- Email: [email protected]
Correlation of mental health problems with psychological constructs in adolescence: final results from a 2-year study
International Journal of Nursing Studies 40 (2003) 115–124
Correlation of mental health problems with psychological constructs in adolescence: final results from a 2-year study$ Young-Ho Kim* Department of Sport and Leisure Studies, Seoul National University of Technology, 172 Kongneung-dong, Nowon-gu, Seoul 139-743, South Korea Received 24 October 2001; received in revised form 1 April 2002; accepted 31 May 2002
Abstract In recent years, it has been widely witnessed that a surprising number of adolescents suffer emotional and mental health problems, and such turmoil is very often carried over into adulthood with serious implications for adjustment during the post-adolescent years. On this point, mental health problems in Korea are only now being considered crucial factors in the health status of adolescents and important public and social issues. It is also true that studies concerning the link between adolescents’ mental health problems and their psychology are limited. The purposes of this study were to investigate mental health problems of Korean adolescents, to reveal factors affecting their negative mental health and to explore a possible relationship between mental health problems and psychological variables. 2052 Korean adolescents selected randomly from junior high and high schools in Seoul, Korea were surveyed. Korean Symptom Checklist, Health Locus of Control Scale, Self-efficacy Scale and Self-esteem Scale were used to identify mental health problems and psychological variables of adolescents. Results indicated that Korean adolescents showed high prevalence in interpersonal sensitivity, depression, anxiety and hostility. In addition, the findings revealed that there were significant differences in adolescents’ mental health problems between gender and age. Furthermore, results revealed that the adolescents’ mental health problems were statistically correlated with psychological variables. This study provides significant information for the relatively unstudied Korean adolescents and also has the potential to influence the development of better mental health programs for adolescents. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: Mental health problem; Psychological variable; Korean adolescent
1. Introduction The term adolescence comes from the Latin ‘‘adolescere’’ meaning ‘‘to grow up’’ and describes that period of time between the beginning of puberty and the attainment of adulthood (Bennett, 1982). Adolescence has been defined biologically, psychologically and sociologically while being described variously as a stage; a crossroad in life; a transition; and a process (Hurrelmann and Losel, 1990; Hogarth, 1991). Kenny $ This study was supported by the research fund of Seoul National University of Technology. *Tel.: +822-970-6275; fax: +822-972-9763. E-mail address: [email protected] (Y.-H. Kim).
and Job (1995) defined adolescence as the period of transition from childhood to adulthood characterized by efforts to achieve goals related to the expectations of the mainstream culture and by spurts of physical, mental, emotional and social development. It is clear that definitions of adolescence can be considered from biological, sociological and psychological perspectives. However, whatever position is taken as a starting point, adolescence is a developmental stage synergizing biological maturation, enhancement of socialization and an increase of psychological skills. Important outcomes of this synergy are health related behaviors and health status both during adolescence itself and in subsequent years (Kim, 1998a).
0020-7489/03/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 3 7 - 8
116
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
In recent years, it has been widely noted that a surprising number of adolescents suffer emotional and mental problems (Heaven, 1996). Of added importance is the fact that such turmoil is very often carried over into adulthood with serious implications for adjustment during the post-adolescent years (Kazdin, 1993). Concerted efforts, in this regard, have been directed towards the development, implementation, and treatment practices with the adolescent population in developed countries. Moreover, there has been a shift towards theoretically based studies and empirically supported practices that mandate mental health care that focuses on the broad ranges of interactions with other negative health behaviors and psychological dispositions in adolescence. Mental health problems presenting during the adolescent years may represent a persistence of problems that arose in childhood or the onset of new illness. These mental health problems generally include interpersonal sensitivity, loneliness, depression, anxiety, hostility, and are sometimes associated with suicide (Jensen, 1991; Waters, 1991). Raphael (1993) reported that anxiety, depression and adjustment problems were the major mental health problems that occurred frequently during adolescence. Within adolescent health, mental health is an issue and the behavioral outcomes of this issue are reflected in the mortality and morbidity statistics (Raphael, 1993). In a US community sample, Kashani et al. (1987) reported that 41% of adolescents had at least one mental problem, and 19% were judged to be functionally and emotionally impaired. Similarly, US statistics related to mental health problems of adolescents indicated that between 12% and 22% of those under the age of 18 had at least one diagnosable mental problem (US DHHS, 1990). In addition, Waters (1991), in an Australian community sample, indicated that 15% of adolescents aged 13 to 17 years had their daily functioning impaired by mental health problem and for 19 years old the figure was 20%. A further Australian study pointed out that an estimated 53% of students were concerned about feeling depressed; 50% were concerned about emotional upsets; and, 48% had negative feeling about themselves or aspects of their life (Nancarrow, 1993). In a recent study, McCauley et al. (1999) investigated gender differences in American adolescents’ mental health. The authors in this study indicated that female adolescents reported significantly lower level of selfconfidence and substantially higher level of depression and anxiety than did males. Such gender differences in adolescents’ mental health were supported by the results of Hishinuma et al. (2000), indicating that female adolescents scored significantly higher on anxiety than their male counterparts. In addition, Neto and Barros (2000) surveyed 487 adolescents in Portugal to examine
age differences in adolescents’ mental health problems. They argued that the students in early adolescence reported higher scores on loneliness and anxiety than did those in late adolescence. Adolescent mental health is as important in Korea as it is in Western countries. During the 1980s, few studies were conducted in Korea to estimate problems related to mental health. In the mid-1990s, the Committee of Adolescent Protection (1995) performed a study of 1326 adolescent in/out-patients in 19 general and psychiatric hospitals in Korea. In this study, 17% of adolescents had anxiety, 23% were judged to have interpersonal sensitivity and 15% were diagnosed with depression. More recently, The Korean Ministry of Health and Welfare (1998) reported that the patient numbers due to mental health problems had increased steadily each year since 1985. Females were twice as likely to suffer mental health problems than males. And, in the adolescent group, the number of patients with mental health problems doubled between 1994 and 1995. In addition, Michalos (1991) indicated that 30% of Korean students experienced anxiety, and 48% of those felt depression in daily life. Results also pointed out that male students had higher anxiety than female students, and females rated higher scores than males for depression. These gender differences in depression were supported by Donnelly (1995) and McCauley et al. (1999), but the result for anxiety was different from the findings of Hishinuma et al. (2000). Such mental health problems not only depend on issues of appropriate socialization and on factors of positive environmental conditions, but also on the individual’s perception of what is real to them. In this regard, Kim (1998a) indicated that adolescents’ mental health problems may result from peer group pressures, family situations, school problems, and more importantly their own psychological dispositions.
