Sociodemographic characteristics associated with adolescent depression in urban and rural areas of Hubei province: a cross-sectional analysis

Depression in adolescence is a public health concern worldwide and associated with substance abuse, academic problems, cigarette smoking, physical health problems, impaired social relationships and suicide [1]. Previous epidemiological and clinical researches have indicated that adolescent depression has numerous individual, family and social factors. Reported risk factors for adolescent depression include being female, anxious, offspring of depressed parents, and being exposed to stress or trauma [2‐4]. However, many of the known contributing factors have been described in the western context. Since adolescents are psychologically vulnerable to the influence of their family and social surroundings, sociodemographic characteristics for adolescent depression may vary across countries, or even vary across regions [5]. China, in particular, has experienced rapid socioeconomic, and health transitions over the last four decades. These huge changes have made China a unique and important object for adolescent depression research.

Meanwhile, given there is large inequality in socio-economic, policy and cultural environment between rural and urban areas in China, research examining the relationship between sociodemographic characteristics and adolescent depression in a specific social context of China is needed. Although some studies have investigated sociodemographic characteristics related to depression in Chinese adolescents [6‐9], few researches have been conducted to systematically investigate the psychological health contrast of adolescents from urban and rural areas [10‐12]. Urban–rural mental health disparities are expected to be even more pronounced in China, since they have important social values and have been well studied in developed countries [13‐15]. Research on depression among rural and urban students can provide evidence on the relationship between depression and sociodemographic status in this unique cultural setting, and may be helpful to develop policies and practices to minimize the risk factors of adolescent depression. In this study, we choose Wuhan city and Jianli county as the objects of urban-rural depression disparity research. Wuhan is the provincial capital of Hubei province and the largest city in central China. Wuhan ranked the 9th in Chinese cities in terms of Gross Domestic Product (GDP) in 2018 based on the National bureau of statistics. Jianli county, however, is one of the most economically undeveloped regions in Hubei province. Nearly 500,000 migrant workers are working outside the city, making left-behind children and depression in adolescence serious public health problems in local area. Therefore, the two regions targeted in this study are appropriate for urban-rural depression disparities research.

Furthermore, as a result of the traditional Chinese culture’s strong stigma toward psychiatric disorders, the serious shortage of psychiatrists and infrastructure (especially in the rural areas) and low mental health literacy, only 8.3 to 27.6% of patients with depressive disorders are diagnosed, and about half of those diagnosed receive effective treatment [16]. Adolescence is the stage in which most mental health problems first manifest [17]. Researches also suggest that delays in seeking help for mental health problems lead to poorer treatment outcomes [18, 19]. Knowledge of differences in risk factors of psychological health can aid in the development of targeted student’s mental health education. In addition, we also aim to develop effective, easy-to-use clinical screening tools to identify high-risk groups of adolescent depression.

A cross-sectional study was therefore designed to find the potential risk factors and their differences between urban and rural areas. We aim to examine the potential relationship between sociodemographic characteristics and depressive symptoms among rural and urban junior middle school students and construct nomograms to predict the risk of adolescent depression based on the selected factors.

Previous studies have shown the existence of various disparities between urban and rural areas in China, while Hukou-based restrictions have legitimized and endorsed institutional inequality. This cross-sectional investigation in central China also showed that there are significant differences in sociodemographic characteristics of junior middle school students in urban and rural areas. As our study showed, the proportion of only children in urban areas was much higher than that in rural areas (60.67% vs. 15.02%). In addition, 51.81% of the junior middle school students in urban areas were boys, while the proportion in rural areas was as high as 62.04%. Similarly, our data showed that there were more left-behind children, more students living in schools and the parents with lower education level in rural areas. However, the difference of depressive proportions in rural and urban students is not significant. 35.11% urban students and 32.47% rural students had depression symptoms (CES-D score ≥ 20).

