STRESS, ANXIETY AND DEPRESSION AMONG

ADOLESCENTS IN SECONDARY SCHOOL BUTWAL

By:

Poonam Rana

MN 2nd year, 10th Batch

Research Proposal Submitted For The Partial Fulfillment Of The Requirements Of

Masters Of Nursing Program From National Medical College Affiliated To Tribhuvan
University.

July, 2023
 CHAPTER I

INTRODUCTION

1.1 Background of the Study

Mental health is a state of mental well-being that enables people to cope with the stresses of life,
realize their abilities, learn well and work well, and contribute to their community. Mental health
is a basic human right and it is crucial to personal, community and socio-economic development
(WHO, 2022)

Adolescence is the period of transition from childhood to adulthood. They fall between 10 to 19
years of age. It denotes a unique stage of development of human and crucial time of laying the
foundations of a good health. They experience growth in all the aspects such as physical,
cognitive and psychosocial, which affects the way they feel, think, perceive, make decisions and
interact with others (WHO, 2022).

Worldwide, an estimated 1.2 billion individuals are adolescents which comprise16 percent of the
world’s population (UNICEF 2018). In Nepal, adolescents cover 23.62 % of total population
(MoPE, 2018)

Adolescence is a period of life with specific health and developmental needs and rights. The
transitions happening during this stage also carry significant new and critical risks but are also
associated with opportunities to positively influence the immediate and future health of young
people. It is also a time to develop knowledge and skills, learn to manage emotions and
relationships, and acquire attributes and abilities that will be important for enjoying the
adolescent years and assuming adult roles (Paras Health, 2022)
Stress is a response to external challenges, like deadlines or difficult decisions. Stress is part of
life. It can sometimes be positive and help with motivation. Too much stress can be
overwhelming. It can make it hard for pre-teens and teenagers to enjoy life. Help pre-teens and
teenagers manage stress by listening and talking, spending time together, and encouraging
healthy lifestyle choices (Rising children)

Stress is an unpleasant subjective feeling perceived when an individual’s situational demands

exceed their adaptive capacity. Psychological stress can also precipitate adverse mental health
outcomes such as anxiety, depression and suicidal ideations. Adolescence is a period of increased
stress perception and reactivity. Various studies suggest rising prevalence of stress among
adolescents and its increasing influence on adolescent health (Krishnaveni et al., 2021)

Anxiety is a common and natural emotion, but it can also cause physical symptoms, such as
shaking and sweating. Anxiety disorders can affect daily life but can often improve with
treatment. According to the Anxiety and Depression Association of America (ADAA), around 40
million people in the United States have an anxiety disorder. It is the most common group of
mental illnesses in the country. However, only 36.9% of people with an anxiety disorder receive
treatment. The American Psychological Association (APA) anxiety an emotion characterized by
feelings of tension, worried thoughts, and physical changes like increased blood pressure.
“Knowing the difference between typical feelings of anxiety and an anxiety disorder requiring
medical attention can help a person identify and treat the condition (Medical News Today)

Depression is a common mental disorder, characterized by persistent sadness and a loss of

interest in activities that you normally enjoy, accompanied by an inability to carry out daily
activities, for at least two weeks. Anxiety is an emotion characterized by feeling of tension,
worried thoughts and physical change like increased blood pressure. People with anxiety
disorders usually have recurring intrusive thoughts or concerns (WHO, 2019)
Adolescents frequently have to cope with various stressors including physical and sexual
changes related to puberty, school life demands, problems with initiating and maintaining
friendships and romantic relationships, career choice and beginnings of their working life, and a
gradual independence from their families that could be potential threats to their healthy
development and well-being. Most important mental health consequences of stress in
adolescence, such as depression, anxiety, suicide, substance use, and antisocial behavior are
reviewed (Krapić et al., 2015)

Depression has been the most common mental illness among adolescents aged 10–19 in South
Korea since 2018. Data from the Health Insurance Review and Assessment Service revealed that
the number of depressed patients aged 10–19 increased by approximately 40,000 in 2020
compared to 2016. Depression in adolescence affects delinquent behavior, school dropout,
suicidal ideation, and suicidal impulses. It is also a major predictor of depression in adulthood
(Lim & Kwon, 2023)

Adolescents with elevated stress levels have been found to indulge in a variety of maladaptive
and harmful activities, such as increased alcohol and substance use, unprotected sexual
intercourse, physical inactivity, unhealthy eating habits, and poor sleep hygiene. Studies have
shown that Indian adolescents face additional stressors from cultural influences, such as strong
parental expectations, constrictive living arrangements, social hierarchies, and academic
concerns, to name just a few (Anjum et al., 2022).