2. Psychological factors related to mental health problems Mental health itself is a complex multi-factorial reality and the overt expression of a complicated interaction of physical, social and psychological factors (Kazdin, 1993). Therefore, factors that impinge upon and effect the mental health of adolescents can be related to issues from the emotional, social, psychological and behavioral domains. In particular, mental health problems of adolescents may be caused by negative psychological propensity, such as low self-esteem and self-efficacy and loss of ability to control health (Hurrelman and Losel, 1990). Traditionally, issues concerning adolescents’ mental health have been focused on providing information, education and counseling programs without considering
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
fully the psychological constructs. As a result, it is timely to rethink the concept of adolescents’ mental health and consider this as part of a comprehensive approach to health care for adolescents. It is recognized that recent research on adolescents’ mental health has been focused on beliefs, attitudes and values related to mental health. Moreover, a large volume of studies have argued that such beliefs and attitudes with regard to mental health can be clearly related to psychological variables (Rivas Torres and Fernandez, 1995; Bolognini et al., 1996; Byrne, 2000; Takakura and Sakihara, 2000; Muris et al., 2001). 2.1. Self-esteem and mental health Self-esteem is widely recognized as a central aspect of psychological functioning and it is related to many other variables, including general satisfaction with one’s life. According to Kalliopuska (1990), self-esteem is part of the individual’s identity that is not static, but rather, is always susceptible to internal and external influences. He also suggests that self-esteem is an internal sense of self-regard, which includes confidence in one’s own abilities and judgments, and it serves as a measure of the self-praise and the favorable perspective with which a person attributes to himself. For example, people who have high self-esteem tend to emphasize their abilities, strengths and good qualities, whereas individuals with low self-esteem focus on their deficiencies, weakness and negative qualities. Schlenker et al. (1976) also suggested that individuals with high self-esteem were used to experiencing personal success and prefer positive feedback about themselves from others. Individuals with low self-esteem were accustomed to experiencing failure and were willing to accept negative feedback. Rosenberg (1985) argued that self-esteem was associated with many psychological variables as well as behavioral ones. He suggested, for example, that when compared to adolescents with high self-esteem, those with low self-esteem were more depressed, less satisfied with life and scored highly on anxiety, aggression and irritability. Bolognini and colleagues (1996) noted that self-esteem was a determining variable in the mental health of early adolescence and that adolescents with low self-esteem tended to report significantly higher scores on depression. Bolognini et al. also revealed that males demonstrated a higher correlation between self-esteem and mental health than did females. Females, however, reported more problems with depression and anxiety than males. Such a relationship between mental health and selfesteem was supported by the findings of Byrne (2000). In this study, the author indicated that adolescents’ anxiety and fear were substantially correlated with low self-
117
esteem. In addition, using the self-esteem construct the results revealed that boys showed a significant decrease in both anxiety and fear during the coping session, while the girls had consistently low levels of self-esteem. 2.2. Self-efficacy and mental health Self-efficacy was introduced by Bandura (1977) in the context of cognitive modification. Self-efficacy relates to ‘‘individuals’ perceptions and refers to beliefs that people can perform successfully the behavior necessary to produce a desired outcome’’ (Bandura, 1986, p. 391). It is reported that one’s self-efficacy produces the selfconfidence necessary for the successful performance of preventive behaviors. A person who has low self-efficacy in a given situation is likely to avoid difficult tasks, shows low aspirations and makes minimal commitments to goals. In contrast, a person with strong self-efficacy, in a particular situation, perceives tasks as challenges rather than threats, tries to overcome the tasks and maintain commitments to goals (Bandura, 1982). The concept of self-efficacy has been applied to such diverse areas as school achievement, and emotional and mental health. For mental health problems, perceived self-efficacy represents the belief that one can change negative mental health by personal action (e.g., skill acquisition to avoid negative mental health) and this belief affects the intention to change negative behavior and the amount of effort expended to attain this goal (Kim, 1998a). Rivas and Fernandez (1995) indicated that selfefficacy was an important factor in maintaining the mental health of adolescents. Specifically, higher selfefficacy was closely related to avoidance of sadness and control of one’s feelings. This study also implied that self-efficacy was significantly and positively correlated with maintenance of self-confidence and underlined the importance of taking psychological factors into account in the design of mental health programs. Muris et al. (2001a) investigated the relationships between adolescents’ depression and self-efficacy in Netherlands. In this study, depression was accompanied by high levels of negative attributions and low levels of self-efficacy. Findings implied that self-efficacy played a meditating role in the decrease of depressive symptoms. Muris et al. (2001b) supported Muris et al. (2001a)’s findings and indicated that self-efficacy was significantly related to not only adolescents’ depression but also their anxiety. They also reported that adolescents’ anxiety and depression was reduced with an increase in their self-efficacy. 2.3. Health locus of control and mental health Health locus of control (HLC), as a psychological construct, originated from Rottor’s (1954) social
118
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
learning theory which sought to explain, predict and influence people’s perception and behavior regarding their health. The main tenet of social learning theory is that the likelihood of a behavior occurring in a given situation is a function of: (a) the individual’s expectancy that the behavior will lead to a particular reinforcement and (b) the extent to which the reinforcement is valued. In this theory, reinforcement has been recognized as a determinant of behavior. The perception of the individual about the sources of this reinforcement is an important element in determining future behavior. In other words, the perception of the individual about reinforcement as a generalized expectancy regarding the perceived relationship between one’s actions and experienced outcomes creates dichotomous variables termed internal and external locus of control (Rottor, 1966). In 1981, Levenson developed a multidimensional perspective of locus of control on the basis of Rottor’s unidimensional model. Here external locus of control is divided into two dimensions; powerful others and chance (an aspect of risk). Control by powerful others refers to the belief that individual health is determined by the actions of doctors and other health professionals through their instructions, medications and recommendations. Control by chance refers to the belief that health risks are largely a matter of luck or fate and cannot be controlled (Levenson, 1981). In exploring the relationship between mental health and HLC, Nada-Raja et al. (1994) examined health beliefs of adolescents regarding mental health. In this study, male students had stronger and simultaneous beliefs in internal, chance and powerful others’ locus of control than females. Females differed significantly from males in that they believed good mental health was associated with external locus of control. The recent study by Takakura and Sakihara (2000) examined locus of control associated with adolescents’ depressive symptoms. The results noted that adolescents’ depression was positively associated with internal HLC and negatively related to powerful other and chance locus of control. Further, authors argued that high levels of internal locus of control might have a crucial role in the prevention of depression in adolescence. Psychological factors that influence the mental health of adolescents in different cultures have frequently been identified. However, the same level of research has not been carried out on the Korean adolescent population. Mental health problems, especially in Korea, are only now being considered crucial factors in the health status of adolescents and important public and social issues. It is also true that data concerning the link between adolescents’ mental health and their psychology are limited.
