UNIVERSITY FOR DEVELOPMENT STUDIES

SCHOOL OF ALLIED HEALTH SCIENCES

DEPARTMENT OF NUTRITIONAL SCIENCES

ASSOCIATION BETWEEN ADOLESSCENT DEPRESSION AND DIETARY

DIVERSITY IN THE TAMALE METROPOLIS

ABDUL LATIF IBRAHIM (CMN/0015/18)

YAKUBU UMU HEIRA (CMN/0056/18)

AHMED HARUNA NAJAT (CMN/0138/18)

A DISSERTATION SUBMITTED TO THE DEPARTMENT OF NUTRITIONAL

SCIENCES, UNIVERSITY FOR DEVELOPMENT STUDIES IN PARTIAL
FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF BACHELOR
OF SCIENCE (BSc.) DEGREE IN COMMUNITY NUTRITION

AUGUST, 2022

I
 DECLARATION
We hereby declare that this dissertation is the result of our original work towards the award
of BSc in Community Nutrition and no part of it has been presented for another degree in this
university or elsewhere. Also, works by others, which served as sources of information, have
been acknowledged by making references to the authors where applicable. We also declare
that the preparation and presentation of this dissertation were supervised following the
guidelines on supervision of dissertation laid down by the University for Development
Studies.

Abdul Latif Ibrahim Signature: ______________ Date: _____/______/_____

(CMN/0015/18)

Yakubu Umu Heira Signature: ______________ Date: _____/______/_____

(CMN/0056/18)

Ahmed Haruna Najat Signature: ______________ Date: _____/______/_____

(CMN/0138/18)

Ms. Victoria Awuni Signature: ______________ Date: _____/______/_____

(Project supervisor)

Dr. Anthony Wemakor Signature: ______________ Date: _____/______/_____

(Head of Department)

I
 DEDICATION
We dedicate this project to our families.

II
III
 ACKNOWLEDGEMENT
First of all, we are very grateful to the Almighty Allah for his divine guidance and protection,

as well as strength and knowledge to carry out this study successfully. We would like to

express our deepest gratitude to everyone who provided us aid in the completion of this

research. Special thanks go to our hardworking supervisor, Madam Victoria Awuni who

assisted us and contributed immensely towards the success of this research. Last but not the

least; we are sincerely grateful to the people of Changli, Kukuo, Sabongida and Tishigu for

this research. May the Almighty Allah bless you all.

IV
 ABSTRACT
Depression is a serious illness with a high lifetime prevalence rate in which diet has been
considered as the modifiable factor. The main aim of this study is to assess the association
between depression in adolescents and dietary diversity in the Tamale metropolis. A cross
sectional study design was used for the study, with a sample size of 419. From analysis
conducted, 53% were possibly depressed.

Results from chi-square analysis and fishers exact test of possible predictors of depression
showed that residential status (χ2= 16.878; p < 0.001), gender (χ2= 4.042; p= 0.044), religion
(χ2= 5.154; p= 0.023), family type (p = 0.001), whom an adolescent shares troubles with (p =
0.001) and socio-economic status (χ2= 18.691; p < 0.001) had significant associations with
the depressive status of respondents. This has been shown in table 4.

From table 7, only the socio-economic (χ 2 = 6.201; p = 0.045) background of respondents

had significant association with dietary diversity.

There was significant association between depression status of adolescents and dietary
diversity.

Also, frequency of consumption from the food groups is shown in figure 2.

The food groups most consumed by our respondents were cereals (99.3%), other vegetables
(74.7%), oils and fats (83.5%), eggs (56.3%), flesh meats (46.3%) at the expense of fish and
sea foods (23.2%), vitamin A rich fruits (18.6%), other fruits among (22.7%) others

We therefore recommend that adolescents should be encouraged to share their troubles with
guardians. WHO, NGOs and other community base organizations should channel their
campaigns towards adolescents’ mental health awareness. We also recommend that further
research should be done on the association between the weight of food intake of adolescents
and depression.

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 TABLE OF CONTENTS

Contents Page
DECLARATION........................................................................................................................I
DEDICATION..........................................................................................................................II
ACKNOWLEDGEMENT.......................................................................................................IV
ABSTRACT..............................................................................................................................V
LIST OF TABLES................................................................................................................VIII
LIST OF FIGURES.................................................................................................................IX
CHAPTER ONE........................................................................................................................1
1.1 Background.......................................................................................................................1
1.2 Problem Statement............................................................................................................4
1.3 Significance of study........................................................................................................5
1.4 OBJECTIVES...................................................................................................................5
1.4.1 Main objective...............................................................................................................5
1.4.2 Specific objectives.........................................................................................................5
CHAPTER TWO.......................................................................................................................6
2.1 Adolescence......................................................................................................................6
2.1.1 Physiological Changes in Adolescence.........................................................................7
2.1.2 Psychological Changes in Adolescence........................................................................8
2.2 Nutritional Needs of Adolescence..................................................................................10
2.3 Dietary diversity.............................................................................................................12
2.4 Depression......................................................................................................................13
2.4.1 Causes of depression...................................................................................................14
2.4.2 Effects of depression...................................................................................................15
2.4.4 Adolescent Depression................................................................................................16
2.4.5 Causes of Adolescent Depression...............................................................................17
2.5 Adolescent Diet and Depression....................................................................................20
CHAPTER THREE..................................................................................................................22
3.1 Study Area......................................................................................................................22
3.2 Study Design..................................................................................................................23
3.3 Study Population............................................................................................................23
3.4 Sample Size....................................................................................................................23
3.5 Sampling procedure........................................................................................................24

VI
 3.6 Data Collection...............................................................................................................25
3.7 Data Analysis..................................................................................................................26
3.8 Ethical Consideration.....................................................................................................27
CHAPTERE FOUR.................................................................................................................28
4.1 Socio-demographic and socio-economic characteristics................................................28
4.2 Prevalence of Adolescent Depression............................................................................30
4.3 Association between respondents’ socio- demographic characteristics, socio-economic
status and depression status..................................................................................................31
4.3.1 Determinants of depressive status...............................................................................33
4.4 Assessment of dietary diversity of respondents.............................................................35
4.5Association between adolescent’s socio-demographic, socio-economic status and
dietary diversity....................................................................................................................36
CHAPTER 5.............................................................................................................................39
5.1 Prevalence of adolescent Depression.............................................................................39
5.2 Association between adolescents’ socio-demographic characteristics, socio-economic
status and depression............................................................................................................39
5.3 Dietary Diversity............................................................................................................41
5.4 Association between adolescent’s socio-demographic, socio-economic, depression and
dietary diversity....................................................................................................................42
CHAPTER SIX........................................................................................................................43
6.1 Conclusion......................................................................................................................43
6.2 Recommendation............................................................................................................43
REFERENCES.........................................................................................................................45
APPENDIX..............................................................................................................................49

LIST OF TABLES

VII
Table 1: Study area sample size...............................................................................................24
Table 2: Socio-demographic and socio-economic characteristics...........................................29
Table 3: Association between socio-demographic characteristics, socio-economic status of
respondents and depression......................................................................................................31
Table 4: Determinants of depressive status..............................................................................33
Table 5: Dietary diversity of respondents................................................................................35
Table 6: Association between adolescents’ socio-demographic, socio-economic, depressive
status and dietary diversity.......................................................................................................36

LIST OF FIGURES

VIII
Figure 1: Prevalence of adolescent depression........................................................................31
Figure 2: Frequency of food consumption...............................................................................36

IX
 CHAPTER ONE
INTRODUCTION

1.1 Background
The term adolescence originated from the Latin word “adolescere” meaning “to grow up” or

“to mature.” It is a phase of transition between childhood and adulthood that includes some

changes in body and mind. World Health Organization (WHO) defines adolescence as a

period of life between 10-19 years of age characterized by physical growth, emotional,

psychosocial and behavioral changes, thus, bringing about transition from childhood to

adulthood. These changes usually take place a year or two earlier in girls than boys. Some of

the changes are externally visible and some are internal. These changes are normal and

natural and are as a result of release of various hormones in both boys and girls (Provisions et

al., 2009),

Although it sometimes seems that adolescents’ bodies transform overnight, the process of

maturation actually occurs over a period of several years. The sequence of physical changes

is largely predictable, but there is great variability in the age of onset of adolescent and the

pace at which changes occur (Kipke, 1999). There are numerous factors that affect the onset

and progression of adolescent, including genetic and biological influences, stressful life

events, socioeconomic status, nutrition and diet, amount of body fat, and the presence of a

chronic illness. The growth spurt, which involves rapid skeletal growth, usually begins at

about ages 10 to 12 in girls and 12 to 14 in boys and is complete at around age 17 to 19 in

girls and 20 in boys (Hofmann & Greydanus, 1997). For most adolescents, sexual maturation

involves achieving fertility and the physical changes that support fertility. For girls, these

changes involve breast budding, which may begin around age 10 or earlier, and menstruation,

which typically begins at age 12 or 13. For boys, the onset of adolescent involves

enlargement of the testes at around age 11 or 12 and first ejaculation, which typically occurs

between the ages of 12 and 14. The development of secondary sexual characteristics, such as

1
body hair and (for boys) voice changes, occurs later in adolescent (American Psychological

Association, 2014.).