A cross-sectional study was conducted on anxiety among secondary school adolescents of

Bharatpur metropolitan city, Chitwan. Systematic sampling technique was used to select 388
higher secondary school adolescents of grade 11 and 12. Among total participants 30.7% had
anxiety symptoms in which 19.9 % had mild anxiety, 7.6% had moderate anxiety and 3.2% had
severe anxiety .Marital status of parents (p= <0.001) ongoing health problems (<0.001), history
of mental illness (<0.001), marital status (p=<0.04) and gender p=(0.015) of respondent were
found to have association with anxiety (Pokharel, Chapagain & Shrestha, 2022).

Negative feelings like depression, anxiety, and stress are among the most common mental health
problems. According to the American Psychiatric Association and the DMS-5 Depression is a
common and serious medical illness that negatively affects how you feel, the way you think and
how you act .Depression has been known as the first mental health priority among adolescents
due to its high prevalence, recurrence, and ability to cause significant impairment. On the other
hand, stress is a challenge or threat to well-being. It is a process in which environmental
demands exceed an organism’s adaptation capacity, lead to mental and biological changes, and
expose people to risks. Stress is an essential part of life because its persistence may lead to
various psychological problems such as involvement in high-risk behaviors. In comparison,
anxiety is a natural reaction to stress. It can be a beneficial implication that often alerts us in
dangerous situations, thereby increasing our readiness to act promptly. Nevertheless, anxiety
disorders are different from feelings of nervousness or anxiousness and entail extreme fear or
anxiety (Hoseini-Esfidarjani et al., 2022)

Mental health conditions are a major burden of disease for adolescents

in China. According to a recent national study of mental health, almost
25 per cent of adolescents reported feeling mild or severe depression. It
is estimated that at least 30 million children and adolescents under 17
years of age in China struggle with emotional or behavioural problems.

Globally, one in seven 10-19-year-olds experiences a mental disorder, accounting for 13% of the
global burden of disease in this age group. Depression, anxiety and stress are among the leading
causes of illness and disability among adolescents .Suicide is the fourth leading cause of death
among 15-29 year-olds. It is estimated that 4.6% of 15–19-year-olds experience an anxiety
disorder. Depression is estimated to occur among 1.1% of adolescents aged 10–14 years, and
2.8% of 15–19-year-olds. Depression and anxiety share some of the same symptoms, including
rapid and unexpected changes in mood. The consequences of failing to address adolescent
mental health conditions extend to adulthood, impairing both physical and mental health and
limiting opportunities to lead fulfilling lives as adults. (WHO, adolescent-mental-health 2021).
In Nepal, 40% of the population is younger than 18 years of age, and as such there is a large
proportion of the population that is at risk of developing a mental disorder. There has been a
recent recognition of child and adolescent mental health problems in Nepal, although prior to this
it had remained almost invisible on the health agenda. In response to growing concern, there is a
need to conduct a review on children and adolescent mental health problems in Nepal
(Chaulagain et al., 2019).

Descriptive cross-sectional study was conducted on Stress, anxiety, and depression among
adolescent students of public schools in Kathmandu. The study included 411 adolescent students
aged 14 to 19 years from six randomly selected public schools of Kathmandu Metropolitan City.
Depression, Anxiety and Stress Scale 21(DASS-21) was administered to the students to identify
the prevalence of depression, anxiety, and stress. Logistic regression analysis was performed to
find out the associated factors of stress, anxiety, and depression. The prevalence of stress,
anxiety, and depression was 27.5%, 56.9% and 41.6% respectively. Factors associated with
stress were being female, high academic pressure, and abuse. The factor associated with anxiety
was high academic pressure and factors associated with depression were being female, high
academic pressure and witnessed/exposed to domestic violence (Choulagai & Professor, 2020).