The purposes of the study were to explore the mental health problems of Korean adolescents, to reveal variables affecting their negative mental health and to explore a possible relationship between mental health problems and psychological factors.
3. Method 3.1. Sample After receiving permission from the principals and parents, 2200 students (male: 1146, female: 1054) ranged from 7th to 12th grade who attended junior high and high schools in Seoul, Korea were asked to participate in a survey designed to assess their mental health problems. Out of a possible 2200, 2052 students (male: 1068, female: 984) were invited to participate in the study; 93.3% gave their consent and completed the survey form. Only 6.7% of the subjects declined participation. The non-participants were not significantly different in age or gender from students who participated. The subjects were selected by a random sampling from six schools, geographically located in the northern areas of Seoul. All students in the age cohort were 14–19 years (M ¼ 16:0 years). 3.2. Instruments For the mental health of Korean adolescents, the instrument applied in the study was Korean Symptom Checklist (Kim et al., 1978). This consisted of 4 subdimensions and 38 items (9 items for interpersonal sensitivity, 13 items for depression, 10 items for anxiety, 6 items for hostility). For content validity of the instrument four experts familiar with the health behavior literature were asked to examine each item for congruence with the concept of mental health problems. From their recommendations, 7 items were altered. Through this process, content validity suitable to the purposes of the study was established. The instrument was given to a pilot sample of 156 secondary school students (male: 88, female: 68) of the similar age to the target sample to obtain reliabilities of the instrument. The obtained data were analyzed for internal consistency on the first administration and for stability on a repeat administration to 64 students in the same sample 2 weeks later. This process obtained test– retest r for the four sub-dimensions: 0.80 for interpersonal sensitivity, 0.90 for depression, 0.91 for anxiety and 0.84 for hostility. To assess Korean adolescents’ beliefs, self-reliability and ability to control health and life satisfaction relating to health, the three instruments translated by Kim
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
(1998a) were used: HLC Scale, Self-efficacy Scale and Self-esteem Scale. The Multidimensional HLC Scale, developed by Wallston et al. (1978), was translated into Korean and used in the study. The revised questionnaire consisted of the three sub-scales and 18 items, and alpha reliabilities of each sub-scale were 0.83 for internal HLC, 0.79 for powerful other HLC, and 0.81 for chance HLC. The Self-efficacy Scale, developed by Sherer et al. (1982), was also revised into a Korean version and adopted for the study. Among 17 items, 13 items were reversed requiring the scores to be converted. A Cronbach alpha coefficient of 0.88 was reported for this questionnaire. The Korean version of the Self-esteem Scale, originally developed by Rosenberg (1965) was applied to the study. This questionnaire consisted of 10 items, and five reversed items required scores to be converted. The test– retest reliability method was performed and a reliability of 0.83 was obtained. The psychometric instruments were sent out to four Korean experts familiar with the health psychology and adolescent health to obtain their comments regarding content and construct validity. They were then asked to check and make suggestions for improving the instruments. From their recommendations, the wording of 11 items was changed in the three psychometric instruments. Through this process, content validity, suitable to the purposes of the study, was established. The pilot forms of the psychometric instruments were translated into Korean, and given to a sample of 156 secondary school students to evaluate item clarity and response variance. Examination of frequency distributions indicated that the full range of responses was being used for most items. The students completed the survey with no difficulties in understanding the items. 3.3. Procedures Before the fieldwork, the principal of each selected school was required to agree to the research being carried out in his or her school. Hence, the researcher approached the principal and explained the aims of the research and procedures of data collection. Through this process, the principal’s permission was received. In addition, the researcher was required to obtain permission of the students and their parents. A letter with a permission slip was provided for this purpose. This letter was sent to each parent before the testing sessions. Only students who returned the permission slips signed by themselves and their parents, took part in this study. To correct the data, times were arranged for subjects to complete the battery of instruments. The aims and processes of testing were explained to the students, and each questionnaire was introduced by the researcher.
119
Students were advised that confidentiality would be maintained and voluntary participation was emphasized. After the questionnaires were distributed, time was allowed for the students to ask questions for clarification about any part of the process. After the students had completed the questionnaires they were collected and a control sheet was attached to the front of the top paper to enable coding to be completed.
4. Results 4.1. Mental health of Korean adolescents in this study Table 1 shows the result of frequency analysis concerning Korean adolescents’ mental health problems. Korean adolescents with 74.3% responded that they have frequently experienced ‘interpersonal sensitivity’ and 56.9% of adolescents have felt ‘depression’, 48.8% for ‘anxiety’ and 41.6% for ‘hostility’ owing to a variety of daily stresses including school. Considering the high prevalence in all sub-dimensions, negative mental health in the Korean adolescents is a crucial factor that might adversely affect their overall health. In addition, there were significant mean differences between male and female adolescents in all subdimensions of mental health problems. Female adolescents reported that they have higher scores on ‘interpersonal sensitivity’ (t ¼ 16:40), ‘depression’ (t ¼ 15:62), ‘anxiety’ (t ¼ 9:89) than males; meanwhile, males have more frequently experienced ‘hostility’ (t ¼ 8:92),
Table 1 Prevalence of mental health problems among respondents Mental health problems Interpersonal sensitivity
Depression
Anxiety
Hostility
Total
Case (N)
Percent (%)
Experienced
1524
74.3
Never experienced Experienced Never experienced Experienced Never experienced Experienced Never experienced
528
25.7
1167 962
56.9 43.1
1001 1051
48.8 51.2
853 1199
41.6 58.4
2052
100.0
Cut-off point: Never experienced: not al all (1). Experienced: Seldom (2), occasionally (3), often (4) and repeatedly (5).
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
120
compared with their female counterparts (all po0:001) (see Table 2). Table 3 shows the mean differences in the subdimensions of mental health problems by age (F ¼ 14:63 for interpersonal sensitivity, F ¼ 6:59 for depression, all po0:001). Adolescents aged 18–19 years reported that they have most frequently experienced ‘interpersonal sensitivity’ and ‘depression’ in the three age groups, although there were no statistical differences in ‘anxiety’ and ‘hostility’ by age (Tables 4 and 5).
