334 Sometimes 1.895 1.249 2.876 0.003* Often 1.442 1.030 2.019 0.033* Parallel line test (p=0.105). Goodness of fit test of overall model: Deviance (Chi-Square=247.828, df=234, p=0.255). ***p<0.001; **0.001