Another change that occurs in adolescence is psychosocial development (Özdemir et al.,

2016). ‘Self-definition and personality development’ occur during the psychosocial

development (The Oxford Handbook of Social Cognition, 2013). Age-specific tasks and

behaviors that reflect adult roles are observed in self-definition. The adolescent gradually

becomes an individual who adopts social duties, tries to live his/her life on his/her own,

assumes adult levels of responsibility, finds his/her own personality by establishing new

relationships. The adolescent becomes selfish, demands more, complains about rules in the

house, finds rights given to him/her insufficient and wants to be free. He/she wants to make

his/her own decisions and choices. The center of his/her social environment shifts from the

family to friends and school groups. He/she does not want to stay home, develops a greater

interest in outside world and gives more importance to friendships (Kurtman, 2005). His/her

interest in classes decreases, studying order is disturbed and school success decreases. He/she

gives negative reactions to his/her parents. Family relationships shifts from dependence to

independence (Akçan Parlaz et al., 2012; Güler, Gönener, Altay, & Gönener, 2009).

Individual’s drifting away from family may lead to feelings of despair, loneliness, and

insecurity (Karadamar et al., 2014).

Adolescence is an important period in developing knowledge and skills, figuring out how to

control emotions and relationships and acquiring attributes and abilities for adulthood.

Depression in adolescence is a common mental health disease with a prevalence of 4-5% in

mid to late adolescence. It is a significant danger factor for suicide and can also lead to social

and educational impairments. Consequently, recognizing and treating this disorder is

significant. Expects and primary care providers are frequently the first line of contact for

adolescents in times of distress and can be crucial to identify mental health issues amongst

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patients. They can facilitate early identification of depression, initiate treatment and refer the

adolescents for mental health specialists. It is important to make a timely and accurate

diagnosis from other psychiatric disorders, due to the recurrent nature of this condition and its

association with poor academic performance, functional impairment and problematic

relationships with parents, siblings and peers. Moreover, depression at this early age is

strongly related to suicidal ideation and attempts (Beirão et al., 2020).

Depression is a serious effective illness with a high lifetime prevalence rate, in which diet has

been considered as the modifiable element (Stefanska et al., 2017).

The impact of diet and nutrition in the development of adolescent depression has been a

concentration of research throughout the course of recent years. Information from the adult

populace has shown that diet quality is connected with better mental health outcomes. A

contrary relationship likewise has been confirmed between healthy diet and depression

(Samuelson, 2017).

One out of six individuals are aged 10-19 years. Adolescence is a distinctive and

developmental time. Physical, emotional, and social changes, including subjection to poverty,

abuse, or violence, can make adolescents vulnerable to depression (World Health

Organization, 2016)

Worldwide, one in seven 10-19 year-olds encounters a mental disorder, representing 13% of

the global burden of disease in this age group (Abdulkarim & Aluko, 2017).

Depression, Anxiety and behavioral disorders are among the main causes of illness among

adolescents (Samuelson, 2017). Studies about associations between diet and depression have

primarily centered on single nutrients or foods. As of late, dietary patterns representing a

combination of foods have attracted more interest than an individual nutrient (Kaner et al.,

2015).

3
1.2 Problem Statement
Depression is one of the most common mental health disorders.

Around 350 million people suffer from depression worldwide; and this number has grown

significantly in recent years (World Health Organization, 2016).

Currently, one out of ten individuals suffer from major depression, and almost one out of

five has suffered from this disorder at some point in their lifespan (World Health

Organization, 2016).

The adolescent prevalence rate of elevated self-reported depressive symptoms from 2001

to 2020 was found to be 34% according to a global systematic review conducted in 2021

by Shorey et al. (2021).

In Ghana, (Kugbey et al., 2015) found out that 37% of their adolescent respondents

reported moderate to extremely severe depression.

The World Health Organization (2016) approximated that depression will be the second

greatest cause of world disability by 2020 and be the largest contributor to diseases by

2030 (WHO; 2016, Kaner et al., 2015).

According to WHO, there is a belief that children and adolescents are unable to be

diagnosed with depression however, adolescents suffer from anxiety and depression at

alarming rates (World Health Organization, 2016).

Also, the association that exists between diet, nutrition and adolescent depression has

been given less attention.

There have been numerous researches concerning the influence of diet and nutrition in

adult mental health disorders such as anxiety and depression, but not in the adolescent

populations (Samuelson, 2017).

4
 Therefore, it is very important for a research to be conducted among adolescent

population in this regard.

This study therefore seeks to assess the association between depressive status and dietary

consumption pattern among adolescents.

1.3 Significance of study

This study will help assess the effects of depression in adolescent dietary consumption

pattern and also their nutritional status

It will also help propose to organizations that are into adolescent and adolescent welfare to

channel their campaigns to mental health

This study will also create awareness in adolescents about the effect of depression on their

dietary pattern.

1.4 OBJECTIVES
1.4.1 Main objective
 The main objective of the study is to assess the association between depression and

dietary diversity among adolescents.

1.4.2 Specific objectives

1. To assess the prevalence of adolescent depression in Tamale metropolis.

2. To assess the dietary diversity of adolescent in Tamale metropolis.

3. To assess the association between adolescent depression and dietary diversity.

5
 CHAPTER TWO
LITERATURE REVIEW

2.1 Adolescence
The word adolescence comes from the Latin word adolescere — which means to grow up.

However, defining the stage of life that stretches between childhood and adulthood has long

posed a conundrum. At the start of the 20th century, G Stanley Hall loosely defined

adolescence as the developmental period ranging from age 14 to 24 years in his treatise on

adolescence. More than 50 years ago, WHO proposed that adolescence spanned from 10 to

20 years of age (Sawyer et al., 2018).

The term adolescence is universally understood to define the period of life between childhood

and adulthood (Kaplan, 2004). This time frame, however, not only describes a very diverse

reality, but adolescence varies considerably across cultures, over time, and within individuals.

Therefore, one developmental term or stage marked “adolescence” clearly fails to provide the

best frame of reference for this diversely experienced developmental period of life. Western

culture, for example, defines adolescence as the time period from adolescence to age 18 or

21, but non-Western cultures tend to mark the beginning of adulthood with rites of passage

often following the onset of adolescence. These rites mark the end of an individual’s

childhood and his or her acceptance into adult society (Degner, 2004).

Adolescence is a state of rapid growth and development, second only to infancy, with

dramatic biological, psychological changes often shaped by socio-cultural factors. It is

usually grouped into three phases: early adolescence (10–13 years), middle adolescence (15-

17) and late adolescence (18–21 years). Physiologically, the early years are dominated by

pubertal changes and the later stages by sexual maturation and development of adult roles and

responsibilities (Id et al., 2020).

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2.1.1 Physiological Changes in Adolescence
Adolescence is an age which can be termed as the initial step to adulthood after being a child.

This is the age when physical and hormonal changes take place in the body putting improved

demand on it.

From a biologic viewpoint, the commencement of adolescence is marked by the start of

adolescence. The physical changes of adolescence are activated by improved pituitary

sensitivity to gonadotropin-releasing hormone, leading to improved release of gonadal

androgens and estrogens. Hormonal changes bring about a procedure of quick physical

changes in height, weight, body shape, and genital growth (Hazen et al., 2015).

For girls, adolescence characteristically commences between the ages of 8 and 13 years with

the growth of breast buds. Consequent sexual development comprises additional growth of

the breasts; enlargement of ovaries, uterus, labia, and clitoris; and deepening of the vaginal

mucosa. Tanner (2010) described five separate stages of sexual maturation in girls built on

breast development and appearance and dispersal of pubic hair. Menarche typically follows 2

to 2 and half years after breast bud development, around a mean age of 13 years.

On regular, boys delay behind girls in most of the noticeable physical changes of

adolescence. Testicular enlargement, the initial sign of adolescence in boys, naturally begins

around 12 years of age and is followed by growth of pubic hair and development of the penis.

Tanner’s (2010) five stages of sexual maturing in boys are based on the presence of the pubic

hair, penis, and testes.

For both boys and girls, a period of quick growth in height and weight follows the beginning

of adolescence. Growth tends to happen drastically in the hands and feet before moving

proximally to the arms and legs and lastly to the trunk. Linear growth can overtake increased

muscle mass and can occur irregularly, contributive to a period of awkwardness experienced

7
by many adolescents. On average, girls reach their highest growth velocity around 12 years of

age, about 2 years earlier than boys (Hazen et al., 2015).

The age of start of adolescence and the quickness with which the changes unfold differ

substantially. Several recognizable features appear to influence the timing of adolescence,

including health, nutritional status, and society. Rates of advanced adolescence in girls,

defined as the presence of secondary sex characteristics before age 8 years or the start of

menarche before age 9 years, also appear to be increasing. This finding may be due, in part,

to increasing rates of obesity (Hazen et al., 2015).