4.2. Correlation between mental health and psychological variables Correlation analysis was conducted to identify the relationships of psychological variables to the subdimensions of adolescents’ mental health. Results revealed that all the sub-domains of psychological variable were significantly correlated with almost all sub-dimensions of mental health. Among them, IHLC was strongly correlated with ‘depression’ (r ¼ 0:44), ‘interpersonal sensitivity’ (r ¼ 0:35) and ‘anxiety’ (r ¼ 0:35). PHLC also had substantial correlations with ‘interpersonal sensitivity’ and ‘anxiety’ (r ¼ 0:24 and 0.15, respectively), meanwhile CHLC was significantly correlated with ‘hostility’ (r ¼ 0:21). Furthermore, the results indicated that the self-efficacy construct was strongly correlated with ‘depression’ (r ¼ 0:43), ‘anxiety’ (r ¼ 0:37) and ‘hostility’ (r ¼ 0:26).
Table 2 Mean and SD of mental health problems by gender Variable
Interpersonal sensitivity Depression Anxiety Hostility n
Male
t
Female
M
SD
M
SD
3.23 3.30 3.49 3.32
0.73 0.79 0.65 0.49
3.89 4.02 3.76 3.03
0.79 0.83 0.57 0.62
16.40n 15.62n 9.89n 8.92n
po0.001.
In the case of self-esteem, there were significantly correlations with ‘depression’, ‘anxiety’ and ‘hostility’, ‘interpersonal sensitivity’ (r ¼ 0:39; 0.39, 0.29 and 0.26, respectively). 4.3. Effect of psychological factors on mental health To examine the effect of sub-dimensions of psychological factor on mental health problems, multiple regression analysis using the analysis of moment of structure (AMOS) program was applied. According to the standardized regression coefficients and squared multiple correlation coefficients, all of the psychological variables had a statistically significant impact on almost all mental health problems. 31% of the total psychological variables accounted for ‘interpersonal sensitivity’ (R2 ¼ 0:31) and among five psychological variables PHLC (b ¼ 0:34) had the strongest effect on ‘interpersonal sensitivity’. In addition, 49% of total psychological variables explained ‘depression’ (R2 ¼ 0:49), and self-efficacy, self-esteem, IHLC and PHLC had a substantial effect on ‘depression’ (b ¼ 0:45; 0.42, 0.41 and 0.15, respectively). Furthermore, 36% of total psychological variables accounted for ‘anxiety’ (R2 ¼ 0:36), and among psychological variables, self-esteem (b ¼ 0:39), self-efficacy (b ¼ 0:37), IHLC (b ¼ 0:36), PHLC (b ¼ 0:24) and CHLC (b ¼ 0:18) had a significant linear relation with ‘anxiety’. The results indicated that 21% of total psychological variables explained ‘hostility’ (R2 ¼ 0:21), and CHLC, self-efficacy and self-esteem statistically substantial effect on ‘hostility’ (b ¼ 0:32; 0.18, and 0.16, respectively). The use of the AMOS program allowed the observed variables in mental health (e.g., depression and anxiety, etc.) and psychological variable (e.g., IHLC and selfefficacy, etc.) to be treated as one factor (Arbuckle, 1997). The AMOS program, then analyzed the possible correlation between the latent variables (e.g., mental health and psychological factors). As a result, a correlation coefficient between mental health and psychological factors was obtained (r ¼ 0:43).
Table 3 Mean and SD of mental health problems by age Variable
Interpersonal sensitivity Depression Anxiety Hostility n
po0.001.
14–15 (year)
16–17 (year)
F
18–19 (year)
M
SD
M
SD
M
SD
3.43 3.40 3.55 2.89
0.68 0.71 0.77 0.62
3.62 3.53 3.54 2.87
0.55 0.80 0.74 0.59
3.92 3.71 3.54 3.01
0.73 0.76 0.75 0.60
14.63n 6.59n 2.10 0.88
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
121
Table 4 Correlation among all variables Variable
IS
D
An
H
IHLC
PHLC
CHLC
SEf
SEs
IS D An H IHLC PHLC CHLC SEf SEs M SD
1.00 0.42** 0.33** 0.34** 0.35** 0.24** 0.04 0.05 0.26** 3.13 0.72
1.00 0.36** 0.56** 0.44** 0.06 0.06 0.43** 0.39** 3.45 0.76
1.00 0.14* 0.35** 0.15* 0.08 0.37** 0.39** 3.58 0.80
1.00 0.07 0.08 0.21** 0.26** 0.29** 3.15 0.62
1.00 0.05 0.08 0.21** 0.24** 4.55 0.79
1.00 0.36** 0.11* 0.16* 3.38 0.69
1.00 0.15* 0.05 3.36 0.65
1.00 0.58** 8.32 1.57
1.00 2.83 0.48
*po0.05; **po0.001. IS: Interpersonal sensitivity; D: Depression; An: Anxiety; H: Hostility; IHLC: Internal health locus of control; PHLC: Powerful other health locus of control; CHLC: Chance health locus of control; SEf: Self-efficacy; SEs: Self-esteem.
Table 5 The Standardized regression coefficient and squared multiple correlation coefficient between mental health problems and psychological factors Variable
Mental health problems IS
Psychological Factor IHLC 0.33** PHLC 0.34** CHLC 0.06 SEf 0.07 Ses 0.27**
D
An
H
0.41** 0.15* 0.04 0.45** 0.42**
0.36** 0.24** 0.18* 0.37** 0.39**
0.07 0.08 0.32** 0.18* 0.16*
R2 0.31 0.49 0.36 Correlation between latent variables: r ¼ 0:43
0.21
*po0.05; **po0.001. IS: Interpersonal sensitivity; D: Depression; An: Anxiety; H: Hostility; IHLC: Internal health locus of control; PHLC: Powerful other health locus of control; CHLC: Chance health locus of control; SEf: Self-efficacy; SEs: Self-esteem.