Descriptive cross-sectional study conducted in the month of July 2018 in an urban school in New
Delhi. A semi-structured, self-administered questionnaire to assess socio-demographic profile as
well as depression anxiety stress scale (DASS)–21 was used to assess depression, stress and
anxiety. Overall prevalence of depression, anxiety and stress were found to be 47.9%, 65.3%,
and 51.8% respectively. Most of student suffered from moderate depression (46.8%), anxiety
(33.3%) and mild stress (60.9%). It was noted that these were more common among female
students, late adolescent age group, students alone/ away from family, students from separated/
single parents, consuming alcohol and family pressure to perform well in school (Kumar,
Yadav,Chauhan & Bodat, 2019)

1.2 Problem Statement

High school education is an important turning point in the life of academic students in Nepal. As
the educational system become more specialized and tough in high school, the student become
more likely to experience stress at this level. This may put them at risk of developing common
mental disorders such as stress, anxiety and depression. There is very few research conducted on
stress, anxiety depression among school adolescents particularly in developing countries such as
Nepal.

Exploring the magnitude and risk factors of symptoms of stress, anxiety and depression are

very crucial to combat the burden of adolescent mental health issues . However there is a limited
access to psychological and psychiatric services as well as the significant social stigma
associated with mental health issue stress, anxiety and depression in early adolescent frequently
go undiagnosed and untreated in Nepal .

In Nepal, the burden of depression and anxiety disorders in terms of morbidity and disability are
overwhelmingly high and have the second-highest prevalence rate 301 per 1,000 of psychiatric
morbidity in comparison to other South Asian countries. Depressive and anxiety disorders are the
most frequent mental disorders and are ranked among the top conditions causing disability
worldwide (Bhatta et al., 2021).

In the USA and Australia, one in five teenagers suffers from mental health problems. In
developing countries, the prevalence of mental disorders among adolescents attending primary
health-care facilities ranges between 12% and 29%. Several studies indicate that the prevalence
rates of the individual disorders: Depression, anxiety, and stress (DAS) are growing among
adolescents (Institute for Health Metrics and Evaluation, 2013).

Prevalence rates of anxiety and depression in adolescence are rising markedly, especially in early
adolescence. At age 14, around 38% of youth in a general population have developed an anxiety
disorder and 3.1% a depressive disorder at least once in their lives. Worldwide prevalence rates
among children and adolescents are 6.5% for any anxiety disorder and 2.6% for any depressive
disorder (Polanczyk , Salum , Sugaya , Caye and Rohde, 2015)
Globally, an estimated 300 million people are affected by depression .Evidences show that
depression is considered a major risk factor for increasing premature death among adolescent.
Adolescent depressive symptoms are emerging as a public health problem, mostly in developed
countries as well as in developing countries. Depression often starts in young age and has
negative consequences in adolescent’s health. The highest prevalence of adolescent suicide is
evidenced in Southeast Asia and Eastern Europe. It can be persistent, comprehensively impairing
adolescent’s ability to function at work or school and to cope with daily life. Literatures have
revealed that sleeping disorder may cause psychiatric disorders and psychological stress leading
to acute and chronic depression. Sleep deprivation in adolescence period is a risk for depression
and suicide and increased substance abuse (Gautam et al., 2021)

Cross-sectional study was conducted on Prevalence and associated factors of depression, anxiety,
and stress among high school students in, Northwest Ethiopia, 2021. A simple random sampling
technique was used to select 849 participants from six high schools in Northwest Ethiopia The
prevalence of depression, anxiety, and stress was 41.4, 66.7, and 52.2% respectively (Nakie et
al., 2022).

1.3 Objective of the Study

General Objective

To assess stress, anxiety, depression and its associated factors among adolescent in secondary
school, Butwal-4 Rupandehi.

Specific Objectives

To assess the level of stress among adolescents.

To assess the level of anxiety among adolescents.
To assess the level of depression among adolescents.
To identify the association of stress with selected demographic variables among adolescents.
To identify the association of anxiety with selected demographic variables among adolescents.
To identify the association of depression with selected demographic variables among
adolescents.
To determine factors associated with stress, anxiety, depression among adolescents.

1.4 Significance of the Study

The finding of the study will be helpful to assess the level stress, anxiety, depression among
adolescent in secondary school, Butwal.
Study will be helpful to manage stress, anxiety, depression among the adolescents by
formulating appropriate policy in local level for managing stress, anxiety and depression
problem in the schools.
The finding of the study will be helpful for school, teacher, parents, and students in providing
support, planning various counseling programs to promote mental health.
Understanding the prevalence of stress, anxiety, depression among adolescents is an essential
component of a sound public policy for the provision of mental health services.
The findings of the study will be helpful to provide baseline data for the future researcher.

1.5 Research Questions

What is the level of stress, anxiety, depression among adolescent?

Is there is association of stress, anxiety, depression with socio- demographic variables?

Is there is association of stress, anxiety, depression with selected variables?