The effect varies with sex. Early-developing males tend to have better self-confidence and a

better likelihood of academic, social, and athletic success than their peers, mostly when

compared with late-developing males. On the other hand, early pubertal growth in girls seems

to be associated to lower self-esteem and more worries about body image. Unlike boys, late-

developing girls, on average, do not seem to have problems with self-esteem. Even when

these changes unfold on schedule, the physical changes of adolescence have a major effect on

the psychological functioning of an individual. Therefore, irrespective of the timing, it is

important to remain sensitive to how physical growth may be affecting the self-esteem and

emotional life of every adolescent patient (Hazen et al., 2015).

2.1.2 Psychological Changes in Adolescence

Adolescence marks the shift from childhood into adulthood. It is characterized by cognitive,

psychosocial, and emotional development. Cognitive development is the advancement of

thinking from the way a child does to the way an adult does. There are 3 main areas of

cognitive development that occur during adolescence (Sanders, 2013).

First, adolescents develop more progressive reasoning skills, including the ability to explore

a full range of possibilities inherent in a situation, think hypothetically (contrary-fact

situations), and use a logical thought process. Second, adolescents develop the capacity to

8
think abstractly. Adolescents progress from being concrete thinkers, who think of things that

they have contact with or knowledge about, to abstract thinkers, who can imagine things not

seen or experienced. This lets adolescents to have the capacity to love, think about

spirituality, and participate in more progressive mathematics. Adolescent who remain at the

level of a concrete thinker focus generally on physically present or real objects in problem

solving and, as a result, may present with difficulty or frustration with schoolwork as they

transition throughout high school (Sanders, 2013).

Adolescents may also experience a personal fable as a result of being able to think more

abstractly. The personal fable is built on the fact that if the imaginary audience (peers) is

watching and thinking about the adolescent, then the adolescent must be special or different.

For decades, this adolescent egocentrism was thought to add to the personal fable of

invincibility (example, other adolescents will get pregnant or get sexually transmitted

infections) and risk-taking behavior. Several studies have found that adolescents perceive

more risk in certain areas than adults but that being aware of the risks fails to stop adolescents

from partaking in risk-taking behavior. Neuroimaging studies demonstrate that adolescents

may experience greater emotional satisfaction with risk-taking behavior. This satisfaction can

predispose adolescents to engage in behavior despite being aware of risks. In addition,

concrete-thinking adolescents may be unable to understand the consequences of actions

(example, not taking medications), may be unable to link cause and effect in regard to health

behavior (example, smoking, overeating, alcohol, drugs, reckless driving, and early sex), and

may not be prepared to avoid risk (example, having condoms and avoiding riding with

intoxicated drivers). Alternatively, adolescent who feel the personal fable is threatened can

present with stress, depression, or multiple psychosomatic symptom (Sanders, 2013).

Third, the formal operational thinking characteristic of adolescence enables adolescents to

think about thinking or meta-cognition. This characteristic allows adolescent to develop the

9
capacity to think about what they are feeling and how others perceive them. This thought

process, combined with rapid emotional and physical changes that occur during adolescent,

causes most adolescent to think that everyone is thinking not just about what they are

thinking about but about the adolescent themselves (Sanders, 2013).

2.2 Nutritional Needs of Adolescence

Adolescence is a transformative life point, with growth and maturation of all organs and

physiological systems. On average, 10–19 year olds gain 20% of their final adult height and

50% of adult weight during this phase, with a considerable remodeling of the skeleton and an

increase in bone mass of up to 40%. Inevitably, the relation between nutrition and adolescent

development is strong. For example, mostly in girls, iron requirements increase sharply

during adolescence to meet additional needs relating to menstruation. Iron deficiency in

adolescent results in compromised growth, decreased cognitive function, and depressed

immune function. Despite this understanding, iron deficiency anaemia remains prevalent

worldwide, showing little reduction over three decades, and is the third most important cause

of lost disability-adjusted life-years in adolescents (Norris et al., 2022).

Not only are there more adolescents nowadays than at any other time point in human history

but they are also growing up at a time of momentous shift—i.e., rapid urbanization, climate

change, food systems shifting towards foods with an increased caloric and decreased

nutritional value, the COVID-19 pandemic, and growing socioeconomic inequality. The

consequences of these changing contexts have profound impacts on adolescent nutrition and

development. Understanding adolescent biology and its relationship to nutrition is essential

for identifying the best timing and form of action, and for avoiding potentially negative

consequences (Norris et al., 2022).

Though the association between diet and health is a complex one, many research studies have

pointed out the critical connection between them. In general, comprehensive nutritional

10
habits that are established during childhood and adolescence are considered vital for good

growth and development, decrease of chronic disease risk, and long-term quality of life. Diet

can significantly affect the health of adolescents in a number of ways (Massey-stokes, 2016).

Healthy eating patterns in childhood and adolescence boost optimal childhood health, growth,

and intellectual development; prevent immediate health problems, such as reduced capacity

for learning and work. It may also avoid long-term health problems such as iron deficiency

anemia, obesity, eating disorders, dental caries, coronary heart disease, cancer, and stroke

(Abdulkarim & Aluko, 2017).

Adolescents constitute a significant quantity of the world’s population particularly in

developing countries.

According to the World Health Organization (WHO), (2016) dietary recommendations for

individuals and populations should offer adequate energy balance for a healthy weight. Such

diet should include a limited intake of fats, while shifting fat consumption away from

saturated fats to unsaturated fats and removal of trans fatty acids. It should also include

increased eating of fruits and vegetables, legumes, whole-grains and nuts, while limiting the

intake of free sugars and salt (Sodium) consumption. A poor dietary habit may be described

as all dietary behaviours that negate the above-mentioned ideals. Studies in both developed

and developing countries have identify some poor dietary habits namely; skipping breakfast,

increased intake of high calorie snack, eating outside the home, consumption of soft-drink

among adolescents and low consumption of fruits, vegetables and use of supplements.

Dietary habits and choice of food influences nutrient and energy consumption and are

developed over a period especially during adolescence. Nutritional problems among

adolescents can arise from the result of dietary inadequacies, principally from poor dietary

choices, which may be related to physiologic, socioeconomic and psychological factors, in

11
the presence of additional nutritional demands imposed by growth sprout during adolescence

(Abdulkarim & Aluko, 2017).

2.3 Dietary diversity

Nutrition is a major factor of health and development. Dietary diversity (DD) and the amount

of animal source foods that an individual consumes are the two most commonly used

measures for dietary quality. Healthy growth and development basically need a balanced diet

of nutrients and vitamins which includes a variety of foods from different food groups

(vegetables, fruits, grains, and animal source foods) (Belachew et al., 2013).

Dietary Diversity (DD) is the number of different food groups or foods consumed in a given

time. Diverse foods are a good source for both macro and micronutrients and best warrant

nutrient adequacy. Increased risk of malnutrition is linked with dietary factors, and

international and local guidelines advice improving dietary diversity. Therefore, DD is

required to meet energy demands and other essential nutrients, particularly for those at risk

for nutritional deficiencies. Understanding dietary diversity may be a suitable pathway to

evaluate inadequate micronutrient and household level food security, sustainable dietary

practices and food pattern changes. Improving DD has been recommended as one approach to

micronutrient deficiency and food insecurity by the Food and Agriculture Organization

(FAO). Some studies have shown that dietary diversity can bring about a healthy weight,

improve nutritional status, and foster a healthier lifestyle. It has also been shown to improve

food security, and it is associated with high agro biodiversity and high food self-sufficiency.

Although DD is universally acknowledged as an important component of healthy foods, DD

is not yet used as a dimension of diet quality, and there is a lack of consensus to operate and

evaluate it (Lanka, 2020).

Dietary diversity can be measured at the household or individual level via the use of a

questionnaire. Mostly it is measured by counting the number of food groups consumed rather

12
than the food items consumed. At the household level, dietary diversity is usually considered

as a measure of access to food (e.g., of households’ capacity to access costly food groups);

while at the individual level, it is considered as the measure of dietary quality, mainly the

micronutrient adequacy of the diet. Although the reference period can vary, it is most often

the previous day or week (Kennedy, G., Terri, Ballard and MarrieClaude, 2010).

2.4 Depression
The word depression originates from the Latin word “depressio” which means sinking. The

person feels sunk with a weight on their existence. It is a mood condition that differs from

normal transient low mood in daily life itself, to clinical syndrome, with severe and

significant duration and related signs and symptoms, different from normality. Depression

consists of a disease with decayed mood as its main symptomatology. There are also painful

feelings, bad humor, anguish and panic attacks, performance decay of various psychic and

cognitive functions, tendency to isolation, demotivation, difficulty to enjoy, hopelessness,

motor inhibition and negative thoughts, including possible delusions in cases of serious

severity. It is seen as mental disease consisting of a mood illness, being its usual symptom. In

this sense, it is defined as a mental condition characterized by the occurrence of sadness, loss

of pleasure, feelings of guilt and low self-esteem, accompanied with alterations in the sleep

pattern and the appetite, lack of concentration, and feelings of being tired, which can become

chronic and recurrent, making the person dysfunctional in their daily activities (Rondón

Bernard, 2018).

