Gender & Behaviour, Vol. 18 No.

2, June 2020 15795 - 15802

Copyright 2020 © Ife Centre for Psychological Studies/Services, Nigeria ISSN: 1596-9231
PSYCHOLOGICAL DISTRESS IN A NATIONAL SAMPLE OF MALE AND FEMALE
ADOLESCENTS FROM PUBLIC AND PRIVATE SCHOOLS IN BAHRAIN

Supa Pengpid1,2 & Karl Peltzer3

1
ASEAN Institute for Health Development, Mahidol University, Salaya
Phutthamonthon, Nakhon Pathom, Thailand
2
Department of Research Administration and Development
University of Limpopo, Turfloop, South Africa
3
Department of Psychology
University of the Free State, Bloemfontein, South Africa

Abstract
The study aimed to estimate the prevalence and correlates of psychological distress among male and female
adolescent school children in Bahrain. Cross-sectional nationally representative data were analysed from
7,141 school students (14 years median age) that participated in the “2016 Bahrain Global School-Based
Student Health Survey (GSHS).” Results indicate that 20.4% of female students and 12.6% of male students
reported multiple psychological distress. In adjusted statistical analysis using multinomial logistic
regression, among both boys and girls, older age, attending a public school, bullying victimization, injury,
low parental and low peer support were associated with multiple and single psychological distress. In
addition, among boys, sometimes, mostly or always feeling hungry increased the likelihood of multiple
psychological distress. Moreover, among girls, current tobacco use, victim of physical assault, sedentary
behaviour and participation in physical fighting were associated with multiple psychological distress. One in
five girls and more than one in ten boys reported multiple psychological distress and gender specific factors
associated with psychological distress were discovered which can guide in developing prevention
programmes.
Keywords: gender, psychological distress, public school, private school, Bahrain

Introduction
“Mental health conditions account for 16% of the global burden of disease and injury in people aged 10–19
years. Half of all mental health conditions start by 14 years of age but most cases are undetected and
untreated.”(WHO, 2019a, p.2). “In the general population, mental health is often measured by indicators of
non-specific psychological distress, including symptoms of depression, anxiety, stress, and somatic
complaints.” (Kessler et al., 2003). For preventing psychological distress and mental ill-health among young
people, risk factors and prevalence rates of psychological distress should be periodically assessed in
population surveys (Kieling et al., 2011). Apart from health care data, there is limited population data on
psychological distress among young people in Bahrain (Al-Ansari et al., 2001). In an adolescent school
survey in Zambia, 15.7% of students reported psychosocial distress (3 or more items) (Siziya & Mazaba,
2015), in Sri Lanka, Mongolia, Nepal and Laos, 32.9% reported (single) psychological distress (Lee, Greene
& Shin, 2019), and 26.6% in Thailand (Pengpid & Peltzer, 2013). As reviewed in Pengpid and Peltzer (2020,
p. 2), ”Risk factors for psychological distress among adolescents may include sociodemographic factors
(female sex, older age), environmental stressors (substance use, risk behaviour, interpersonal violence, health
risk behaviour and injury) and lack of protective factors, such as low parental support.” This analysis aimed at
investigating the prevalence, protective and sociodemographic variables, and environmental stressors
associated with psychological distress among male and female school adolescents in Bahrain.

Methods
Sample and procedure
Cross-sectional nationally representative data from the “2016 Bahrain GSHS” were analyzed (WHO, 2019b).
More detailed information the sampling methods and the data can be found at WHO (2019b); the overall
response rate was 79%.”(WHO, 2019b) “A national ethics committee approved the study and informed
consent was obtained from the participating schools, parents and students.”(WHO, 2019b)

Measures
The questionnaire used is described in Table 1 (WHO, 2019b). “The psychological distress items (no close
friends, loneliness, anxiety, suicidal ideation and suicide attempt, details in Table 1) were summed, and

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grouped into 0=0 no, 1=1 single and 2-5=2 multiple distress” (Pengpid & Peltzer, 2019). “Adequate physical
activity was defined as at least 60 minutes of moderate to vigorous-intensity physical activity daily” (WHO,
2017).” “Adequate FV consumption was classified as five or more servings in a day” (WHO, 2003). “The
four items on parental or guardian support were summed, and classified into three groups, 0-1 low, 2 medium
and 3-4 high support.” (Pengpid & Peltzer, 2020).

