Purpose : Mental disorders begin to occur at the age of 10-29 years about 10-20 %. Protective factors to prevent mental disorders in adolescents were self-esteem, family relationships and social support. The purpose of this study was to determine the relationship between the protective factors of self-esteem, family relationships, and social support and adolescent mental health.
Methodology: This research employs a correlative design. The subjects were 452 students in 8 grade (aged < 15 years old) that chosen by a purposive sampling technique. Data were collected by five questionnaires: demographic data, Rossenberg Self-Esteem Scale, Family Relation Index, Child and Adolescent Social Support Scale, Mental Health Continuum Short Form.
Main Findings: The results show that the protective factors of self-esteem, family relationships, and social support have a positive and significant influence on adolescent mental health (p < 0,05).
Applications: These findings showed the important role of protective factors (self-esteem, family relationships, social support) to adolescent mental health. Schools, parents and mental health nurses need to develop programs to promote mental health by improving the protective factors of self-esteem, family relationships, and social support.
Novelty/Originality: There are no studies involving comprehensive protective factors include individuals, families and communities on adolescent mental health.
Mental health is a state of balance between the self and the environment. This is demonstrated by self-control and the ability to overcome tensions associated with everyday life 1. In a healthy mental state, the individual will use all of his or her strength to the greatest extent possible and establish relationships with the surrounding social environments. Conversely, an individual who is not able to solve problems well and who tends to avoid involvement with the community is at risk of developing mental disorders.
Mental disorders usually begin during adolescence. As many as 10-20% of mental disorders occur at the age of 10-29 years and exhibiting the highest occurrence of emotional disturbance 2,3. Early psychosis occurs during the ages of 15-25 years 4. In Indonesia, mental health disorders occur largely at the age of 15 years or older 5. Untreated mental disorders in adolescents can affect all aspects of their lives. Adolescents’ development, educational achievement, and productivity are impaired by the impact of mental disorders 6. Mental disorders lead to many other disabilities and decreased productivity and quality of life that the individual may experience long-term.
Teenage development includes biological, psychological, and social changes that can also become stressors. The surge of changes teenagers experience can trigger inner conflicts or conflicts with their environments 7. Other factors such as poor physical conditions, parental divorce, violence, financial problems, and sexual abuse can add to these stressors. If the various pressures and problems are not well compensated for, they can affect mental development, often triggering the occurrences of mental health disorders.
Protective factors can prevent adolescent mental disorders. According to O’Connell et al 8, protective factors include personal (positive self-concept, optimistic attitude, and self-contentment), family (family conditions and family support), and community (social support). Of all the protective factors, studies show that family climate, self-concept, and social support play major roles in decreasing the incidence of adolescent mental disorders 9. Therefore, these factors can have positive effects on adolescent mental health.
Self-esteem is defined as the valuation of oneself. A current trend exhibits social interactions among teenagers often triggering comparisons of themselves with their peers. Teenagers with good self-valuation will feel content with themselves and be resilient to have risk behavior (substance abuse, alcohol consumer, embellishment) and manifestations of depression, anxiety, suicide and other mental disorders 10. Family also influences adolescent mental health. Good relationships among family members contribute to the development of interpersonal skills, build self-confidence and lower the incidence of depression 11,12. Social support allows teenagers to gain acceptance and feel loved and cared for by others, enabling them to cope with the stressors of life in positive ways. A study by 13, showed a decrease in stress and depression levels in adolescents with high social support. These instances demonstrate the importance of increasing protective factors to foster healthy mental states in adolescents.
Research related to protective factors mostly covers only one factor exclusively. In Indonesia, no studies have covered all three protective factors in a comprehensive way. Because of this, our study aims to determine the relationship of the three stated protective factors and adolescent mental health.
This research is a descriptive-correlative study that aims to describe facts related to the population and detect the existence of relationships from one variable to another. The research design used is a cross-sectional design, where this design is suitable for measurements with more than two variables and the measurement of each variable can be done one time without any follow-up. This study aims to find out the relationship between protective factors (self-esteem, family relationships and social support) on adolescent mental health.