 1.6 Conceptual Framework
Socio-demographic Variables
Age
Sex
Ethnicity
Religion
Family type Normal
de
Grade
Educational status of father

Educational status of mother

 Stress
Occupation status of father  Anxiety Mild
 Depression
Occupation status of mother

Monthly income

Moderate

Severe

Extremely severe

Associated factors
Socialization
Bullied electronically, school
Result in last examination
1.7 Variables

Independent Variables

Age

Sex

Ethnicity

Religion

Family type

Grade

Faculty

Educational status of father

Educational status of mother

Occupation status of father

Occupation status of mother

Monthly income

Socialization

Bullied electronically, school

Result in last examination

Family pressure to perform well in school

Current place of residence

Parent status

Severe events in family within 1 year

Dependent variables

Stress

Anxiety

Depression

1.8 Operational Definitions

Depression

Depression is a mental disorder which consists of certain characteristics such as; depressed
mood, loss of interest, low self-worth, disturbed appetite and concentration.
Level of depression distinguished by DASS21 scale.

Normal (0–9)

Mild (10–13)

Moderate depression (14–20)

Severe depression (21–27)

Extremely severe depression (>27)

Anxiety

Anxiety is a sense of fear, autonomic arousal, skeletal muscle effects, and subjective experience
of anxious affect. Level of anxiety distinguished by DASS-21 scale.

Normal (0–7)

Mild (8–9)

Moderate anxiety (10–14)

Severe anxiety (15–19) and

Extremely severe anxiety (>19)

Stress

Stress is a feeling of emotional or physical tension. It can come from any event or thought that
makes you frustrated, anger or nervous.

It assesses difficulty relaxing, nervous arousal, and being easily upset / agitated, irritable / over-
reactive and impatient. Level of stress distinguished by DASS-21 scale.
Normal (0–14)

Mild (15–18)

Moderate stress (19–25)

Severe stress (26–33) and

Extremely severe stress (>33)

Adolescents

Adolescents in this study refer to students of age 15-19 years and who are studying in grade 11
and 12 of Shree Kanti secondary school, Butwal-4, Rupandehi.

CHAPTER II:

LITERATURE REVIEW

2.1 Introduction

The literature review comprises of Global and National earlier studies conducted on stress
anxiety depression among adolescents. The literature review was done by searching journals,
books, articles, abstract, computer search engine, etc.
2.2 Review of literature

A cross-sectional study was conducted among 453 students of five randomly selected high
schools in Tokha Municipality of Kathmandu. The overall prevalence of DAS was found to be
56.5% (95% CI: 51.8%, 61.1%), 55.6% (95%CI: 50.9%, 60.2%) and 32.9% (95%CI: 28.6%,
37.4%) respectively. In the multivariable model, nuclear family type, students from science or
humanities faculty, presence of perceived academic stress, and being electronically bullied were
found to be significantly associated with depression. Female sex, having mother with no formal
education, students from science or humanities faculty and presence of perceived academic stress
were significantly associated with anxiety. Likewise female sex, currently living without parents,
and presence of perceived academic stress were significantly associated with stress (Karki et al.,
2022).

Descriptive cross-sectional study was conducted on Stress, anxiety, and depression among
adolescent students of public schools in Kathmandu. The study included 411 adolescent students
aged 14 to 19 years from six randomly selected public schools of Kathmandu Metropolitan City.
Depression, Anxiety and Stress Scale 21(DASS-21) was administered to the students to identify
the prevalence of depression, anxiety, and stress. Logistic regression analysis was performed to
find out the associated factors of stress, anxiety, and depression. The prevalence of stress,
anxiety, and depression was 27.5%, 56.9% and 41.6% respectively. Factors associated with
stress were being female, high academic pressure, and abuse. The factor associated with anxiety
was high academic pressure and factors associated with depression were being female, high
academic pressure and witnessed/exposed to domestic violence (Choulagai & Professor, 2020).

A descriptive cross-sectional study was done among school-going adolescents of a school from 1
October 2021 to 31 November 2021. The whole sampling method was used. Percentage and
frequency were calculated for binary data. Among 95 patients, the depression was found in 31
(32.63%), anxiety in 36 (37.89%), and stress in 3 (3.16%)(Shrestha et al., 2023).
 CHAPTER III

RESEARCH METHODOLOGY

This chapter deals with the description of the research methodology adopted to assess stress,
anxiety, depression among adolescent in secondary school, Butwal.