Depression is a common mental illness that presents with depressed mood, loss of interest or

pleasure, feelings of guiltiness or low self-worth, troubled sleep or appetite, low energy, and

poor concentration. These complications can become chronic or persistent and lead to

substantial impairments in an individual's capacity to take care of his or her everyday

responsibilities. At its worst, depression can lead to suicide, a disastrous fatality associated

13
with the loss of about 850 000 lives every year. Depression is the chief cause of disability as

measured by YLDs and the 4th leading contributor to the global burden of disease (DALYs)

in 2000. By the year 2020, depression is expected to reach 2nd place of the standing of

DALYs calculated for all ages, both sexes. Currently, depression is already the 2nd cause of

DALYs in the age group 15-44 years for both genders combined. Depression happens in

persons of all genders, ages, and backgrounds. Depression is a sickness of the brain. There

are a variety of causes, including genetic, environmental, psychological, and biochemical

factors. Depression frequently starts between the ages of 15 and 30, and is much more

common in women. Women can also get postpartum depression after the birth of a baby.

Depression is one part of disorder. There are real treatments for depression, including

antidepressants and talk therapy. Most people do best by using both. Depression is common,

touching about 121 million people worldwide. Depression is among the foremost causes of

disability globally. Depression can be dependably detected and treated in primary care. Fewer

than 25 % of those affected have access to effective treatments. Antidepressant medications

and brief, structured forms of psychotherapy are effective for 60-80 % of those affected and

can be delivered in primary care. However, fewer than 25 % of those affected (in some

countries fewer than 10 %) have such treatments. Barriers to effective care comprise the lack

of resources, lack of trained providers, and the social stigma connected with mental disorders

including depression. Research by 20 different researchers, says depression affects nearly 121

million people universal. It is the second contributor to shorter lifetime for persons in the 15-

44 age groups (Kumar et al., 2020).

2.4.1 Causes of depression

Dissimilar to other illnesses or disorders, there is no simple explanation as to what causes

depression. In general, depression can be as a result of a number of reasons including stresses

which can range from mild to severe, together with vulnerability or predisposition to

depression that can result from biological, genetic or psychological factors. Each type of

14
depression is linked with different mixtures of causes. For psychotic or melancholic

depression, physical and biological factors are significant. In contrast, for non-melancholic

depression, the role of personality and stressful life occasions are important.

There is no particular recognized cause of depression. Rather, it possibly results from a blend

of genetic, biochemical, environmental, and psychological factors. Research point out those

depressive illnesses is illnesses of the brain. Brain-imaging technologies, such as magnetic

resonance imaging (MRI), have indicated that the brains of people who have depression do

not look similar to those of people without depression. The parts of the brain in charge of

regulating mood, thinking, sleep, appetite and behavior appear to function unusually. In

addition, important neurotransmitters—chemicals that brain cells use to communicate—

appear to be out of balance. But these images do not reveal why the depression has happened.

Some types of depression tend to run in families, suggesting a genetic link. Nonetheless,

depression can occur in people without family histories of depression as well. Genetics study

shows that risk for depression results from the effect of multiple genes acting together with

environmental or other factors. In addition, trauma, loss of a loved one, a difficult

relationship, or any stressful situation may activate a depressive disorder. Subsequent

depressive disorders may occur with or without an obvious trigger (National Institute of

Mental Health, 2017).

2.4.2 Effects of depression

In any given year, roughly 20 % of children and adolescents worldwide have mental health

problems, as well as major depressive disorder. Depression has been graded as the second

most common cause of death in adolescents, through suicide. As mental health problems

often start in childhood or adolescence, they are strongly linked with other developmental and

health conditions affecting quality of life, social, academic performance, personality

disorders and substance abuse in adult life (Khanna et al., 2019).

15
The most disturbing effect of depression is death by suicide. Depression does not only leads

15% of its victims to committing suicide, it kills them at a younger age. However, the number

of suicides linked to depression does not truly signify the weight of suffering caused by

depression on society. The number of deaths does not take into consideration the age at which

death occurs. Diseases that kill at a younger age are a bigger public health worry than those

that affect largely older individuals. A major study by WHO, the World Bank and Harvard

University on the Global Burden of Diseases has establish that depression was the fourth

leading cause of disease burden in the 1990s worldwide, comprising fatal or non-fatal cases,

but in terms of death, depression ranked 95th among 107 diseases and injuries included in the

study. To sufficiently represent the true burden of a disease requires an approach that takes

into account: both death and disability, the age at which death or disability occurs, the

duration of disability, and the severity of disability due to disease. Thus, worldwide, the loss

of DALYs from neuropsychiatric disorders is more than 10%, about the same as caused by

cardiovascular diseases, and depression accounted for nearly one-third of all neuropsychiatric

DALYs. Thus, depression causes significant disability in the social and occupational

functioning of the individual. Moreover, caregivers of depressed people may themselves

suffer from impairment in their functioning, adding to the burden of disease in the patient.

Depressed people also tend to suffer more from various medical disorders, and die

prematurely. Thus it has been shown that patients above the age of 55 with depression had a

death rate four times higher than those without depression. Most of these deaths occurred

from heart disease or stroke. Also, depressed people tend to use medical services more often,

as they suffer from various medical disorders from time to time, thus raising the cost of

medical services to the community at large (Khandelwal et al., 2001).

2.4.4 Adolescent Depression

Adolescent depression is growing at an alarming rate (Backman et. al, 2002). In 2015, an

estimated 3 million adolescents in the United States had at least one major depressive

16
disorder in the past year. Lifetime prevalence rates of depression in adolescents are estimated

to range from 15% to 20% equated to adult time rates (Kaminski & Garber, 2002).

Many accept as true that children and adolescents are unable to be diagnosed with these

situations, but adolescents suffer from anxiety and depression at disturbing rates (World

Health Organization, 2016). In the United States, adolescents aged 13-19 years old suffer

from major depressive disorder at a rate of 11.7% (Merikangas, He, Burstein et al., 2010).

Along with anxiety, depression is one of the major contributors to mental health disorders in

adolescents (Kaner et al., 2015).

There is longitudinal evidence from a study (birth-26 years old) that shows that child and

adolescent beginning of depression may be dissimilar from the adult start of depression by

childhood risk factors (Merikangas et. al, 2010). Some of these factors contain developmental

deficits, family dysfunction, instability, psychopathology, criminality in the biological family,

and inhibited or uncontrolled temperaments in childhood. Early start of depression has been

revealed to predict future depressive episodes throughout the lifespan. Depression in

adolescence is typically extensive in duration with a high risk of relapse. Several studies have

shown the average extent of a depressive episode to be 6 to 9 months (Milin, 2003). The

longer the duration of the depressed episode, the higher likelihood of it persisting and

recurring. However, in a study of adolescents where the depressive episodes were short in

nature, the substantial risk of reoccurrence still existed (Beirão et al., 2020).

2.4.5 Causes of Adolescent Depression

The adversity adolescent experience rises dramatically during mid-to-late adolescence,

particularly for girls. Poor interpersonal skills, coupled with bad thought processes, can create

problems for adolescents negotiating changing relationships with peers and families,

searching for independence while trying to fit in, and concurrently trying to succeed in a

competitive academic and social environment (Burns et al., 2002).

17
Cumulative adverse life events can lead right to depression, poor academic attainment and

increased risk-taking behavior. Depressing life events can comprise exposure to family or

community violence, chronic poverty, child physical and sexual abuse, bereavement or

parental divorce or separation (Burns et al., 2002).

Individual cognitive features can influence a person’s interpretation of negative life events.

One theory is that individuals predisposed to depression perceive adverse experiences using

“negative cognitive schemata” (stable memory structures that guide information processing).

Following a negative life event, such as a relationship breakdown, an individual might

describe him- or herself as inadequate, the world as unfair, and the future as hopeless (Burns

et al., 2002).

The “learned helplessness” theory of depression proposes that persons are susceptible to

depression because they have pessimistic attribution to neutral events. For example, during a

basketball game a player might miss a shot. If they have a pessimistic attributional style, they

may believe they missed the shot because they are hopeless. They have accredited this event

to a cause that is internal (self-referent), stable (a personality characteristic), and global

(likely to affect other situations). In contrast, a player who explains the missed goal as a result

of being distracted attributes the failure to a cause that is external, unstable, and specific.

Research shows that a pessimistic attributional style relates with subsequent negative life

events to guess ensuing increases in depressed mood. In general, these findings are valid for

both males and females (Burns et al., 2002).