Data analysis
Data were analysed with “STATA software version 15.0 (Stata Corporation, College Station, Texas, USA)”,
considering the multi-stage sampling of the survey. Frequencies were calculated as well as Chi-square tests.
Multinomial logistic regression was utilized to identify predictors of single and multiple psychological
distress (the reference variable was “no psychological distress”) stratified by gender. P<0.05 was considered
significant. Missing data were excluded from the analyses.

Results
Sample characteristics
The study participants included 7,141 school students (14 years median age, 3 years interquartile range),
48.9% were female, and 11.2% had a low socioeconomic status (mostly or always experienced hunger). More
than one in five participants (20.8%) were current tobacco users, 17.9% had parents who used tobacco, 65.2%
had exposure to secondary smoke (past week), 2.1% had ever used cannabis and 1.6% ever amphetamine.
Almost a third of the students (28.6%) had been bullied in the past month, 44.9% had sustained a serious
injury in the past 12 months, 41.4% had been in a physical fight in the past 12 months, 27.2% had been
attacked in the past year, 34.6% were daily drinking soft drinks and 47.1% had at two or more days fast food
in the past week. Regarding protective variables, the majority of students (65.1%) attended school (past
month), 19.8% had sufficient physical activity, 71.6% attended on two or more days physical education
classes a week, 41.7% did not engage in sedentary behaviour, 64.9% had high peer and 48.3% had high
parental support. In all, 10.4% of female students and 12.6% of male students reported multiple psychological
distress. The prevalence of multiple psychological distress was significantly higher among girls than boys
(P<0.001). (see Table 2).

Associations with psychological distress by gender

In adjusted multinomial logistic regression analysis, among both boys and girls, older age, attending a public
school, bullying victimization, injury, low parental and low peer support were associated with single as well
as multiple psychological distress. In addition, among boys, sometimes, mostly or always feeling hungry was
positively and exposure to secondary smoke was inversely associated with multiple psychological distress.
Moreover, among girls, current tobacco use, sedentary behaviour and interpersonal violence were associated
with multiple psychological distress (see Table 3).

Discussion
The study among adolescents in Bahrain found 38.7% had (multiple=16.5% and single=22.2%) psychological
distress, which is lower than in Zambia (79.5%) (Siziya & Mazaba, 2015) and similar to Tanzania (41%
“elevated level of mental health problems”) (Nkuba, Hermenau, Goessmann & Hecker, 2018) and in four
Asians countries (32.9% any distress) (Lee et al., 2019). This study found a higher proportion of
psychological distress among girls than boys, which concurs with previous investigations (e.g., Siziya &
Mazaba, 2015; Tabak et al., 2008). The study found a higher prevalence of psychological distress in students
attending public than private schools. It is not clear as to why there is a higher prevalence of psychological
distress in public or government than private secondary schools in Bahrain. Public secondary education is free
in Bahrain for all Bahraini and non-Bahraini students (egovernment, 2020). Private secondary schools in
Bahrain are costly and may not be accessed by poorer families, increasing education inequality in Bahrain
(Abdelbaki, 2012).

Current tobacco use, being bullied, injury, attacked and in physical fight (environmental stressors) increased
the likelihood for psychological distress among boys and/or girls in this study. Similar results were found in
previous research investigations (e.g., Jaisoorya et al., 2017; Siziya & Mazaba, 2015). It is possible that the
several environmental stressors, such as being bullied, tobacco use, attacked, fighting and injury, cluster with

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psychological distress, and should therefore be targeted in an integrated manner in school health interventions
to prevent psychological distress.

Low peer and low parental support increased the likelihood of psychological distress in this survey, which
confirms previous research (Lee et al., 2019; Siziya & Mazaba, 2015). Unlike some previous research results
(e.g., Glozah et al., 2018; Hong & Peltzer, 2017), this survey did not show that adequate fruit and vegetable
consumption and adequate physical activity was protective against psychological distress. However, in this
survey only sedentary behaviour among girls was associated with multiple psychological distress. This study
also did not find an association between school attendance, participation in physical education classes and
psychological distress, while in a study in Nepal school truancy and in a multi-country study poor health
education (Lee et al., 2019) increased the odds for psychological distress.

Study limitations
The investigation was limited to adolescent attending school and self-reported data. However, both public and
private school adolescent were included in this nationally representative survey. Psychological distress was
not assessed with specifically designed questionnaires, which should be included in future surveys.

Conclusions
A high prevalence of psychological distress was discovered among adolescents attending public or private
schools in Bahrain. Several indicators for psychological distress were identified, including older age, hunger,
tobacco use, injury, interpersonal violence, low peer and parental support and sedentary behaviour among
girls. These risk indicators should be addressed in programmes that are geared towards the prevention of
psychological distress in this adolescent school population.