Setting and Sample
The sample consist of eight-grade students (middle adolescents) in East Jakarta Junior High Schools that met the inclusion criteria and agreed to participate. The sample was determined using the purposive sampling technique to arrive at a total of 452 student respondents. The sample selection based on the stage of development of middle adolescents where the dominant development is psychosocial development that is appropriate with the study 14. The sample selection of adolescents aged <15 years also by the consideration of Riskesdas 2013 15,4 which states that the incidence of early psychosis occurs mostly at the age of 15-25 years. The inclusion criteria included adolescents aged <15 years and willing to become respondents. While the exclusion criteria are adolescents aged ≥ 15 years, adolescents who do not go to school or permit school and adolescents who refuse to become respondents.
This research was approved by The Ethical Committee Faculty of Nursing Universitas Indonesia (No.118/UN2.F12.D/ HKP.02.04/2018). Ethical approval was obtained from the Research Committee at the author’s faculty.
Data were collected by using some instruments. The following instruments were used: Demographic data, Rosenberg Self-Esteem, Index of Family Relation, Child and Adolescent Social Support, and Mental Health Continuum-Short Form, which was modified based on validity and reliability test results.
Data Collection/ Procedure
Data were collected from May 2nd until 9th 2018. The research procedure was filled-out informed consent forms and questionnaires by respondents. First of all, the researcher provides the opportunity for respondents to ask questions regarding filling out questionnaires. The questionnaire was administered in the each classroom and was completed in the same day.
Data was analyzed in order to describe the characteristics of participants and exhibit the correlation between the protective factors and adolescent mental health. Spearman correlation was used to identify the relationship between each protective factors and mental health. Data analysis were also accompanied by normality tests using the Kolmogorov-Smirnov test.
Table 1 shows adolescent characteristics consisting of age, sex, living status, and family history of mental disorders. The age data have 3 category : 12 (0.2 %), 13 (23.9 %) and 14 (75.9 %) years old. Most adolescents in our study were 14 years old, with 12-year-olds making up the youngest participants in the sample. Female adolescents exhibit a higher proportion (54 %). The majority of adolescents in this sample live with their biological fathers and mothers as nuclear families (85 %). Most of the adolescents have no family history of mental disorders (98.5 %).
|12 13 14||1343||0.275.9|
|Biological Father and Mother Father Mother Extended Family Stepfather/Stepmother||38410||852.2|
|Family History of Mental|
|Adolescent Mental Health||R||P values|
|Social support : parents||High||189||48||173||43.9||32||8.1||.62||< .001|
|Social support : teachers||High||168||48.8||143||41.6||33||09.6||.36||< .001|
|Social support : classmates||High||167||53||129||41||19||6||.56||< .001|
|Social support : close friends||High||177||50.6||140||40||33||9.4||.48||< .001|
|Social support : school||High||118||63.1||62||33.2||7||3.7||.58||< .001|
Table 2 shows a significant correlation between self-esteem and adolescent mental health (p<0.001). The r value of 0.54 shows the positive and moderate correlation between self-esteem and adolescent mental health. Table 2 also shows that there is a significant correlation between family relationships and adolescent mental health (p<0.001). The r value of 0.86 shows a positive and high correlation strength between family relationships and adolescent mental health. Social support (parents, teachers, classmates, close friends, and school) shows a significant (p<0.001) and positive correlation with adolescent mental health about 0.62, 0.36, 0.56, 0.48, and 0.58 in sequence. Based on the r value, social support from parents has a strong correlation with mental health, while social support from teachers has a weak correlation. Social support from classmates, close friends, and the school has moderate correlation strength.
