Psycho-social factors associated with high depressive symptomatology in female adolescents and gender difference in adolescent depression: an epidemiological survey in China’s Hubei Province

For the past few years, depression have become a major public health problem worldwide [1]. According to the World Health Organization (WHO), depression will be the leading cause of disease burden by 2030 [2]. In China, the new update from the National Health and Health Commission (2018) shows that about 30 million children and adolescents under the age of 17 are suffering from psychological disorders in China [3], while psychological disorders such as depression, anxiety and bipolar disorder have been neglected for a long time in China. Given that quite a few depression diagnoses have their initial origins in adolescence, it is important to identify depression and prevent the establishment of maladaptive cognitive or behavioral patterns among early adolescence [4‐6].

The sociodemographic characteristics of China may play a prominent role in the occurrence of depressive symptoms in Chinese adolescents, since adolescents are more vulnerable to the surrounding environment and the individual psychological factors [7‐10]. The situation of female adolescents in China is even more difficult. Gender factors have already been widely discussed and a considerable number of studies suggested that females, both adults and adolescents, have higher risk of depression than males [11, 12]. Furthermore, owing to entrenched traditional social roles, son preference has always been a common problem in China. In recent years, early marriage and procreation rate of women rise again, although they dropped between 1990 and 2015 [13], which suggested that the educational inequities in female adolescents of China has recently exacerbated. However, few researchers have explored the different sociodemographic related factors between female adolescents and male adolescents.

Hence, it’s necessary to conduct an exhaustive study about gender difference of psycho-social factors in China to provide clues for early intervention of adolescent depression. Furthermore, Hubei province, the place targeted in this study, had the highest rates of suicide in China [14], so it is appropriate for depression research. The objective of this study is to explore psycho-social factors of female adolescents with high depressive symptomatology and gender differences in depressive symptoms among Chinese adolescents.

In this study, we aimed to explore psycho-social factors of female adolescents with high depressive symptomatology and gender differences in depressive symptoms among Hubei province. The total prevalence of this study was 34.0%, it’s similar to other areas in East Asia, including Shenzhen (34.7%), Taiwan (30.2%) and Korea (31.4%) [22‐24].

It is a unique phenomenon in China, especially in China’s urban areas, that middle school students were divided into key classes and non-key classes according to their academic achievement [25]. Key classes mean “better students”, “better teachers” and more high-quality educational resources, and adolescents in non-key class may experience discrimination. In this study, we found that compared to low depressive symptomatology, high depressive symptomatology group have more key class students (46.3% VS. 41.6%). However, after adjusting for confounding variables, key class was not a significantly associated factor for presenting with high depressive symptomatology.

New research from the UK is suggesting that higher birth order (later born) children were at increased risk of suicide attempts and psychiatric disorders in adolescence [26] and sibling bullying may be a significant driver for this phenomenon [27, 28]. Contrary to previous survey, we mentioned that birth order was not significantly associated with high depressive symptomatology in both male and female adolescents. We suspect it because parents in China tend to favor the younger children, especially their youngest sons. The results of the present study also support this idea, we can see that male adolescents were obviously more than female adolescents among these youngest children (N = 857, 70.1% VS. 29.9%).

Recent years, the physical psychological problems of left-behind children in China have aroused extensive concerns. Left-behind children have more mental and behavioral problems compared with general population of children [29, 30]. Meanwhile, some studies also present different results [31]. In China, the long-term impacts of traditional concepts lead parents to focus almost exclusively on their children’s academic performance rather than on psychological well-being [32]. Adolescents living with parents might suffering physical and verbal punishment when they didn’t study hard, which increased the risk of high depressive symptomatology. Some researchers have also found that adolescents whose father came back home more frequently displayed poorer health-related quality of life [33]. Thus, the current view on relationship between left-behind and depressive symptoms remains controversial. In this study, left behind status were not significantly related to high depressive symptomatology in both mela and female adolescents.

This study shown that the prevalence of high depressive symptomatology in female adolescents was significantly higher than male adolescents. Further subgroup analysis revealed that age, single parent family and fathers’ education background were associated with high depressive symptomatology in female adolescents, fathers’ education background was only associated with high depressive symptomatology in female adolescents, but not with male adolescents.