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Table 1. Description of variables

Variables Question Response options (coding scheme)
“11 years old or younger to 18 years old or
Age “How old are you?”
older”
Sex “What is your sex?” “Male, Female”
“During the past 30 days, how often did you
“1= never to 5= always (coded 1=1, 2=2 and
Hunger go hungry because there was not enough food
3–5=3)”
in your home?"
Psychological distress
No close friends “How many close friends do you have?” “1 = 0 to 4 = 3 or more (coded 1+=0, 0=1)”
“During the past 12 months, how often have “1=never to 5=always (coded 1–3=0 and 4–
Loneliness
you felt lonely?” 5=1)”
“During the past 12 months, how often have
“1=never to 5=always (coded 1–3=0 and 4–
Anxiety you been so worried about something that
5=1)”
you could not sleep at night?”
“During the past 12 months, did you ever
Suicide ideation “Yes, No”
seriously consider attempting suicide?”
“During the past 12 months, how many times “1=0 times to 5=6 or more times (coded
Suicide attempt
did you actually attempt suicide?” 1=0 and 2–5=1)”
Environmental stressors
“During the past 30 days, on how many days
did you smoke cigarettes/use any tobacco
“1=0 days to 7=All 30 days (coded 1=0 and
Current tobacco use products other than cigarettes, such as
2-7=1)”
Sheesha, Medwakh, chewed tobacco, or
electronic cigarettes?”
“Neither, My father or male guardian, My
“Which of your parents or guardians use any
Parental tobacco use mother or female guardian, Both” (coded
form of tobacco?”
0=neither and 1=either)
“During the past 7 days, on how many days “1=0 days to 5=all 7 days (coded 1=0 and 2-
Secondary smoke
have people smoked in your presence?” 5=1)”
“During your life, how many times have you “1=0 times to 5=20 or more times (coded
Cannabis use
used marijuana (also called grass, weed)?” 1=0 and 2-5=1)”
“During your life, how many times have you
“1=0 times to 5=20 or more times (coded
Amphetamine use used amphetamines or methamphetamines
1=0 and 2-5=1)”
(also called speed, crystal)?”
“During the past 30 days, on how many days “1=0 days to 7=All 30 days (coded 1=0 and
Bullied
were you bullied?” 2–7=1)”
“During the past 12 months, how many times “1=0 times to 8=12 or more times (coded
Physically attacked
were you physically attacked?” 1=0 and 2–8=1)”
“During the past 12 months, how many times “1=0 times to 8=12 or more times (coded
In a physical fight
were you in a physical fight?” 1=0 and 2–8=1)”
“During the past 12 months, how many times
were you seriously injured?” ”(An injury is
serious when it makes you miss at least one “1=0 times to 8=12 or more times (coded
Injury
full day of usual activities (such as school, 1=0 and 2–8=1)”
sports, or a job) or requires treatment by a
doctor or nurse.)”
“During the past 30 days, how many times per
day did you usually drink carbonated soft
drinks, such as Pepsi, Coca Cola, 7 Up, Sprite, “1=not in the past days to 7=5 or more
Soft drinks
Mountain Dew, Fanta, or any other times per day (coded 1-2=0 and 3-7=1)”
carbonated soft drink? (Do not include diet
soft drinks)?”
“During the past 7 days, on how many days
did you eat food from a fast food restaurant,
Fast food consumption such as Mc Donald’s, Pizza Hut, KFC, Burger “1=0 to 8=7 days (coded 1-2=0 and 3-8=1)”
King, Hardees, or any other fast food
restaurants or cafeterias?”