Parental depression is a risk feature for adolescent depression. Children with a depressed

parent are four times more likely to develop an affective disorder; they have a 40% chance of

experiencing depression by age 20 years, and a 60% chance by age 25 years. Maternal

depression is linked to depression in young individuals after monitoring for other factors,

including socioeconomic status. Prospective studies show that maternal depression may

18
affect girls more significantly than boys. Parental psychopathology has solid support as a risk

factor, but it is uncertain whether this risk is mediated through a biological vulnerability, the

effects of poor parenting caused by that psychopathology or the transmission of attitudes and

values which predispose an individual to later psychiatric disorder. Low self-esteem is often

highlighted as a forecaster of adolescent depression. This claim is supported by longitudinal

research which shows that children who see themselves as academically, socially, or

physically incompetent are more susceptible to subsequent depression than are children who

see themselves as capable. Such beliefs grow during middle childhood and early adolescence,

and rise from evaluations children receive from their peers, teachers or parents and from the

experience of undesirable events. Moderating influences which affect negative beliefs may

not appear until late adolescence or young adulthood (Burns et al., 2002).

Social-skills shortfalls are linked with concurrent depression and with a wide range of other

psychological problems, both in adults and in children. Recent prospective revisions have

shown that negative perceptions about social competence, self-efficacy or peer acceptance

guess symptoms of depression. In contrast, high self-perceived social competence acts as a

protective factor in adolescent who are at bigger risk of depression as a result of negative life

events or parental psychopathology (Burns et al., 2002).

School is an important ground for social and emotional development; however, it can also be

a foundation of negative life events. Poor academic attainment and beliefs about academic

ability, coupled with depression, result in poor school engagement, enhanced perceptions of

school-related stress, and increased problem behaviors. Children aged 5–9 years whom

teachers believe are unpopular and who are rejected or neglected by their peers are more

likely to become depressed during adolescence.

19
In short, adversity and deprivation are risk factors for depression, either directly or because

they cause the negative and pessimistic thinking that turns surmountable negative happenings

into the defeats that produce depression (Burns et al., 2002).

2.5 Adolescent Diet and Depression

Over the past decade, numerous studies have proposed that diet could play an important role

in treatment and prevention of depression. Two main methods have been used to examine this

relationship. A number of studies have explored the impact of individual nutrients such as n-3

fatty acids, vitamins such as B12 and minerals such as Zn, Se and Fe. In addition, numerous

intervention studies have surveyed the effect of supplements containing more than one

nutrient (e.g. multivitamins, EPA and DHA) on mood (Walsh, 2010)

However, the idea of examining individual nutrients to determine whether that single

ingredient is accountable for improving mood is problematic. Mood regulation is predisposed

by a number of different neurochemical pathways (example, serotonin and dopamine), with

each needing several nutrients to supply the metabolites essential for production of the

individual neurotransmitters involved in regulation of mood.

Another approach has been to explore on the effects of whole diet and eating patterns on

mood. In correlational epidemiological studies of adults, an ‘unhealthy’ and ‘Westernized’

diet was linked with an increased possibility of mental disorders and psychiatric distress,

while a ‘healthy’ or ‘good-quality’ diet was associated with well mental health (Khanna et al.,

2019).

However, numerous other factors such as socio-economic status (SES), household income

and educational levels also influence dietary choice, and thus need to be involved as possible

confounders (Khanna et al., 2019).

Given the growth of the brain during childhood and adolescence, and the appearance of

depression during adolescence, the influence of diet on mental health may reasonably be
20
greater during this period than later in life. In addition, adolescents typically become

increasingly autonomous and make more decisions about the type and amount of food they

eat, including ‘junk’ and ‘fast’ foods. Therefore, the association between diet and mental

health in adolescent warrants specific attention (Khalid et al., 2016).

Data from findings of current systematic reviews and meta-analysis completes a significant

evidence of association between unhealthy eating patterns and poor mental health among

children and adolescents. Similarly, high consumptions of fruit, vegetables, fish, and whole

grains may be linked to a reduced depression risk in adults and adherence to a Mediterranean

diet may contribute to the prevention of a sequence of brain diseases.

Research studies connecting diet to psychiatric disorders have, to date, tended to focus on

associations between consumptions of specific nutrients in adolescents and depression and

schizophrenia. The most studied nutrients, and those for which the evidence is strongest, are

omega-3 (n-3) fatty acids and folate/folic acid. Observational and intervention studies show

these nutrients to be little in the foods of persons who are depressed, while supplementation

leads to improvements in symptoms. However, there is rising interest in the possible

importance of diet for maintaining good mental health, and research is beginning to examine

other nutrients, foods, food groups and patterns of eating. Within a few years, the evidence

base for dietary advice for mental health is likely to develop substantially (Bamber et al.,

2007).

21
 CHAPTER THREE
METHODOLOGY

3.1 Study Area

This study was conducted in Tamale metropolis.

The Tamale metropolis is one of the six Metropolitan Assemblies in the country and the only

Metropolis in the five Northern regions namely: Upper East, Upper West and Northern

regions. It is in the central part of the region and shares boundaries with Sagnarigu district to

the west and North, Mion district to the east, East Gonga to the south and central Gonga to

the south-west (GSS, 2010) and has Tamale as its capital. The population of Tamale

Metropolis, according to the 2010 Population and Housing Census (PHC), is 233,252

representing 9.4% of the region’s population.

From the 2010 PHC, the population of adolescents within the ages of 10-19 in Tamale

Metropolis was 46,820. The number of males was 23,555 (50.3%) and the number of females

was 23,265 (49.7%).

Majorities (90.5%) of the population in Tamale Metropolis are Muslims and Christians

constitute only 8.8%. About 0.2% have no religious affiliation. Among the Christians, the

Catholics have the highest proportion of 3.0%, followed by Pentecostal/Charismatic (2.4%)

and Protestants (2.4%).The proportion of Traditionalists in the Metropolis is 0.3%.

According to the 2010 PHC, of persons 3 years and older currently in school in the

Metropolis, about 81.5% are enrolled in basic school (Nursery, kindergarten, primary,

JSS/JHS/), 11.6%t in secondary/senior high school, 0.7% in vocational/technical/commercial

school, and 4.6% in tertiary institutions. There are more males than females enrolled in

almost all the levels of education.

22
The economically active population in the Tamale Metropolis is 63.3% of which 92.6% are

employed and 7.4% are unemployed. The proportion of economically active males is 65.5

percent of which 92.8% are employed and 7.2% are unemployed. For females, economically

active population is 61.1% with 92.3% employed and 7.7% unemployed.

3.2 Study Design

A cross-sectional study was adopted for this study.

3.3 Study Population

The study population comprised of adolescents within the ages 10 to 19 who live in Tamale

Metropolis. Adolescence was categorized into three stages; the early adolescence which

ranges from the ages 10-14, middle adolescence which ranges from the ages 15-18 and late

adolescence which also ranges from the ages 19-21 years.

3.4 Sample Size

The minimum sample size was calculated using the Cochran’s formula for cross-sectional

studies (Israel, 1992).

Z 2 pq
N= 2
d

Where:

P = prevalence of adolescent depression in the world, (37%) according to Kugbey et al.

(2015)

Z = standard normal distribution (1.96)

q = 1- p (1- 0.37)

d = margin of error = 0.05

Then;

23
 1.962 × 0.37 ×0.63
The sample size, N = = 336.6 ≈ 337
0.052

5
Multiplying by 5% = ×337=16.85
100

Therefore, the sample size = 353.85 ≈ 354

However, 419 adolescents participated in the study.

3.5 Sampling procedure

A multi-stage cluster sampling procedure was used for the selection of study respondents

(GDHS, 2014).

This was done in two stages. The first stage was centered on the selection of the study area

and the second stage was on the selection of houses.

For the first stage, 20 communities with the largest population within the Tamale metropolis

was selected and then divided into 4 groups in which each group contained 5 communities.

After which 1 community was selected randomly from each group. The name of each

community was written on a paper and placed in four different bowls according to how they

were grouped. One paper was selected from each bowl and the selected communities became

the study area. The selected communities were Tishigu, Chengli, sabongida, Kukuo.

Table 1: Study area sample size

COMMUNITY SAMPLE SIZE

Changli 75

Kukuo 159

Sabonjida 57

Tishigu 128

24
For the second stage, we identified the center of the community and spin a bottle; the

direction of the spun bottle was then followed to select the required participant from the

community.

3.6 Data Collection

The data collection was conducted using close-ended structured questionnaire.

The first part of the questionnaire was based on the socio-demographic and socio-economic

information which included gender, age, religion, educational background, socio-economic

status, ethnicity, nutritional status, social groups, whom respondents shared trouble with,

number of close friends, family type and residential status of respondents.

With regards to the socio economic status, household assets were assessed by listing some

household items which included; radio, clock\watch, colour TV, black and white TV, sewing

machine, mattress, bed, table, chair, refrigerator, computer, DVD\VCD player, electric fan,

telephone\mobile, bicycle, motorcycle, animal-drawn cart; car\truck and ownership of

livestock and participants were asked to select those they had in their house hold and

principal component analysis was run.

The second part was based on the assessment of adolescent depression. The depression status

was assessed by adopting the 6-item Kutcher adolescent depression scale which was 6

questions and each question had 4 responses (The & Week, 2008). (HARDLY EVER = 0,

MUCH OF THE TIME = 1, MOST OF THE TIME = 2, ALL OF THE TIME = 3).