5. Discussion This study makes a unique contribution to the existing knowledge about Korean adolescents. Adolescent mental health in Korea is not a prime focus for educators, health workers, government bureaucrats or politicians. Indeed, mental health care is in its infancy and only just emerging as a social educational issue. Along with such a socially undervalued context, there has been very limited research into adolescent mental health and psychology in Korea. Before discussing the implications of the findings, it is important to consider the methodological limitations of
this study. This study did not focus on obtaining data from the lower socioeconomic, rural or out-of-school adolescents. Therefore, data obtained from the adolescents in the midrange socioeconomic status region of Kyunggi-do cannot be considered representative of the eligible population of all Korean adolescents. One of the frequently questioned methodological limitations in survey research is how to apply the adopted instruments developed in other countries. However, the validity of the instruments used in this study has been proved by the similarity between behavioral and psychological findings obtained by other Korean studies with the same instruments (Kim, 1998a, 1998b, 1999; Hyun, 2001). This study adopted only age and gender as the demographic factors which can possibly affect adolescents’ mental health problems. Hence, it cannot identify the potential influence of other demographic factors such as family income and parents’ education on the mental health problems of adolescents. The primary focus of this study was to explore the possible relationship between adolescents’ mental health problems and some psychological variables. Therefore, interaction effects between mental health problems and demographic factors have not been considered. In spite of such methodological limitations, this study provides much needed information about Korean adolescents in terms of their mental health issues and aspects of psychological constructs which relate directly to negative mental health. It further explored the relationship of these constructs to negative mental health, all of which are the foci of this research. The study identified that Korean adolescents in this study had a problem with their mental health. Almost half of adolescents experienced depression, anxiety and hostility. It might be possible to explain that such mental health problems are because of too much stress about
122
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
study, parents’ excessive expectation and demand and exclusion from a peer group. 74.3% of respondents reported that they have experienced interpersonal sensitivity. It could be possible to interpret that many adolescents alone in modern society have tended to spend considerable time with computers and as a result, they are likely to be egocentric and fail in building meaningful interpersonal relationships. This could not be substantiated from literature and thus, there is a need for further study to see whether it is an aspect of Korean culture. Many Western studies support this study’s findings. According to Nancarrow (1993), a large volume of students was concerned with general mental heath problems. The results showed that an estimated 53% of students were concerned about feeling depressed; 50% were concerned about emotional upsets; and, 48% had negative feeling about themselves or aspects of their life. Such negative issues in adolescent mental health are not confined in one society, but applied in all societies around the world. These findings should provide effective data to promote adolescents’ mental health in school health education and community-based health care. From the findings, there were significant differences between male and female adolescents in all dimensions of mental health problems. Compared with their male counterparts female adolescents scored highly in interpersonal sensitivity, depression and anxiety. It is generally recognized that female adolescents in or over puberty tend to have an emotional disposition and hence are likely to be sensitive to the common events in everyday life. This result was supported by the findings of McCauley et al. (1999) and Hishinuma et al. (2000), indicating that female adolescents were more likely to be anxious and depressed than males. In addition, adolescent’ mental health was in part different between the three age groups. Of the three groups, adolescents aged 18–19 years reported that they have most frequently experienced interpersonal sensitivity and depression. It is not unexpected that older adolescents have a higher possibility of experiencing mental health problems than younger adolescents. Mental health itself is a complex concept, and the specific components of mental health are elusive and intangible elements. In addition, these mental health problems depend on people’ perceptions and behaviors through their interactions in and with their environment. In this regard, the result about age difference can be explained that in a developmental viewpoint, older adolescents, in general, have experienced a variety of negative and uncomfortable events through their lifetime than adolescents in early and middle adolescence. This could not be substantiated from the literature and thus, there is a need for further study to see whether it is an aspect of Korean culture.
From a large number of previous studies it has been concluded that psychological variables are significantly related to mental health problems of adolescents and identifying such a relation was a key focus of this study. Regarding a relationship of mental health problems with psychological variables in adolescence, this study revealed that the three psychological variables had direct effects on almost all of the domains of mental health problems. The results were supported by evidence presented in previous research (Copper et al., 1998; Strauss, 2000; Takakura and Sakihara, 2000; Muris et al., 2001b), and in practical terms reinforced the argument for consideration of psychological aspects in the development of mental health programs. These identified correlations allowed for further exploration of possible relationships between the subdimensions in negative mental health and the constructed psychological factor. Clearly, the correlation model proposed in this study was an adequate fit to explore possible links expressed numerically in terms of correlations, and equally and clearly the relationships between mental health problem and the psychological factor were significant. Such findings of the existence of significant relationships suggest understanding could be increased if further studies were to be undertaken to look at relationships between psychological factors and other specific dimensions of adolescent health. On the basis of these findings, this study provides significant information not previously obtained on psychological factors related to Korean adolescents’ mental health problems. In Korea, the field of adolescent mental health is just beginning to develop, and there is a lack of research, which describes adolescents’ risk behavior and health psychology. In a perspective of exploratory research, it is important to share the results because there are virtually no studies of the relationships between mental health and psychological constructs in Korea. For Korea, this study has the potential to influence the development of better mental health care and mental health promotion programs for adolescents. More importantly, the findings of this study suggest that nurses should take a more assertive role in promoting and designing risk reduction interventions congruent with the values and perceptions of Korean adolescents. The ideas and issues identified through this study are in line with the results of previous research in the field on adolescent mental health. Some questions have been answered, and underlying premises have been confirmed. There are, however, additional issues that require further elaboration and investigation. A further study should be considered using more sophisticated techniques to measure mental health problems of Korean adolescents. It is important to adequately prepare, better equip and encourage health workers to
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
deal with the physical, psychological and social needs of adolescents of different demographic and ethnic backgrounds.