Adolescents’ self-esteem and mental health exhibit a positive correlation. Studies have shown improvement in adolescent mental health with an increase in self-esteem 10. Other studies also support a positive correlation between self-esteem and mental health 16,17. This is because adolescents with positive self-esteem will demonstrate positive social behaviors and characteristics such as assertiveness, strong social abilities, and adaptability in various events and conditions. Adolescents with high self-esteem have strong self-defense mechanisms to be able to resist the bad influences they encounter. Some interventions to increase self-esteem should be considered as to maintain health promotion behavior that can perceived health status, self-efficacy 16. This strength can prevent them from experiencing symptoms of depression 17,18. Therefore, self-esteem can be a factor in preserving the mental health of adolescents.
Harmonious family relationships also contribute significantly to the development of good mental health in adolescents. The quality of family life plays a very important role in shaping healthy mental attitudes and strong personalities in children 19. Acceptance, warmth, support, and monitoring from the family can encourage adolescents to build resilience and adaptability. Another study suggests that harmonious relationships support adolescents in achieving optimal mental development 20. From the above arguments, it is clear that strong, harmonious family relationships can help adolescents achieve healthy mental states.
The variety of sources of adolescent social support, including parents, teachers, classmates, close friends, and schools, have significant correlations with adolescent mental health as well. This is consistent with previous research results 21,22. Previous studies reveal that social support may reduce symptoms of anxiety and depression in adolescents 23. Therefore, social support appears to be a main factor in preventing mental health problems in adolescents.
Adolescents make up a group of individuals susceptible to mental health problems that stem from various stressors faced during development. When faced with these stressors, adolescents with high social support from parents, teachers, peers, and schools will find it easy to seek advice, feedback, and solutions to solve their problems. Different sources of support allow them to pull from a variety of perspectives or perceptions to find solutions and feedback 24. Support from parents and schools, especially, should be increased because these sources have the greatest correlation coefficients compared to other types of support.
Adolescents with high social support will gain emotional reinforcement and motivation, which helps them to become psychologically and emotionally stronger and less potential to be hopeless. The problem-solving will be more positive outcome, build hope and self-esteem, even enforce a particular lesson for adolescents to learn 22,25. Any positive impact resulting from social support can allow individuals to become mentally healthy.
All factors, namely the individual protective factor (self-esteem), family protective factor (family relationships), and community protective factor (social support), have significant correlations with adolescent mental health. Therefore, it is necessary to promote mental health by increasing the protective factors of self-esteem, family relationships, and social support. Studies suggest that education and training programs in school based on the PRECEDE-PROCEED model can effectively improve the self-esteem and mental health of adolescents 26,27. Based on the PRECEED-PROCEDE model, the process of changing behavior starts from assessment, problem setting and planning. The next stage is implementation by education, setting rules and creating a supportive environment. Then, these interventions are evaluated 28. Other research suggest to create a support group among adolescents, increase self-acceptance, and do some activities that you good at to increase the level of self-esteem 29,1,30. The way to maintain harmonious relationship is carry-out rituals or activities with family members that fosters intimacy and communication among them 31. Thus, parents, teachers, classmates, close friends and school should be the basis of social support source for adolescent 32,33,23. These social supports include emotional, appraisal, informational and instrumental form. Schools and mental health nurses can work together to build mental health promotional programs that take the form of education and life skills training based on the PRECEDE-PROCEED model to increase protective factors and the mental health of adolescents.
This study shows a significant correlation between the protective factors (self-esteem, family relationship, and social support) and adolescent mental health. Therefore, schools, parents and mental health nurses need to develop programs to promote mental health by increasing the protective factors of self-esteem, family relationships, and social support. The PRECEED-PROCEDE model can be used to build an effectiveness mental health program in school.
LIMITATION AND STUDY FORWARD
Future studies should analysis another protective factors from individuals, families and social support aspect.