A 24-hour recall was used to assess the dietary diversity of the respondents. The recall was

conducted to identify the foods consumed by adolescents during the previous day prior to

data collection. Based on the responses given by the respondents, a score of “one” was given

if a respondent consumed food from a particular food group, and a score of “zero” if vice-

versa.

25
The food items used for the collection were based on the food groupings by Food and

Agriculture Organization. The food groups used were cereals, white root and tubers, vitamin

A rich vegetables and tubers, dark green leafy vegetables, other vegetables, vitamin A rich

fruits, other fruits, organ meat, flesh meats, eggs, fish and sea foods, legumes, nuts and seeds,

milk and milk products, oils and fats.

3.7 Data Analysis

Analyses of all data were conducted using SPSS statistical software version 20. Demographic

variables were summarized using frequencies and percentages. Socio-economic status was

also calculated by running a principal component analysis (PCA) to generate a scores. The

scores were broken down into tertiles. All score at 1st tertile were labeled low, 2nd tertile

were labeled as average and 3rd tertiles were labeled high.

With the adolescent depression assessment, the score for the 4 responses of a respondent to

the 6 questions were summed up to form a single total score. A total score that was greater

than or equal to 6 indicated a possible depression and a total score less than 6 indicated no

possible depression for a respondent.

Based on the dietary diversity score, respondents were given a score of ‘0ne’ if he or she

consumed food from a particular group, and a score of ‘zero’ if vice-versa. The sums of all

points were calculated for the dietary diversity score for each individual. The classification of

Dietary Diversity score was obtained from the 14 food groups recommended by FAO. A

scale was established for this distribution: low (1-4), medium, average (5-9) and high (10-14)

(KAL et al., 2016).

Chi-square analysis and fisher’s exact test were conducted to determine the association

between demographic characteristics and depression state. Further binary logistic analyses

were conducted between associated variables and depression.

26
Similarly, chi-square analysis and fisher’s exact test were used to determine the association

between adolescent demographic characteristics, depression state and dietary diversity.

3.8 Ethical Consideration

Ethical clearance was sought from the University for Development Studies (UDS). Consent

was sought from parents, adolescents and teachers (during visitation to basic schools) before

involving them in the study. In seeking consent from the parents and respondents, there was a

brief explanation on the study.

An introductory letter was taken from the Head of Department of Nutritional sciences.

The study was explained to participants and assurance was given to all participants that their

information will be confidential. The names of respondents were not taken during the data

collection in order to ensure anonymity.

27
 CHAPTERE FOUR
RESULTS

4.1 Socio-demographic and socio-economic characteristics

The socio-demographic characteristics of the study respondents are presented in Table 1. The

total number of respondents in this study was 419. Majority (75.2%) of the adolescents lived

in a peri-urban area, 19.8% lived in an urban area and only 5% lived in a rural area.

From the study, 22.4% of the study respondents were in their early adolescence which falls

within the age range of 10-13 years. About 73.5% were in their mid-adolescence thus, the age

ranges of 14-17 years and just a few of them constituting a percentage of 4.1% were in their

late adolescence which also falls within the range of 18-19 years.

Generally, 39.6% were males and 60.4% were females. The most dominant tribe and

religious groups were Dagombas (74.2%) and Islam (84%) respectively. There were minor

ethnic groups classified as others (Buli, Busa, Ewe, Frafra, Fulani, Konkomba, Kotokoli,

Laaba, Sissala and Yoruba).

From the research, majority of the participants were in basic school constituting a total

number of 374. Thirty-four of them were in senior high and 10 out of the total were not

schooling. Only 1 person was at the tertiary level.

More than half (67.5%) of the adolescents lived with both parents, while 16.5% and 14.8%

lived with external family members and mothers only respectively. Those who lived with

their fathers only were 4% and 1% of the adolescent lived with their siblings.

From our analysis, majority (97.4%) of our study participants had more than 1 friend and 11

out of the total population had only 1 friend

28
About 97.3% of the respondents did not belong to any social group while 2.7% belonged to a

social group. Based on our analysis, 191 adolescents from our study population which

constitute the percentage of 45.6% shared their troubles with their family members, also 92 of

them shared their troubles with their friends constituting a percentage of 22%, and a

percentage of 32% do not share their troubles with anyone. It was also observed that 0.2%

shared their troubles with their religious leaders and 0.2% out of the total population also

shared their troubles with their teachers.

According to the study, 26.3% of our study respondents were from a low-income household.

Most of the respondents (68.7%) Sixty-eight came from a household with an average income

whiles 5.0% of the adolescents came from a high-income household.

Table 2: Socio-demographic and socio-economic characteristics

VARIABLES FREQUENCY
Residential status
Urban 83
Peri-urban 315
Rural 21

Age
Early adolescence 94

Middle adolescence 308

Late adolescence 17

Gender
Male 166
Female 253

Ethnicity
Dagomba 311
Moshi 19
Gonja 29
Mamprusi 15
13
Dagaaba
Hausa 4
Akan 9
Others* 19

29
Religion
Christianity 67
Islam 352

Educational status
Not schooling 10
Basic school 374
Sec/voc/technical 34
Tertiary 1

Whom do you live with

Both parents 283
Mother only 62
Father only 4
Siblings 1
External family member(s) 69

Number of close friends

1 friend 10
More than 1 408

Social group
Yes 11
No 408

Trouble sharing
Family member 191
Friends 92
No one 134
Others 2

Social economic status

Low 110
Average 288
*
: Buli, Busa, Ewe, Frafra, Fulani, Konkomba, Kotokoli, Laaba, Sissala and Yoruba

4.2 Prevalence of Adolescent Depression

After calculating for the depression state of the study respondents, it was found out that, the

proportion of adolescents with possible depression was 53% and adolescents with no possible

depression were 47%. This is shown in figure 1.

30
 47%

53%

Possibble depression

No Possible depression

Figure 1: Prevalence of adolescent depression

4.3 Association between respondents’ socio- demographic characteristics, socio-

economic status and depression status
Results from chi-square analysis and fishers exact test of possible predictors of depression

showed that residential status (χ2= 16.878; p < 0.001), gender (χ2= 4.042; p= 0.044), religion

(χ2= 5.154; p= 0.023), family type (p = 0.001), whom an adolescent shares troubles with (p =

0.001) and socio-economic status (χ2= 18.691; p < 0.001) had significant associations with

the depressive status of respondents. This has been shown in table 4 below.

Table 3: Association between socio-demographic characteristics, socio-economic status

of respondents and depression

DEPRESSIVE STATUS
Possible Probably not
depression depressed
Exposure variable n (%) n (%) χ2 (P-value)
Residential status 16.878 (<0.001)
Urban 30 (13.5) 53 (26.9)
Peri-urban 185 (83.3) 130 (66.0)
Rural 7 (3.2) 14 (7.1)

Age 3.979 (0.137)

Early adolescence 42 (18.9) 52 (26.4)
Middle adolescence 169 (76.1) 139 (70.6)
31
 11 (5.0) 6 (3.0)
Late adolescence

Gender 4.043 (0.044)

Male 98 (44.1) 68 (34.5)
Female 124 (55.9) 129 (65.5)

Religious affiliation 5.154 (0.023)

Christianity 44 (19.8) 23 (11.7)
Muslims 178 (80.2) 174 (88.3)

Educational status *0.219

Not schooling 8 (3.6) 2 (1.0)
Basic school 197 (88.7) 177 (89.8)
Sec/Voc/Technical 17 (7.7) 17 (8.6)
Tertiary 0 (0) 1 (0.5)
Whom do you live with *0.001
Both parents 136 (61.3) 147 (74.6)
Mother only 33 (14.9) 29 (14.7)
Father only 2 (0.9) 2 (1)
Siblings 0 (0) 1 (0.5)
External family member(s) 51 (23) 18 (9.1)

Number of close friends *0.100

1 friend 5 (2.3) 5 (2.6)
More than 1 217 (97.7) 191 (97.4)

Social group *0.550

Yes 5 (2.3) 6 (3)

No 217 (97.7) 191 (96.9)

Trouble sharing *<0.001

Family member 62 (27.9) 129 (65.5)
Friends 64 (28.8) 28 (14.2)
No one 95 (42.8) 39 (19.8)
Others 1 (0.5) 1 (0.5)

Socio-economic status
Low 76 34 18.691 (<0.001)
Average 140 148
High 6 15

32
n: Sample size. χ2: Chi-square statistic. Emboldened p-value: p<0.05. *: p-value from fisher’s exact test.

4.3.1 Determinants of depressive status

The results of the determinants of depressive status are shown in Table 4.1.

Binary logistic regression analysis showed that those who lived with a particular family type

and those who shared their troubles with others were consistently significant in their

association with depression status. Respondents that lived with external family members were

(AOR= 2.195, p= 0.017) were 2 times likely to be possibly depressed compared to those who

lived with both parents.