Achievement and gender were found to be associated with depression symptoms for both urban and rural students. Gender factors have already been widely discussed and a considerable number of studies have examined correlations between depression and gender, suggesting that females, both adults and adolescents, have higher risk of depression than males [22]. The traditional Chinese society attaches great emphasis on education and achievements, rendering highly competitive education system [23]. Hence, the students with poor achievement tend to have lower self-esteem and more pressure on psychology. Meanwhile, some variables associated with depression symptoms in urban students were found to be different from rural students. Our study shows left-behind is associated with depression in rural students, rather than urban students. Official statistics indicate that approximately 61 million children and adolescents are left behind in rural areas, accounting for 38% of rural children in China. Approximately 70% of these left-behind children (LBC) cannot see their parents at all during a year except for holidays and festivals [24]. Considerable evidence has confirmed that children with long-term separation from parents are more likely to suffer from emotional trauma, low self-esteem, anxiety, and depression than children from intact families [25, 26]. In this study, the proportion of rural LBC in our study was 51.24%, indicating that the increasing number of LBC is becoming a social problem in rural China. We also found the LBCs are more likely from non-key classes and with higher proportion of poor achievement, and fewer LBCs have exercise habits, which were possibly due to the lack of parental supervision and education. Given the large number of LBCs and the high incidence of LBC depression, more attention and care should be given to this high-risk group of depression.

On the other hand, urban students who are in non-key class and older were more likely to be depressed, while there was no such trend among rural students. It is a unique phenomenon that junior middle school students are divided into key class and non-key class based on their entrance test scores in China [27]. This phenomenon appears more commonly in urban areas of China. Key classes mean “better students”, “better teachers” and more high-quality educational resources. Since adolescence is a susceptive period for self-esteem, potential discrimination on the non-key classes adolescents needs to be addressed.

Considerable evidences have confirmed that physical exercise can prevent and treat depression. According to WHO physical activity recommendations, children and youth aged 5–17 years old should accumulate at least 60 min of moderate to vigorous intensity physical activity daily, at least 3 times per week. In our study, the exercise habit was associated with lower risk of depression in urban adolescents, suggesting that physical activity is beneficial to the mental health of adolescents, and the importance of exercise should be more pronounced in China.

In 1979, the Chinese government started promoting and implementing the one-child policy (OCP) to ease the enomous pressure of population explosion. Previous studies have shown that one-child policy affects personality traits and depressed mood [28]. Although some of them showed that only children have elevated risk for engaging in negative psychosocial consequences, such as increasing sense of loneliness, sadness, and nervousness [29, 30], only children could possess a higher level of mental health without suffering from resource dilution [29]. In this study, there was no correlation between depression and only children. However, there were significant differences in sociodemographic characteristics of the only children and sibling children.

Numerous studies have documented that inability to recognize mental disorders reduced likelihood of help-seeking [31]. Furthermore, there is also growing evidence showing that early and correct recognition of mental disorders contributes to early treatment, and thus leads to better long-term health outcomes for those with mental disorders. The literatures offered China-based research, examining sociodemographic characteristics potentially associated with adolescent depression. Moreover, it offered effective and convenient clinical tools-nomograms, for individualized depression risk evaluation. Although nomograms have been used to provide individualized evaluation of the clinical event incidence on many occasions, the application of nomogram in screening adolescent depression is relatively rare. In the present study, two predictive nomograms included all significant independent factors which were selected by the multiple logistic regression analyses for sociodemographic characteristics in urban areas and rural areas, respectively. Guided by the nomograms, we can better predict the depression risk based on the different characteristics of urban or rural junior middle school students, which can help us to carry out identification and psychological intervention in time.

The results indicate that although there are some different sociodemographic characteristics associated with adolescent depression in rural and urban areas, the proportions of depression symptoms in rural and urban junior school students is not significantly different. The protective factors of depression in urban students are exercise habit, younger age, key class, better academic achievement and male gender, while LBC, poor academic achievement and female had higher risk for adolescent depression in rural area. Furthermore, nomograms, the effective and convenient clinical tools, were established for depression screening for junior school students.