References Arbuckle, J., 1997. AMOS Users’ Guide: Version 3.6. SmallWaters Corporation, Chicago. Bandura, A., 1977. Self-efficacy: toward a unifying theory of behavioral change. Psychological Review 84, 191–215. Bandura, A., 1982. The assessment and predictive generality of self-perception of efficacy. Journal of Behavioral Theory and Experimental Psychiatry 13 (3), 195–199. Bandura, A., 1986. Social Foundation of Thought and Action: A Social Cognitive Theory. Prentice-Hall, Englewood Cliffs NJ. Bennett, D., 1982. Problems for adolescent and youth in the community. New Doctor, March 19–21. Bolognini, M., Plancherel, B., Bettechart, W., Halfon, O., 1996. Self-esteem and mental health in early adolescence. Journal of Adolescence 19, 233–245. Byrne, B., 2000. Relationship between anxiety, fear, self-esteem and coping strategies in adolescence. Adolescence 35 (137), 215–301. Committee of Adolescent Protection, 1995. A National Health Survey for Korean 1994. Government Publishing Services, Seoul. Copper, M.L., Shaver, P.R., Collins, N.L., 1998. Attachment styles, emotion regulation and adjustment in adolescence. Journal of Personality and Social Psychology 74 (5), 1380– 1397. Donnelly, M., 1995. Depression among adolescents in Northern Ireland. Adolescence 30, 339–350. Heaven, P.C.L., 1996. Adolescent Health: The Role of Individual Differences. Routledge, London. Hishinuma, E.S., Miyamoto, R.H., Nishimura, S.T., Nahulu, S.B., 2000. Differences in state-trait anxiety inventory scores for ethnically diverse adolescent in Hawaii. Cultural Diverse Ethnic Minority Psychology 6 (1), 73–83. Hogarth, C., 1991. Adolescent Psychiatric Nursing. Mosby Year Book, St. Louis. Hurrelmann, K., Losel, F., 1990. Health hazards in adolescence. De Gruyter, Berlin. Hyun, S.K., 2001. The effect of physical activity on health related psychological constructs in the old females. Master Thesis, HanYang University, Korea. Unpublished. Jensen, P., 1991. Mental health and disorder in children and adolescents: current status and research needs. Community Health 14 (3), 1–11. Kalliopuska, M., 1990. Self-esteem and empathy as related to participation in the arts or sports activities. In: L. Oppenheimer (Ed.), The Self-concept, European Perspectives on its Development, Aspects and Application. Springer, New York, pp. 120–123. Kashani, J.H., Beck, N., Hoeper, E.W., Fallahi, C., Corcoran, C.M., MaAllister, J.A., Rosenberg, T.K., Reid, J.C., 1987. Psychiatric disorders in a community sample of adolescents. Adolescent Journal of Psychiatry 144, 584–589.
123
Kazdin, A., 1993. Adolescent mental health: prevention and treatment programs. American Psychologist 48, 127–141. Kenny, D.T., Job, R.F.S., 1995. Australia’s Adolescent: a health psychology perspective. University of New England Press, Armidale, Australia. Kim, Y.H., 1998a. Adolescents’ perceptions with regard to health risks, health profile and the relationship of these variables to a psychological factor—a study across gender and different cultural settings. Ph.D. Thesis, University of Wollongong, Australia, unpublished. Kim, Y.H., 1998b. Health related psychological constructs in adolescence: differences in gender and culture. Korean Journal of Sport for All 11, 563–571. Kim, Y.H., 1999. Adolescents’ risk perception to health and its relationship with psychological variables. Third International Congress Asian-South Pacific Association of Sport Psychology(ASPASP), Wuhan, China. Kim, G.I., Won, H.T., Lee, J.H., Kim, G.Y., 1978. A Korean version study of symptom checklist: the response nature of normal person. Journal of Neuro psychological Medicine 17 (4), 449–487. Levenson, H., 1981. Differentiating among internality, powerful others and chance. In: Lefcourt, H.M. (Ed.), Research With the Locus of Control Construct, Vol. 1. Academic Press, New York. McCauley, O.C., Lerner, R.M., Lerner, J.V., Von E, .A., 1999. Does self-competence predict gender differences in adolescent depression and anxiety? Journal of Adolescence 22 (3), 397–411. Michalos, A.C., 1991. Global Report on Student Well-being, Vol. 1: Life Satisfaction and Happiness. Springer, London. Muris, P., Bogie, N., Hoogsteader, A., 2001a. Effects of an early intervention group program for anxious and depressed adolescents: a pilot study. Psychological Report 88 (2), 481–482. Muris, P., Schmidt, H., Lambrichs, R., Meesters, C., 2001b. Protective and vulnerability factors of depression in normal adolescents. Behavioral Research and Therapy 39 (5), 555–565. Nada-Raja, S., McGee, R., Williams, S., 1994. Health beliefs among New Zealand adolescents. Journal of Pediatric of Child Health 30, 523–529. Nancarrow, M., 1993. Adolescent health in hunter region: a survey of student perception and concerns. Thesis, University of Wollongong, Australia, unpublished. Neto, F., Barros, J., 2000. Psychosocial concomitants of loneliness among students of Cape Verde and Portugal. Journal of Psychology 134 (5), 503–514. Raphael, B., 1993. Adolescent resilience: the potential impact of personal development in school. Journal of Pediatric and Child Health 29 (Suppl. 1), 31–36. Rivas Torres, R.M., Fernandez, P., 1995. Self-esteem and value of health as determinants of adolescent health behavior. Journal of Adolescent Health 16, 60–63. Rosenberg, M., 1965. Society and Adolescent Self-image. Princeton University Press, Princeton. Rosenberg, M., 1985. Self-concept and psychological well-being in adolescence. In: Leary, P.L. (Ed.), The Development of the Self. Academic Press, New York. Rottor, J.B., 1954. Social Learning and Clinical Psychology. Prentice Hall, Englewood Cliffs, NJ.
124
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
Rottor, J.B., 1966. Generalized expectancies for internal and external control of reinforcement. Psychological Monographs: General and Applied 80, 1–28. Schlenker, B.R., Soraci, S., McCarthy, B., 1976. Self-esteem and group performance as determinants of ego-centric perceptions in cooperative groups. Human Relations 29, 1163–1176. Sherer, M., Maddux, J.E., Mercandane, B., Prentice-Dunn, S., Jacobs, B., Rogers, R.W., 1982. The self-efficacy scale: construction and validation. Psychological Reports 51, 663–671. Strauss, R.S., 2000. Child obesity and self-esteem. Pediatrics 105 (1), 15–16. Takakura, M., Sakihara, S., 2000. Gender differences in the association between psychological factors and depressive
symptoms in Japanese junior high school students. Journal of Epidemiology 10 (6), 383–391. The Ministry of Health and Welfare, 1998. Annual Report for Health, Government Printing Service, Seoul, Korea. US Department of Health and Human Services, 1990. National Plan for Research on Child and Adolescent Mental Disorders, National Institute of Mental Health. US Government Printing Service, Washington DC. Wallston, K.A., Wallston, R.S., DeVellis, R., 1978. Development of the multidimensional health locus of control scale. Health Education Monograph 6, 160–170. Waters, B.C., 1991. Emerging issues in adolescent mental health. Behavioral Medicine Conference, University of Sydney, Sydney.