With reference to respondents who shared their troubles with a family member, those who

shared their troubles with friends were 4 times (AOR= 3.637, p = <0.001) more likely to be

possibly depressed.

Similarly, those who shared their troubles with no one were 4 times (AOR= 3.579, P<0.001)

more likely to be possibly depressed compared to those who share their troubles with a

family member.

Table 4: Determinants of depressive status

POSSIBLE DEPRESSION

Variable AOR (95% CI) p-value

Residential status

Urban* 1

Peri-urban 1.541 (0.875 – 2.712) 0.134

Rural 0.858 (0.278 – 2.645) 0.790

33
Gender

Female* 1

Male 0.740 (0.476 – 1.151) 0.181

Religious affiliation

Islam* 1

Christianity 1.296 (0.704 – 2.285) 0.405

Whom do you live with

Both parents* 1

Mother only 1.145 (0.621 – 2.112) 0.665

Father only 0.821 (0.098 – 6.851) 0.856

Siblings 0.000 (0.000 -) 1.000

External family member(s) 2.195 (1.151 – 4.1866) 0.017

Trouble sharing

Family member* 1

Friends 3.637 (2.056 – 6.434) <0.001

Others 2.618 (0.146 – 47.028) 0.515

No one 3.576 (2.134 – 5.992) <0.001

Socio-economic status

High* 1

Low 3.004 (0.998 – 9.044) 0.050

Average 1.452 (0.514 – 4.103) 0.482

AOR: Adjusted Odds Ratio. CI: Confidence Interval. *: reference. Emboldened p-value: p<0.05.

34
4.4 Assessment of dietary diversity of respondents
From our study, we found out that majority (90.2%) of our respondents had an average

diverse diet while those who had low and high diverse diets were 7.6% and 2.1% respectively

(Table 5)

Table 5: Dietary diversity of respondents

DIETARY DIVERSITY FREQUENCY

Low 32

Average 378

High 9

Also, frequency of consumption from the food groups is shown in figure 2.

The food groups most consumed by our respondents were cereals (99.3%), other vegetables

(74.7%), oils and fats (83.5%), eggs (56.3%), flesh meats (46.3%) at the expense of fish and

sea foods (23.2%), vitamin A rich fruits (18.6%), other fruits among (22.7%) others.

35
 Oil and fats

Milk and milk products

Legumes, nuts and seeds

Fish and sea food

Eggs

Flesh meat

Organ meat

Other fruits

Vitamin A rich fruits

Other vegetables

Dark green leafy vegetables

Vitamin A rich vegetables and tubers

White roots and tubers

Cereals
0 50 100 150 200 250

Non-depressed Depressed

Figure 2: Frequency of food consumption

4.5Association between adolescent’s socio-demographic, socio-economic status and

dietary diversity
In Table 7 below, only the socio-economic (χ 2 = 6.201; p = 0.045) background of

respondents had significant association with dietary diversity.

There was significant association between depression status of adolescents and dietary

diversity.

Table 6: Association between adolescents’ socio-demographic, socio-economic,

depressive status and dietary diversity

DIETARY DIVERSITY
Diverse foods No diverse food
Exposure variable n (%) n (%) χ2 (p-value)
Residential status 1.404 (0.496)
Urban 52 (18.8) 31 (21.8)
Peri-urban 209 (75.5) 106 (74.6)
36
Rural 16 (5.8) 5 (3.5)

Age 1.208 (0.546)

Early adolescence 66 (23.8) 28 (19.7)
Middle adolescence 201 (72.6) 107 (75.4)
Late adolescence 10 (3.6) 7 (4.9)

Gender 0.227 (0.634)

Male 112 (40.4) 54 (38)
Female 165 (59.6) 88 (62)

Religious affiliation 1.089 (0.297)

Christianity 48 (17.3) 19 (13.4)
Muslims 229 (82.7) 123 (86.6)

Educational status *0.575

Not schooling 5 (50) 5 (50)
Basic school 250 (66.8) 124 (33.2)
Sec/Voc/Technical 21 (61.8) 13 (38.2)
Tertiary 1 (100) 0 (0)

Whom do you live with *0.377

Both parents 180 (63.6) 103 (36.4)
Mother only 46 (74.2) 16 (25.8)
Father only 2 (50) 2 (50)
Siblings 1 (100) 0 (0)
External family member(s) 48 (69.6) 31 (30.4)

Number of close friends *1.000

1 friend 7 (2.5) 3 (2.1)
More than 1 269 (97.5) 139 (97.9)

*0.070
Social group
Yes 4 (36.4) 7 (63.6)
No 273 (66.8) 135 (33.2)

Trouble sharing *0.206

Family member 117 (42.2) 74 (52.1)
Friends 65 (23.5) 27 (19.0)
No one 94 (33.1) 40 (28.2)
Others 1 (0.4) 1 (0.7)

Socio-economic status
37
Low 78 (28.2) 32 (22.5) 6.201 (0.045)
Average 190 (68.6) 98 (69)
High 9 (3.2) 12 (8.5)

Depression 0.606 (0.436)

Possible depression 143 (51.6) 79 (55.6)
Probably not depressed 134 (48.4) 63 (44.4)

n: Sample size. χ2: Chi-square statistic. *: p-value from fisher’s exact test. Emboldened-value: p<0.05.

38
 CHAPTER 5
DISCUSSION

5.1 Prevalence of adolescent Depression

According to World Health Organization 2016, depression is a mental disorder that people of

all ages can be diagnosed with but many people are of the believe that adolescents cannot

suffer from depression and only adults can be diagnosed with the depression.

According to a study conducted in the United states by Merikanga et al., adolescents aged 13-

19 years are diagnosed with major depressive disorder at a rate of 11.7%.

From our study, we found out that adolescents can also be diagnosed with depression and

more than half were possibly depressed. The rate at which adolescents suffer from depression

is alarming. Depression in adolescent is increasing probably because of the believe that

adolescents cannot be diagnosed with depression and little attention has been given to it.

However, according to World health organization, by 2030, depression will be the second

most prominent cause of world disability and it is expected to be the largest contributor to

disease of which adolescents are not isolated. This shows attention need to be channeled to

adolescents as well because they are vulnerable

5.2 Association between adolescents’ socio-demographic characteristics, socio-economic

status and depression
Generally, this study showed that there is a strong positive association between residential

status and depression. This means that the area a respondent lives determines his/her

possibility of being depressed. For example, respondents that live in a peri-urban area are

more likely to be depressed than those in urban areas.

Depression frequently starts between the ages of 15 and 30, and is much more common in

women (Kumar et al., 2020). This has manifested in the current study where female

39
respondents were more likely to be depressed compared to males respondents. This might be

as a result of the different physiological set up of males and females.

Also, the religion of respondents and their possibility of being depressed showed a positive

association. This means that religion has an influence on the depressive status of adolescents.

Per the results from the study stud, respondents who were Muslims and Christians had a

significant association with depression. Religious people are mostly told that, whatever

happens in their lives is ordained by God and they should pray to God in every situation. As a

result of this, situations they even need to speak up, they don’t and keep it to themselves

which may result in them being depressed. This might not be entirely true thou.

A significant association was also recorded between the type of family a respondent live with

and depression. This shows that the type of family a respondent live with has influence on

one being depressed. According to Burns (2002), parental depression is a risk feature for

adolescent depression. Children with a depressed parent are four times more likely to develop

a depressive disorder. However, contrary to Burns assertion, the finding from the study

showed that respondent who rather lived with external family member(s) were more likely to

be depressed compared to those who live with both parents. This could be as a result of

inadequate attention. Moreover, our study was not centered on whether the family type they

lived with is depressed or not.

Furthermore, there was a significant association between adolescents who shared their

troubles and depression. This shows that, the person the adolescent shares his or her troubles

with, influences their possibility of being depressed. Also, from our analysis, respondents

who do not share their problems with anyone and those who share their problems with friends

are more likely to be depressed compared to those who share their trouble with family

members. This could be as a result of bad peer influence on the side of those who shared their

troubles with their peers. However, this may not be entirely true. Those who did not share

40
their troubles with anyone might have also end up taking the wrong decision which may have

resulted to them being depressed

Lastly, a significant association was recorded between respondents’ family socio-economic

status and depression. From the study, it showed that those from average and low socio-

economic background were more likely to be depressed compared to those whose family

income was high. This might be because, respondents from high income family get whatever

they want or ask for while respondents from average and low income family might not get

whatever they ask for and might end up into thinking on how to impress their friends without

what they asked for and might lead to depression.

5.3 Dietary Diversity

According to Lanka (2020), dietary diversity is the consumption of different number of food

groups in a given period of time.

According to Kennedy, G., Terri, Ballard and MarrieClaude (2010) dietary diversity is

measured by counting the number of food groups consumed and not food items.

In determining whether a respondent had a diverse food or not, we summed up the food

groups consumed by a respondent and grouped them as having low, average or high diverse

food.

From the study, it showed that majority (90.2%) of the respondents had an average diverse

diet while those who had low and high diverse diets were 7.6% and 2.1% respectively. This

could be as a result of majority of the respondents coming from an average socio-economic

background and very little are from the low and high socio-economic background.

