How do country-level inequality and poverty affect mental health for adolescents?
Creators: name: Zaneva, Mirela
name: Reeves, Aaron
name: Bowes, Lucy
Publisher: name: Open Science Framework
Year: 2023
Subjects: subject: Psychiatry and Psychology
subject: Mental Disorders
subject: Social and Behavioral Sciences
subject: Medicine and Health Sciences
subject: Gini
subject: inequality
subject: mental health
subject: adolescents
subject: SES

description: How do country-level inequality and poverty affect mental health for adolescents? Research Questions: In this project we are interested in understanding: Q1: How do country-level inequality and individual-level poverty affect mental health for adolescents? Q2: Do any effects observed differ by gender? Q3: Do any effects observed differ by age? Q4: Is there a 3-way interaction such that girls become worse off later on in adolescence? Data We will use secondary data from the Global School-based Student Health Survey (GSHS). This is public anonymized school-based data. There are currently four phases of data collections (2003-2008; 2009-2012; 2013-2017) which are associated with small variations in survey items. Further information about methodology and collection procedures are available here: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/global-school-based-student-health-survey Selection of countries We will include all countries for which data was collected in the period 2010-2018 and for which our outcome and predictor variables are included. We anticipate this to be approximately n=90 countries. For countries that are represented more than once in this period, we will include all entries. Variables All variables of interest are present in the core module questionnaire. Outcome: We are interested in mental health outcomes. Previous research with the GSHS has used the available mental health survey single items as proxies for different aspects of mental health (e.g. Arat &amp; Wong, 2017; Campisi et al., 2020; Mahfoud et al., 2011; Ranasinghe, Ramesh, &amp; Jacobsen, 2016). Based on the previous literature, we will examine the two items that have been interpreted as proxies for anxiety (“During the past 12 months, how often have you been so worried about something that you could not sleep at night?”) and for suicide ideation (“During the past 12 months, did you ever seriously consider attempting suicide?”). We will examine these items both on their own (separate regressions for each outcome) as well as in an combined fashion (as both items address rumination and worry). In the GSHS, the item for anxiety is measure on a 5-point scale (‘Never’, Rarely’, ‘Sometimes’, ‘Most of the time’, ‘Always’) and the item for suicide ideation is measured on a binary scale (‘No’ or ‘Yes’). Previous researchers have dichotomized variables from the GSHS mental health questionnaire (e.g. (Astante et al., 2017; Arat &amp; Wong, 2017; Seidu et al. 2020) and we will similarly consider dichotomizing the anxiety measure (‘Never’ = 0, all other responses = 1). Nevertheless, our final decision on how to combine the measures for anxiety and suicide ideation will also be guided by examining descriptive statistics and plotting the data, so we may potentially consider an additive approach. Predictors: At the individual-level our predictors will be age, sex, and poverty as measured through the hunger variable (During the past 30 days, how often did you go hungry because there was not enough food in your home?). The hunger variable has previously been used as a proxy for socioeconomic status (e.g. Balogun et al., 2014; Pengpid &amp; Peltzer, 2018; Seidu et al. 2020) At the country level, our predictor will be inequality as measured through the SWIID Gini Index (Standardized World Income Inequality Database; Solt, 2020; https://fsolt.org/swiid/). We prefer the SWIID Gini Index over the World Bank’s Gini index as we have ascertained that the latter lacks information for certain years and countries included in the GSHS. Hypotheses: In the following mental health (MH) outcomes includes anxiety on its own, suicide ideation on its own, and their combined measure H1: Material deprivation (indexed by hunger) is associated with worse MH outcomes H2: Country level inequality (indexed by GINI) is associated with worse MH outcomes H3: Country-level inequality is associated with worse MH for those worst-off H4: Both inequality and poverty are associated with worse MH outcomes for girls Analyses: We will run a series of multilevel regression models to address the research questions. We will report adjusted (for age and sex) and unadjusted models. Our models will include a random intercept for each country-year pair. We chose this approach rather than including a random intercept for country and a random intercept for year to avoid cross-classified random intercepts. For each mental health outcome, we will run a separate multilevel regression. Q1: How do country-level inequality and poverty affect mental health for adolescents? (main effects) MH ~ poverty + age + sex + inequality + (1 | country-year) Q2: Do the effect(s) differ by gender (gender interactions) MH ~ poverty + sex*poverty + inequality*sex + age + sex + (1 | country-year) Q3: Do the effect(s) differ by age (age interactions) MH ~ poverty + poverty*age + inequality*age + age + sex + (1 | country-year) Q4: Do the effect(s) differ by age and gender (age*gender interactions MH ~ poverty + sex*poverty + inequality*sex + poverty*age + inequality*age + age*sex*poverty + age*sex*inequality + age + sex + (1 | country-year) References Asante, K. O., Kugbey, N., Osafo, J., Quarshie, E. N. B., &amp; Sarfo, J. O. (2017). The prevalence and correlates of suicidal behaviours (ideation, plan and attempt) among adolescents in senior high schools in Ghana. SSM-population health, 3, 427-434. Arat, G., &amp; Wong, P. W. C. (2017). The relationship between physical activity and mental health among adolescents in six middle-income countries: A cross-sectional study. Child &amp; Youth Services, 38(3), 180-195. Balogun, O., Koyanagi, A., Stickley, A., Gilmour, S., &amp; Shibuya, K. (2014). Alcohol consumption and psychological distress in adolescents: a multi-country study. Journal of adolescent health, 54(2), 228-234. Campisi, S. C., Carducci, B., Akseer, N., Zasowski, C., Szatmari, P., &amp; Bhutta, Z. A. (2020). Suicidal behaviours among adolescents from 90 countries: a pooled analysis of the global school-based student health survey. BMC public health, 20(1), 1-11. Mahfoud, Z. R., Afifi, R. A., Haddad, P. H., &amp; DeJong, J. (2011). Prevalence and determinants of suicide ideation among Lebanese adolescents: results of the GSHS Lebanon 2005. Journal of Adolescence, 34(2), 379-384. Pengpid, S., &amp; Peltzer, K. (2018). Parental involvement, health behaviour and mental health among school-going adolescents in seven Pacific Island countries. Journal of Human Behavior in the Social Environment, 28(8), 1068-1077. Seidu, A. A., Ahinkorah, B. O., Agbaglo, E., Darteh, E. K. M., Ameyaw, E. K., Budu, E., &amp; Iddrisu, H. (2020). Are senior high school students in Ghana meeting WHO’s recommended level of physical activity? Evidence from the 2012 Global School-based Student Health Survey Data. PloS one, 15(2), e0229012. Solt, F. (2020). Measuring income inequality across countries and over time: The standardized world income inequality database. Social Science Quarterly, 101(3), 1183-1199. Ranasinghe, S., Ramesh, S., &amp; Jacobsen, K. H. (2016). Hygiene and mental health among middle school students in India and 11 other countries. Journal of infection and public health, 9(4), 429-435.