Correlation of mental health problems with psychological constructs in adolescence: final results from a 2-year study$ Young-Ho Kim* Department of Sport and Leisure Studies, Seoul National University of Technology, 172 Kongneung-dong, Nowon-gu, Seoul 139-743, South Korea Received 24 October 2001; received in revised form 1 April 2002; accepted 31 May 2002
Abstract In recent years, it has been widely witnessed that a surprising number of adolescents suffer emotional and mental health problems, and such turmoil is very often carried over into adulthood with serious implications for adjustment during the post-adolescent years. On this point, mental health problems in Korea are only now being considered crucial factors in the health status of adolescents and important public and social issues. It is also true that studies concerning the link between adolescents’ mental health problems and their psychology are limited. The purposes of this study were to investigate mental health problems of Korean adolescents, to reveal factors affecting their negative mental health and to explore a possible relationship between mental health problems and psychological variables. 2052 Korean adolescents selected randomly from junior high and high schools in Seoul, Korea were surveyed. Korean Symptom Checklist, Health Locus of Control Scale, Self-efficacy Scale and Self-esteem Scale were used to identify mental health problems and psychological variables of adolescents. Results indicated that Korean adolescents showed high prevalence in interpersonal sensitivity, depression, anxiety and hostility. In addition, the findings revealed that there were significant differences in adolescents’ mental health problems between gender and age. Furthermore, results revealed that the adolescents’ mental health problems were statistically correlated with psychological variables. This study provides significant information for the relatively unstudied Korean adolescents and also has the potential to influence the development of better mental health programs for adolescents. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: Mental health problem; Psychological variable; Korean adolescent
1. Introduction The term adolescence comes from the Latin ‘‘adolescere’’ meaning ‘‘to grow up’’ and describes that period of time between the beginning of puberty and the attainment of adulthood (Bennett, 1982). Adolescence has been defined biologically, psychologically and sociologically while being described variously as a stage; a crossroad in life; a transition; and a process (Hurrelmann and Losel, 1990; Hogarth, 1991). Kenny $ This study was supported by the research fund of Seoul National University of Technology. *Tel.: +822-970-6275; fax: +822-972-9763. E-mail address: [email protected] (Y.-H. Kim).
and Job (1995) defined adolescence as the period of transition from childhood to adulthood characterized by efforts to achieve goals related to the expectations of the mainstream culture and by spurts of physical, mental, emotional and social development. It is clear that definitions of adolescence can be considered from biological, sociological and psychological perspectives. However, whatever position is taken as a starting point, adolescence is a developmental stage synergizing biological maturation, enhancement of socialization and an increase of psychological skills. Important outcomes of this synergy are health related behaviors and health status both during adolescence itself and in subsequent years (Kim, 1998a).
0020-7489/03/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 3 7 - 8
116
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
In recent years, it has been widely noted that a surprising number of adolescents suffer emotional and mental problems (Heaven, 1996). Of added importance is the fact that such turmoil is very often carried over into adulthood with serious implications for adjustment during the post-adolescent years (Kazdin, 1993). Concerted efforts, in this regard, have been directed towards the development, implementation, and treatment practices with the adolescent population in developed countries. Moreover, there has been a shift towards theoretically based studies and empirically supported practices that mandate mental health care that focuses on the broad ranges of interactions with other negative health behaviors and psychological dispositions in adolescence. Mental health problems presenting during the adolescent years may represent a persistence of problems that arose in childhood or the onset of new illness. These mental health problems generally include interpersonal sensitivity, loneliness, depression, anxiety, hostility, and are sometimes associated with suicide (Jensen, 1991; Waters, 1991). Raphael (1993) reported that anxiety, depression and adjustment problems were the major mental health problems that occurred frequently during adolescence. Within adolescent health, mental health is an issue and the behavioral outcomes of this issue are reflected in the mortality and morbidity statistics (Raphael, 1993). In a US community sample, Kashani et al. (1987) reported that 41% of adolescents had at least one mental problem, and 19% were judged to be functionally and emotionally impaired. Similarly, US statistics related to mental health problems of adolescents indicated that between 12% and 22% of those under the age of 18 had at least one diagnosable mental problem (US DHHS, 1990). In addition, Waters (1991), in an Australian community sample, indicated that 15% of adolescents aged 13 to 17 years had their daily functioning impaired by mental health problem and for 19 years old the figure was 20%. A further Australian study pointed out that an estimated 53% of students were concerned about feeling depressed; 50% were concerned about emotional upsets; and, 48% had negative feeling about themselves or aspects of their life (Nancarrow, 1993). In a recent study, McCauley et al. (1999) investigated gender differences in American adolescents’ mental health. The authors in this study indicated that female adolescents reported significantly lower level of selfconfidence and substantially higher level of depression and anxiety than did males. Such gender differences in adolescents’ mental health were supported by the results of Hishinuma et al. (2000), indicating that female adolescents scored significantly higher on anxiety than their male counterparts. In addition, Neto and Barros (2000) surveyed 487 adolescents in Portugal to examine
age differences in adolescents’ mental health problems. They argued that the students in early adolescence reported higher scores on loneliness and anxiety than did those in late adolescence. Adolescent mental health is as important in Korea as it is in Western countries. During the 1980s, few studies were conducted in Korea to estimate problems related to mental health. In the mid-1990s, the Committee of Adolescent Protection (1995) performed a study of 1326 adolescent in/out-patients in 19 general and psychiatric hospitals in Korea. In this study, 17% of adolescents had anxiety, 23% were judged to have interpersonal sensitivity and 15% were diagnosed with depression. More recently, The Korean Ministry of Health and Welfare (1998) reported that the patient numbers due to mental health problems had increased steadily each year since 1985. Females were twice as likely to suffer mental health problems than males. And, in the adolescent group, the number of patients with mental health problems doubled between 1994 and 1995. In addition, Michalos (1991) indicated that 30% of Korean students experienced anxiety, and 48% of those felt depression in daily life. Results also pointed out that male students had higher anxiety than female students, and females rated higher scores than males for depression. These gender differences in depression were supported by Donnelly (1995) and McCauley et al. (1999), but the result for anxiety was different from the findings of Hishinuma et al. (2000). Such mental health problems not only depend on issues of appropriate socialization and on factors of positive environmental conditions, but also on the individual’s perception of what is real to them. In this regard, Kim (1998a) indicated that adolescents’ mental health problems may result from peer group pressures, family situations, school problems, and more importantly their own psychological dispositions.