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Protective factors
“During the past 30 days, how often did your
parents or “1=never to 5=always (coded 1–3=0 and 4–
Parental supervision
guardians check to see if your homework was 5=1)”
done?”
“During the past 30 days, how often did your
Parental parents or “1=never to 5=always (coded 1–3=0 and 4–
connectedness guardians understand your problems and 5=1)”
worries?”
“During the past 30 days, how often did your
“1=never to 5=always (coded 1–3=0 and 4–
Parental bonding parents or guardians really know what you
5=1)”
were doing with your free time?”
“During the past 30 days, how often did your
Parental respect for “1=never to 5=always (coded 1–3=0 and 4–
parents or guardians go through your things
privacy 5=1)”
without your approval?”
“During the past 30 days, how often were
“1=never to 5=always (coded 1–3=0 and 4–
Peer support most of the students in your school kind and
5=1)”
helpful?”
“During the past 30 days, on how many days
“1=0 days to 5= 10 or more days (coded
School attendance did you miss classes or school without
1=1 and 2–5=0)”
permission?”
“During this school year, on how many days
Attending physical “1=0 days to 6=5 or more days (coded 1-
did you go to physical education (PE) class
education classes 3=0 and 4-6=1)”
each week.”
“Physical activity is any activity that increases
your heart rate and makes you get out of
breath some of the time. Physical activity can
be done in sports, playing with friends, or
Physical activity walking to school. Some examples of physical “0=0 days to 7=7 days (coded 0-6=0 and
activity are running, fast walking, biking, 7=1)”
dancing, football, swimming, and aerobics.
During the past 7 days, on how many days
were you physically active for a total of at
least 60 minutes per day?”
“How much time do you spend during a
typical or usual day sitting and watching
“1=less than 1 hour per day; 2=1-2 hrs/day;
Leisure-time sedentary television, playing computer games, talking
3=3-4 hrs/day; 4=5-6 hrs/day; 5=7-8
behavior with friends, or doing other sitting activities,
hrs/day and 6=8 or more hours per day”
such as studying or using any electronic
devices like IPads?”
“During the past 30 days, how many times per
day did you usually eat fruit such as dates, “1=I did not eat fruit during the past 30
Fruits
bananas, apples, oranges, mangos, berries, or days to 7=5 or more times per day”
any other fruits?”
“During the past 30 days, how many times per
day did you usually eat vegetables, such as “I did not eat vegetables during the past 30
Vegetables
lettuce, cucumbers, tomatoes, carrots, or any days to 7=5 or more times per day ”
other vegetables?”

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Table 2: Descriptive statistics of independent variables and by psychological distress

Psychological distress Multiple psychological distress
Variable Total sample Single Multiple Boys Girls
N (%) % % % %
Socio-demographics
All 7141 22.2 16.5 11.4 18.8
Sex
Female 3449 (48.9) 23.8 20.4 --- ---
Male 3685 (51.1) 20.6 12.6
Age in years
13 or less 2745 (34.5) 19.7 13.3 9.9 14.6
14-15 2798 (39.6) 21.1 17.3 12.2 20.8
16 or more 1594 (25.9) 27.3 19.5 12.6 22.9
Hunger
Never 3220 (43.5) 20.0 13.1 8.7 14.9
Rarely 3238 (45.4) 22.7 16.8 11.3 20.5
666 (11.2) 29.1 28.3 25.7 28.8
Sometimes/mostly/alway
s
School type
Private 3385 (47.4) 23.7 17.9 9.6 15.8
Public 3756 (52.6) 17.9 12.5 13.7 22.0
Environmental stressors
Current tobacco use 1182 (20.8) 23.9 26.7 19.8 43.7
Parental tobacco use 1262 (17.9) 24.9 21.4 14.7 25.4
Secondary smoke 4276 (65.2) 23.4 18.2 12.5 23.6
Ever cannabis use 128 (2.1) 26.6 44.7 39.0 70.6
Ever amphetamine use 88 (1.6) 29.6 40.7 35.3 87.5
Bullied 1921 (28.6) 23.3 27.9 18.8 36.9
Attacked 2037 (27.2) 23.6 23.9 16.1 31.3
In physical fight 2865 (41.4) 22.7 21.4 14.2 29.5
Injury 2802 (44.9) 24.4 20.9 14.4 27.2
Soft drinks (≥1/day) 2253 (34.6) 22.8 19.1 14.2 23.2
Fast food (≥2/week) 3178 (47.1) 22.7 18.1 11.8 22.2
Protective factors
Parental/guardian
support index 1878 (27.0) 26.6 28.3 19.9 32.2
0-1 1752 (24.7) 22.5 17.1 11.9 19.1
2 3345 (48.3) 19.6 9.2 6.2 10.5
3-4
Peer support 4468 (64.9) 20.4 12.9 7.6 14.6
(mostly/always)
School attendance 4445 (65.1) 20.6 12.7 9.1 12.5
Attending physical 4232 (71.6) 22.4 15.8 10.2 19.6
education classes (≥2
times/week)
Physical activity 1475 (19.8) 21.7 16.5 12.1 20.1
Sedentary <3 hrs 3040 (41.7) 20.7 12.8 10.6 13.6
Fruit and vegetable 1551 (21.0) 23.1 15.6 12.0 15.6
consumption (≥5 or more
a day)