The methodology includes research design, research setting and population, sampling,
instrumentation, data collection procedure and data analysis.

3.1 Research Design

Descriptive, cross- sectional study will be used to assess stress anxiety depression among
adolescents in secondary school, Butwal.

3.2 Research Setting and Population

The research will be conducted in Shree Kanti higher secondary school which is one of the top 5
government community school in Rupandehi District. It is situated at Hatt Bazaar Line Butwal-4
Rupandehi. The school was established in 2010 B.S and running under the effective management
of Government of Nepal. This secondary school is affiliated with National Examination Board
(NEB) and offers plus two (10+2) programs. The school received best community school award
in 2072BS amongst schools of western Nepal.
Population of the study will be those all students studying in grade 11, 12 of Shree
Kanti Secondary School Butwal -4, Rupandehi. The total populations who are studying in class
XI and XII were 1507

Inclusion and Exclusion Criteria

Inclusion Criteria

Those students studying in class 11, 12 of Shree Kanti secondary school Butwal-4 Rupandehi.

Those students who are willing to participate in the study.

Exclusion Criteria

Those who are not interested and not available at the time of data collection period.

3.3 Sampling

3.3.1Sampling size estimation

The sample size was 337

Sample Size calculation:

Cochran’s formula for finite population

n= n0

1+ (n0-1)

n0: Cochran’s sample size computed using the formula for ideal sample size; 385

N: the size of the population: 1507

N=385
1+(385-1)

1507

n= 306

To minimize Non response rate error, 10 % non – response rate was considered

i.e. 10% of 306 is 31 samples.

Therefore, final sample size, n = 306 + 31 = 337.

The number of students from each faculty was taken using the formula of proportionate stratified
sampling technique i.e.

n = sample ¿ ¿ Total student ¿ × number of students in a class

Total students of class 11 and 12 in 3 faculty = 1507

337
Science = × 620 = 133
1570

337
Commerce = × 840 = 180
1570

337
Humanities = × 110 = 24
1570

3.3.2 Sampling Technique

Simple random sampling technique was used.

3.4 Research Instrument

Self-administered questionnaire will be developed after extensive reviewing of related literature.
Standard tool, DASS 21 scale developed by Lovibond and Lovibond (1995) will be used to
assess level stress, anxiety, depression among adolescents.The Depression, Anxiety and Stress
Scale - 21 Items (DASS-21) is a set of three self-report scales.

Research Instrument consist of 3 parts.

Part I- questions related to socio-demographic information, familial and academic

characteristics variables to obtain regarding age, sex, religion, level of education, parent’s
education, parent’s occupation, type of family, current place as residence

Part II: question related to factors associated with Depression, Anxiety and Stress such as
economic status, socializing, and bullying, academic performance

Part III: question related to stress, anxiety, and depression using DASS 21 scale developed
by Lovibond and Lovibond (1995) .The Depression, Anxiety and Stress Scale - 21 Items (DASS-
21) is a set of three self-report scales designed to measure the emotional states of depression,
anxiety and stress. Each of the three DASS-21 scales contains 7 items, divided into subscales
with similar content. Scores for depression, anxiety and stress were calculated by summing the
scores for the relevant items.

Severity Level Depression Anxiety Stress

Normal 0-9 0-7 0-14

Mild 10-13 8-9 15-18

 Moderate 14-20 10-14 19-25

Severe 21-27 15-19 26-33

Extremely severe 28+ 20+ 34+

Note: Total Scores need to be multiplied by 2 to calculate the final score

3.5 Ethical Consideration

Formal Approval will be taken from the Research Committee of National Medical College
Teaching Hospital.

Approval from the Institutional Review Committee of National Medical College Teaching
Hospital will be obtained.

Formal permission will be taken from Principle from Shree Kanti secondary school, butwal-4,
Rupandehi.

The written informed consent will be obtain from the guardian of all participants. As well as
assent will be obtained from the participants.

Privacy will be maintained during data collection and confidentiality of data will be maintained.

3.6 Data Collection Plan

Before data collection, administrative approval will be obtained from concern authority and the
data will be collected within 4 weeks period.
The objectives of the study will be explained to the participants and written consent will be
obtained from all participants. The participants will be assured for the privacy and
confidentiality.

3.7 Data Analysis Plan

The collected data will be checked, reviewed and organized for its accuracy, completeness and
consistency.

The collected data will be compiled and coded, edited, classified and tabulated.

The data will be entered and analyzed in statistical package of social science (SPSS).

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