The higher your socio-economic status, the more likely you are to purchase quality and

diverse food and vice-versa.

41
5.4 Association between adolescent’s socio-demographic, socio-economic, depression
and dietary diversity
According to Khalid et al (2016), factors such as socio-economic status, household income

and educational levels also influence dietary choice.

This study has also shown a positive association between respondents’ family’s socio-

economic status and dietary diversity. This means that socio-economic status of a

respondent’s family determines his/her ability to consume diverse food. The ability to buy

and eat quality and diverse food obviously depends on ones’ economic status so therefore it is

quiet not surprising there is an association between socio-economic status and dietary

diversity. This might be as result of the age category we chose, mostly at this stage, what you

eat is determined by your parent.

However, the depressive status of study respondents lost at the bivariate analyses stage.

42
 CHAPTER SIX
CONCLUSION AND RECOMMENDATION

6.1 Conclusion
The study assessed the association between depression and dietary consumption pattern

among adolescents in the Tamale metropolis.

The study showed a higher prevalence of depression among adolescents within the study area

and majority of them being females.

The study showed a significant association between residential status, gender, religion, family

type , whom an adolescent shares troubles with, socio-economic status and depression status

of respondents. Also some factors were found to contribute to the development of depression

among respondents with some of the factors being residential status, family type and socio-

economic status among others.

The study indicated no association between adolescent depression and consumption of

diverse diet.

6.2 Recommendation
From the study, it is recommended that, adolescents are encouraged to share their troubles

with guardians.

Also, guardians taking care of adolescents are encouraged to give enough attention to them to

prevent the onset of depression among adolescents.

Furthermore, World Health Organization (WHO), Non-Governmental Organizations (NGOs)

and other community based organizations should channel their campaigns toward adolescent

mental health awareness.

Also, it is recommended for similar studies to be conducted among adolescents in other

localities for more knowledge and understanding to be gained on this topic.

43
Further research should also be conducted on the association between the weight of food

intake of adolescents and depression.

44
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48
 APPENDIX
INFORMATION SHEET

We are students at the University for Development Studies undertaking research on

“Association between Adolescent Depression and Dietary Diversity in Tamale Metropolis”.
You have been selected to participate in this study. We have a set of questions and would be
grateful if you could answer them to get views on the subject. We wish to assure you that
your responses and experiences shared in this study would be kept anonymous and
confidential. Your participation in this study is voluntary and any information requested is
purely for academic purposes. We are most grateful.

INFORMED CONSENT

I have had details of the study explained to me and questions have been answered to my
satisfaction; I understand and may ask further questions.

I have decided to be part of the study on condition that under no circumstances should any
reference to my actual identity be made known to persons outside this study as promised by
the researcher.

Respondent’s signature/Thumbprint ……………...... Researcher’s

signature………………

Date of interview:………………………………..

49
Code:………………………………………………

SECTION A: SOCIO-DEMOGRAPHIC
Kindly tick the appropriate answer

1. Respondents’ residential status.

 Urban
 Peri-urban
 Rural

2. What is your gender?

 Male
 Female
3. What is your age? (Kindly write the number)
…………………………

4. Which ethnic group do you belong to?

 Dagomba
 Moshi
 Gonja
 Mamprusi
 Dagaaba
 Hausa
 Akan
 Others (specify……………………)
5. What is your religious affiliation?
 Christianity
 Islam
 Traditionalist
 Other (Specify)………………………….
6. What is your schooling status?
 Not schooling
 Basic school
 Secondary/Vocational/Technical school
 Tertiary school
7. How many members are in your household?

……………………………….
8. Whom do you live with?
 Both parents
 Mother only
 Father only
 Siblings
50
  External family member (s)
9. How many close friends do you have?
……………………………………..
10. Do you belong to any social group?
 Yes
 No
11. Whom do you share your troubles with?
 Family member
 Friends
 Teacher
 Religious leader
 Counsellor
 No one
12. Height (cm)
………………………….
13. Weight (kg)
……………………………...

Socio-economic characteristics

Kindly tick appropriate answer

14. What type of house do members of the household dwell in?

 Blockhouse
 Brickhouse
 Mud house
15. What kind of toilet facility do members of the household usually use?
 Own flush toilet
 Own pit toilet
 Public or shared pit toilet
 No facility
16. What is the source of lighting for the household?
 Electricity
 Gas
 Kerosene
17. What type of fuel does your household mainly use for cooking?
 Electricity
 LPG
 Charcoal
 Kerosene
 Firewood
18. What is the main source of drinking water for members of the household?
 Pipe water
 Borehole
51
  Dug well
 Bottle/Sachet water
19. Does your household have any of these assets? Kindly tick the appropriate answer.
Radio Yes No
Clock or watch
Colour TV
Black and white TV
Sewing Machine
Mattress
Bed
Table
Chair
Refrigerator
Computer
DVD/VCD player
Electric Fan
Telephone/mobile
Bicycle
Motorcycle
Animal-drawn cart
Car/truck
Ownership of livestock

SECTION TWO: Depression status

Over the last week, how have you been “on average” or “usually” regarding the
following? Kindly tick the appropriate answer.

1. Low mood, sadness, feeling blah or down, depressed, just can't be bothered.
 Hardly ever
 Much of the time
 Most of the time
 All the time
2. Feelings of worthlessness, hopelessness, letting people down, not being a good
person.
 Hardly ever
 Much of the time
 Most of the time
 All the time
3. Feeling tired, feeling fatigued, low in energy, hard to get motivated, have to push to
get things done, want to rest or lie down a lot
 Hardly ever
 Much of the time
 Most of the time
 All the time
52
4. Feeling that life is not very much fun, not feeling good when usually would feel good,
not getting as much pleasure from fun things as usual.
 Hardly ever
 Much of the time
 Most of the time
 All the time

5. Feeling worried, nervous, panicky, tense, keyed up, anxious.

 Hardly ever
 Much of the time
 Most of the time
 All the time
6. Thoughts, plans or actions about suicide or self-harm.
 Hardly ever
 Much of the time
 Most of the time
 All the time

53
 SECTION THREE: DIETARY ASSESSMENT OF RESPONDENTS

DIETARY DIVERSITY QUESTIONNAIRE

Please describe the foods (meals and snacks) that you ate or drunk yesterday during the day and
night, whether at home or outside the home. Start with the first food or drink of the evening.

… before breakfast?

… for breakfast?

… between breakfast and

lunch?

… for lunch?

… between lunch and

dinner?

… for dinner?

… after dinner?

During the last day or night,

did you eat any fruit, If yes, specify:
vegetables, or snacks which …………………………………………………..

54
you did not mention?

This section must be field by enumerator using the field 24 hr recall:

Question YES=1
number Food group Examples NO=0
1 CEREALS corn/maize, rice, wheat, sorghum, millet
or any other grains or foods made from
these (e.g. bread, noodles, porridge or
other grain products) + insert local foods
e.g. ugali, nshima, porridge or paste
2 WHITE ROOTS white potatoes, white yam, white cassava,
AND TUBERS or other foods made from roots
3 VITAMIN A pumpkin, carrot, squash, or sweet
RICH potato that are orange inside + other
VEGETABLES locally available vitamin A rich
AND TUBERS vegetables (e.g. red sweet pepper)
4 DARK GREEN dark green leafy vegetables, including
LEAFY wild forms + locally available vitamin A
VEGETABLES rich leaves such as amaranth, cassava
leaves, kale, spinach
5 OTHER other vegetables (e.g. tomato, onion,
VEGETABL eggplant) + other locally available
ES vegetables
6 VITAMIN A ripe mango, cantaloupe, apricot (fresh or
RICH FRUITS dried), ripe papaya, dried peach, and 100%
fruit juice made from these + other locally
available vitamin A rich fruits
7 OTHER other fruits, including wild fruits and
FRUITS 100% fruit juice made from these
8 ORGAN liver, kidney, heart or other organ meats
MEAT or blood-based foods
9 FLESH MEATS beef, pork, lamb, goat, rabbit, game,
chicken, duck, other birds, insects
10 EGGS eggs from chicken, duck, guinea fowl
or any other egg
11 FISH fresh or dried fish or shellfish
AND
SEAFOO
D
12 LEGUMES, dried beans, dried peas, lentils, nuts, seeds
NUTS AND or foods made from these (eg. hummus,
SEEDS peanut butter)
13 MILK AND milk, cheese, yogurt or other milk

55
 MILK products
PRODUCTS
14 OILS AND oil, fats or butter added to food or used
FATS for cooking
15 SWEETS sugar, honey, sweetened soda or
sweetened juice drinks, sugary foods
such as chocolates, candies, cookies and
cakes
16 SPICES, spices (black pepper, salt), condiments
CONDIMENTS (soy sauce, hot sauce), coffee, tea,
BEVERAGES alcoholic beverages
17 Did you eat anything (meal or snack) OUTSIDE the home
yesterday?

56