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Table 3: Associations with psychological distress

Male Female
Single psychological Multiple psychological Single psychological Multiple
distress distress distress psychological
distress
Variables ARRR (95% CI) ARRR (95% CI) ARRR (95% CI) ARRR (95% CI)
Socio-demographics
Age in years
13 or less 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
14-15 1.16 (0.81, 1.65) 1.31 (0.87, 1.97) 1.30 (1.02, 1.66)* 1.69 (1.28, 2.23)***
16 or more 1.73 (1.22, 2.45)** 2.28 (1.37, 3.82)** 1.94 (1.61, 2.35)*** 1.92 (1.25, 2.95)**
Hunger (mostly/always)
Never 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Rarely 0.95 (0.66, 1.35) 0.91 (0.60, 1.37) 1.10 (0.82, 1.47) 0.84 (0.58, 1.23)
Sometimes/mostly/always 2.26 (1.49, 3.44)*** 2.83 (1.59, 5.04)*** 1.31 (0.93, 1.84) 1.29 (0.75, 2.23)
School type
Private 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Public 1.32 (1.07, 1.64)* 1.85 (1.15, 2.99)* 1.93 (1.51, 2.48)*** 1.66 (1.23, 2.24)***
Environmental stressors
Current tobacco use 1.27 (0.88, 1.82) 1.32 (0.88, 1.97) 1.01 (0.61, 1.67) 2.68 (1.68, 4.28)***
Parental tobacco use 0.98 (0.72, 1.33) 1.13 (0.71, 1.78) 1.31 (0.99, 1.74) 1.36 (0.95, 1.93)
Secondary smoke 1.07 (0.77, 1.49) 0.78 (0.63, 0.98)* 1.11 (0.79, 1.59) 1.30 (0.91, 1.86)
Bullied 1.40 (1.11, 1.75)** 2.46 (1.79, 3.38)*** 1.91 (1.34, 2.71)*** 4.08 (3.04, 5.49)***
Attacked 1.08 (0.81, 1.43) 1.32 (0.85, 2.06) 1.13 (0.79, 1.61) 1.56 (1.06, 2.29)*
In physical fight 1.02 (0.85, 1.24) 0.99 (0.70, 1.39) 0.86 (0.62, 1.18) 1.26 (1.01, 1.56)*
Injury 1.46 (1.22, 1.75)*** 1.65 (1.22, 2.25)*** 1.44 (1.20, 1.71)*** 1.89 (1.35, 2.65)***
Soft drinks (≥1/day) 0.90 (0.66, 1.24) 1.20 (0.73, 1.99) 1.05 (0.80, 1.37) 0.93 (0.59, 1.47)
Fast food (≥2/week) 1.01 (0.77, 1.32) 1.00 (0.72, 1.41) 1.05 (0.77, 1.44) 1.04 (0.76, 1.43)
Protective factors
Parental/guardian support
index 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
0-1 0.65 (0.53, 0.79)*** 0.65 (0.49, 0.84)** 0.79 (0.56, 1.13) 0.61 (0.45, 0.83)**
2 0.68 (0.52, 0.88)** 0.30 (0.19, 0.49)*** 0.54 (0.42, 0.70)*** 0.31 (0.20, 0.48)***
3-4
Peer support (mostly/always) 0.60 (0.46, 0.77)*** 0.48 (0.36, 0.65)*** 0.66 (0.50, 0.88)** 0.49 (0.38, 0.63)***
School attendance 1.05 (0.74, 1.48) 1.20 (0.83, 1.72) 1.13 (0.86, 1.49) 0.86 (0.61, 1.21)
Attending physical education 0.80 (0.58, 1.11) 0.61 (0.34, 1.10) 0.92 (0.69, 1.23) 0.86 (0.66, 2.29)
classes (≥2 times/week)
Physical activity 1.01 (0.77, 1.33) 1.16 (0.81, 1.65) 1.23 (0.86, 1.76) 0.87 (0.48, 1.58)
Sedentary <3 hrs 0.95 (0.69, 1.32) 0.83 (0.59, 1.15) 0.81 (0.58, 1.13) 0.67 (0.52, 0.87)**
Fruit and vegetable consumption 1.29 (0.89, 1.86) 1.45 (0.73, 1.99) 1.22 (0.92, 1.64) 0.85 (0.68, 1.07)
(≥5 or more a day)
CRRR: Crude Relative Risk Ratio; ARRR=Adjusted Relative Risk-Ratio; CI=Confidence Interval; ***P<0.001; **P<0.01; *P<0.05

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