- Adachi, P. J. C., & Willoughby, T. (2014). It’s Not How Much You Play, but How Much You Enjoy the Game: The Longitudinal Associations Between Adolescents’ Self-Esteem and the Frequency Versus Enjoyment of Involvement in Sports. Journal of Youth and Adolescence, 43(1), 137–145. https://doi.org/10.1007/s10964-013-9988-3
- Ahmed, W., Minnaert, A., van der Werf, G., & Kuyper, H. (2010). Perceived Social Support and Early Adolescents’ Achievement: The Mediational Roles of Motivational Beliefs and Emotions. Journal of Youth and Adolescence, 39(1), 36–46. https://doi.org/10.1007/s10964-008-9367-7
- Badan Penelitian dan Pengembangan Kesehatan. (2013). Riset Kesehatan Dasar (RISKESDAS) 2013. Laporan Nasional 2013, 1–384. https://doi.org/1 Desember 2013
- Cheng, Y., Li, X., Lou, C., Sonenstein, F. L., Kalamar, A., Jejeebhoy, S., … Ojengbede, O. (2014). The association between social support and mental health among vulnerable adolescents in five cities: Findings from the study of the well-being of adolescents in vulnerable environments. Journal of Adolescent Health, 55(6), S31–S38. https://doi.org/10.1016/j.jadohealth.2014.08.020
- Coverdale, G. E., & Long, A. F. (2015). Emotional wellbeing and mental health: An exploration into health promotion in young people and families. Perspectives in Public Health. https://doi.org/10.1177/1757913914558080
- Curtis, A. C. (2015). Defining Adolescence. Journal of Adolescent and Family Health, 7(2), 1–39. https://doi.org/http://scholar.utc.edu/jafh/vol7/iss2/2/
- Demir, T., Karacetin, G., Demir, D. E., & Uysal, O. (2011). Epidemiology of depression in an urban population of Turkish children and adolescents. Journal of Affective Disorders, 134(1–3), 168–176. https://doi.org/10.1016/j.jad.2011.05.041
- Farshi, M. G., Sharifi, H. P., & Rad, M. A. (2013). The Relationship between Self-Esteem, Mental Health and Quality of Life in Patients with Skin Diseases. Asian Journal of Medical and Pharmaceutical Researches, 3(2), 50–54.
- Glanz, K., Rimer, B. K., & Vismanath, K. (2008). Health behavior and health education: Theory, research, and practice. San Francisco: Jossey-Bass A Wiley Imprint.
- Graziano, F., Bonino, S., & Cattelino, E. (2009). Links between maternal and paternal support, depressive feelings and social and academic self-efficacy in adolescence. European Journal of Developmental Psychology, 6(2), 241–257. https://doi.org/10.1080/17405620701252066
- Haroz, E. E., Murray, L. K., Bolton, P., Betancourt, T., & Bass, J. K. (2013). Adolescent Resilience in Northern Uganda: The Role of Social Support and Prosocial Behavior in Reducing Mental Health Problems. Journal of Research on Adolescence, 23(1), 138–148. https://doi.org/10.1111/j.1532-7795.2012.00802.x
- Heinssen, R. K., Goldstein, A. B., & Azrin, S. T. (2014). Evidence-Based Treatments for First Episode Psychosis: Components of Coordinated Specialty Care. NIMH White Paper.
- Hockenberry, M. J., & Wilson, D. (2015). Wong’s Nursing Care of Infants and Children (10th Ed). Missouri: Elsevier Mosby.
- IDAI. (2013). Masalah Kesehatan Mental Emosional Remaja, 1–7. Retrieved from http://www.idai.or.id/artikel/seputar-kesehatan-anak/masalah-kesehatan-mental-emosional-remaja
- Jang, H. J., & Jeon, M. K. (2015). Relationship between self-esteem and mental health according to mindfulness of university students. Indian Journal of Science and Technology, 8(21). https://doi.org/10.17485/ijst/2015/v8i21/78459
- Kartono, K. (2002). Hygiene Mental. Bandung: Mandar Maju.