Previous research has suggested that females, whether adults or adolescents, were more likely to suffer depression, and this gender difference emerges from adolescence [34]. As shown in Fig. 1, in this study, the prevalence increased with age in both female adolescents and male adolescents (female 34.3% vs. male 24.2% in 11–12 group, 39.1% vs. 30.4% in 13–14 group, 44.4% vs. 35.9% in 15–16 group, respectively), and the gender difference existed in each age group. Previous studies suggested that the gender difference of depression in adolescents emerges between ages 12 and 15, while females experience increases in depression symptoms in early adolescence and males experience increases in depression symptoms in later adolescence [35‐38]. A recent longitudinal study indicated that girls’ diagnostic rates of depression increased from ages 11 through 14, whereas boys’ diagnostic rates of depression increased from ages 15 through 18 [39]. However, all these researches were conducted in United States. The national adolescent sample in China showed that prevalence of depressive symptoms in both boys and girls had increased from 7th to 9th grade [40]. This may be due to the cultural differences between China and United States. Asian cultures often value modesty and self-effacement as cultural virtues and inhibit the expression of positive emotion [41, 42], which would also lead to differences in prevalence between male and female adolescents. A cross-cultural comparative study found that after controlling for level of income, age, education, and previous chemotherapy, there was a significant cultural difference in the positive affect subscale between Chinese and US female [43]. These results are consistent with other cross-cultural comparisons of CES-D scores from healthy community Asian populations including South Koreans, Japanese, and Chinese, which have reported that scores on positive affect components are lower, and can lead to higher depressive symptom scores [41, 42, 44‐46].

Subgroup analysis shows that female adolescents whose father with primary school education or below were more susceptible to high depressive symptomatology (Table 4). From Fig. 2 we can see that prevalence of high depressive symptomatology in girls whose father with primary school education or below was much higher than any other girls, whereas prevalence of high depressive symptomatology in male adolescents has remained relatively unaffected by fathers’ education level.

Traditional preferences for sons are deep-rooted in rural areas of China, especially in low educated communities [47‐50]. According to the Global Gender Gap Report 2018, China ranked dead last among 149 countries in terms of “sex ratio at birth”. This is the result of many factors, such as the Confucian cultural tradition, the socioeconomic system, and gender ideology. In the context of traditional patriarchal, patrilineal and patriarchal systems, sons are considered to have unique value, as they inherit the family name and property and represent an economic value premium to the family and parents [48, 50‐52]. Under the one-child policy in China, a family with strong preference for sons may be trying to conduct gender selection [49]. Since the universal two-child policy was finally introduced in 2016, the families with an only daughter are more inclined to have another son [49]. Under such circumstances, female adolescents often face inequity in education and constrained by low expectations. Our study also confirms this conjecture to some extent. From the comparison of psycho-social characteristics between boys and girls (Table 2) we can see that proportion of male adolescents in rural areas was significantly higher than female adolescents (51.3 vs. 41.2%). In addition, significantly more girls have younger brother at home (33.8 vs. 20.0%) and less girls have older sister (11.9 vs. 27.5%). These unusual proportions could show that son preference is still widespread in China, especially in rural areas. Meanwhile, we observed that more female adolescents’ parents, both fathers and mothers, have higher education level. The role that fathers’ educational level plays in depressive symptoms may be explained by previous studies showing that fathers with a higher educational level tend to be warmer and more communicative with their children and to possess better emotional skills [53, 54]. Fathers with primary school education or below usually unable to provide favorable education and economic conditions to their daughters, which may also increase the prevalence of high depressive symptomatology. A study reported that father’s education level was positively associated with girl’s well-being in rural China [55], indicating that better educated fathers may value their daughters’ development more. Moreover, growing body of researches indicated that parental preference for sons might reduce under the modern outlook of fertility in urban areas but remained strong among rural-urban migrants [48, 49, 56], which means it’s the higher education levels of parents, not living areas, reduce the preference for sons.

Our study focuses on psycho-social factors related to female adolescents with high depressive symptomatology and gender differences in depressive symptoms among Chinese adolescents. We found that adolescents from single parent family, adolescents with older age and adolescents with less physical activity were more susceptible to high depressive symptomatology. However, fathers’ education background was only associated with high depressive symptomatology in female adolescents. Female adolescents whose father with primary school education or below deserves more attention. In China, especially in low educated communities, son preferences still widespread and popularization of rural compulsory education is the priority of China’s educational development. Furthermore, it is imperative to confirm these findings through nationally representative study.