- Kemenkes RI. (2013). Riset Kesehatan Dasar 2013. Ministry of Health Republic of Indonesia, (1), 1–303. https://doi.org/10.1007/s13398-014-0173-7.2
- Mann, M., Hosmar, C. M. H., Schaalma, H. P., & DeVries. (2004). Self-esteem in a broad-spectrum approach for mental health promotion. Health Education Reseahrc, 19(4), 357–372. https://doi.org/https://doi.org/10.1093/her/cyg041
- Matthews, D. W. (2008). Strengthening Family Relationships. Retrieved January 25, 2018, from http://www.advocatesforyouth.org/publications/1229-strengthening-family-relationships
- Merikangas, K., Jian-ping, H., Burstein, M., Swanson, S., Avenevoli, S., Lihong, C., … Swendsen, J. (2011). Lifetime Prevalence of Mental Disorders in US Adolescents: Results from the National Comorbidity Study-Adolescent Supplement. Journal of the American Academy Children Adolescent Psychiatry, 49(10), 980–989. https://doi.org/10.1016/j.jaac.2010.05.017
- Mo, P. K. H., & Mak, W. W. S. (2008). Application of the PRECEDE model to understanding mental health promoting behaviors in Hong Kong. Health Education & Behavior : The Official Publication of the Society for Public Health Education, 35(4), 574–87. https://doi.org/10.1177/1090198108317409
- Moore, G., Cox, R., Evans, R., Hallingberg, B., Hawkins, J., & Littlecott, H. (2018). School , Peer and Family Relationships and Adolescent Substance Use , Subjective Wellbeing and Mental Health Symptoms in Wales : a Cross Sectional Study. Child Indicators Research, 1–15. https://doi.org/10.1007/s12187-017-9524-1
- Moshki, M., Atarodi, B. A., Moslem, A., & Taheri, M. (2012). Applying an Educational-participatory Program based on the PRECEDE Model for Promoting Self-esteem and Mental Health of Students in Iran. International Journal of Preventive Medicine, 3(4), 241–248.
- Mulligan, A. (2011). The relationship between self-esteem and mental health outcomes in children and youth. New York. Retrieved from http://www.excellenceforchildandyouth.ca/sites/default/files/resource/EIS_Self_Esteem_MH.pdf
- O’Connell, M. E., Boat, T., & Warner, K. E. (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities (Vol. 23). Washington DC: National Academies Press.
- Pritchard, R., Pryor, J., & Murphy, M. (2007). Healthy Family Relationships.
- Sarafino, E. P., & Smith, T. W. (2011). Health psychology biopsychosocial interactions (7th Ed). Hoboken: John Wiley & Sons, Inc. https://doi.org/10.1016/0022-3999(91)90058-V
- Shives, L. R. (2011). Basic Concepts of Psychiatric-Mental Health Nursing (8th Ed). Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins.
- Wang, X., Cai, L., Qian, J., & Peng, J. (2014). Social support moderates stress effects on depression. International Journal of MentalHealth Systems, 8(41), 1–5. https://doi.org/10.1186/1752-4458-8-41
- Wangge, B. D. R., & Hartini, N. (2013). Hubungan antara Penerimaan Diri dengan Harga Diri pada Remaja pasca Perceraian Orangtua. Jurnal Psikologi Kepribadian Dan Sosial, 2(1), 1–6.
- Whiteford, H. A., Ferrari, A. J., Degenhardt, L., Feigin, V., & Vos, T. (2015). The global burden of mental, neurological and substance use disorders: An analysis from the global burden of disease study 2010. PLoS ONE, 10(2). https://doi.org/10.1371/journal.pone.0116820
- Wille, N., Bettge, S., & Ravens-Sieberer, U. (2008). Risk and protective factors for children’s and adolescents’ mental health: Results of the BELLA study. European Child and Adolescent Psychiatry, 17(SUPPL. 1), 133–147. https://doi.org/10.1007/s00787-008-1015-y
- World Health Organization. (2017). Adolescents and mental health. Retrieved January 1, 2018, from http://www.who.int/maternal_child_adolescent/topics/adolescence/mental_health/en/