2. Psychological factors related to mental health problems Mental health itself is a complex multi-factorial reality and the overt expression of a complicated interaction of physical, social and psychological factors (Kazdin, 1993). Therefore, factors that impinge upon and effect the mental health of adolescents can be related to issues from the emotional, social, psychological and behavioral domains. In particular, mental health problems of adolescents may be caused by negative psychological propensity, such as low self-esteem and self-efficacy and loss of ability to control health (Hurrelman and Losel, 1990). Traditionally, issues concerning adolescents’ mental health have been focused on providing information, education and counseling programs without considering
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
fully the psychological constructs. As a result, it is timely to rethink the concept of adolescents’ mental health and consider this as part of a comprehensive approach to health care for adolescents. It is recognized that recent research on adolescents’ mental health has been focused on beliefs, attitudes and values related to mental health. Moreover, a large volume of studies have argued that such beliefs and attitudes with regard to mental health can be clearly related to psychological variables (Rivas Torres and Fernandez, 1995; Bolognini et al., 1996; Byrne, 2000; Takakura and Sakihara, 2000; Muris et al., 2001). 2.1. Self-esteem and mental health Self-esteem is widely recognized as a central aspect of psychological functioning and it is related to many other variables, including general satisfaction with one’s life. According to Kalliopuska (1990), self-esteem is part of the individual’s identity that is not static, but rather, is always susceptible to internal and external influences. He also suggests that self-esteem is an internal sense of self-regard, which includes confidence in one’s own abilities and judgments, and it serves as a measure of the self-praise and the favorable perspective with which a person attributes to himself. For example, people who have high self-esteem tend to emphasize their abilities, strengths and good qualities, whereas individuals with low self-esteem focus on their deficiencies, weakness and negative qualities. Schlenker et al. (1976) also suggested that individuals with high self-esteem were used to experiencing personal success and prefer positive feedback about themselves from others. Individuals with low self-esteem were accustomed to experiencing failure and were willing to accept negative feedback. Rosenberg (1985) argued that self-esteem was associated with many psychological variables as well as behavioral ones. He suggested, for example, that when compared to adolescents with high self-esteem, those with low self-esteem were more depressed, less satisfied with life and scored highly on anxiety, aggression and irritability. Bolognini and colleagues (1996) noted that self-esteem was a determining variable in the mental health of early adolescence and that adolescents with low self-esteem tended to report significantly higher scores on depression. Bolognini et al. also revealed that males demonstrated a higher correlation between self-esteem and mental health than did females. Females, however, reported more problems with depression and anxiety than males. Such a relationship between mental health and selfesteem was supported by the findings of Byrne (2000). In this study, the author indicated that adolescents’ anxiety and fear were substantially correlated with low self-
117
esteem. In addition, using the self-esteem construct the results revealed that boys showed a significant decrease in both anxiety and fear during the coping session, while the girls had consistently low levels of self-esteem. 2.2. Self-efficacy and mental health Self-efficacy was introduced by Bandura (1977) in the context of cognitive modification. Self-efficacy relates to ‘‘individuals’ perceptions and refers to beliefs that people can perform successfully the behavior necessary to produce a desired outcome’’ (Bandura, 1986, p. 391). It is reported that one’s self-efficacy produces the selfconfidence necessary for the successful performance of preventive behaviors. A person who has low self-efficacy in a given situation is likely to avoid difficult tasks, shows low aspirations and makes minimal commitments to goals. In contrast, a person with strong self-efficacy, in a particular situation, perceives tasks as challenges rather than threats, tries to overcome the tasks and maintain commitments to goals (Bandura, 1982). The concept of self-efficacy has been applied to such diverse areas as school achievement, and emotional and mental health. For mental health problems, perceived self-efficacy represents the belief that one can change negative mental health by personal action (e.g., skill acquisition to avoid negative mental health) and this belief affects the intention to change negative behavior and the amount of effort expended to attain this goal (Kim, 1998a). Rivas and Fernandez (1995) indicated that selfefficacy was an important factor in maintaining the mental health of adolescents. Specifically, higher selfefficacy was closely related to avoidance of sadness and control of one’s feelings. This study also implied that self-efficacy was significantly and positively correlated with maintenance of self-confidence and underlined the importance of taking psychological factors into account in the design of mental health programs. Muris et al. (2001a) investigated the relationships between adolescents’ depression and self-efficacy in Netherlands. In this study, depression was accompanied by high levels of negative attributions and low levels of self-efficacy. Findings implied that self-efficacy played a meditating role in the decrease of depressive symptoms. Muris et al. (2001b) supported Muris et al. (2001a)’s findings and indicated that self-efficacy was significantly related to not only adolescents’ depression but also their anxiety. They also reported that adolescents’ anxiety and depression was reduced with an increase in their self-efficacy. 2.3. Health locus of control and mental health Health locus of control (HLC), as a psychological construct, originated from Rottor’s (1954) social
118
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
learning theory which sought to explain, predict and influence people’s perception and behavior regarding their health. The main tenet of social learning theory is that the likelihood of a behavior occurring in a given situation is a function of: (a) the individual’s expectancy that the behavior will lead to a particular reinforcement and (b) the extent to which the reinforcement is valued. In this theory, reinforcement has been recognized as a determinant of behavior. The perception of the individual about the sources of this reinforcement is an important element in determining future behavior. In other words, the perception of the individual about reinforcement as a generalized expectancy regarding the perceived relationship between one’s actions and experienced outcomes creates dichotomous variables termed internal and external locus of control (Rottor, 1966). In 1981, Levenson developed a multidimensional perspective of locus of control on the basis of Rottor’s unidimensional model. Here external locus of control is divided into two dimensions; powerful others and chance (an aspect of risk). Control by powerful others refers to the belief that individual health is determined by the actions of doctors and other health professionals through their instructions, medications and recommendations. Control by chance refers to the belief that health risks are largely a matter of luck or fate and cannot be controlled (Levenson, 1981). In exploring the relationship between mental health and HLC, Nada-Raja et al. (1994) examined health beliefs of adolescents regarding mental health. In this study, male students had stronger and simultaneous beliefs in internal, chance and powerful others’ locus of control than females. Females differed significantly from males in that they believed good mental health was associated with external locus of control. The recent study by Takakura and Sakihara (2000) examined locus of control associated with adolescents’ depressive symptoms. The results noted that adolescents’ depression was positively associated with internal HLC and negatively related to powerful other and chance locus of control. Further, authors argued that high levels of internal locus of control might have a crucial role in the prevention of depression in adolescence. Psychological factors that influence the mental health of adolescents in different cultures have frequently been identified. However, the same level of research has not been carried out on the Korean adolescent population. Mental health problems, especially in Korea, are only now being considered crucial factors in the health status of adolescents and important public and social issues. It is also true that data concerning the link between adolescents’ mental health and their psychology are limited.
The purposes of the study were to explore the mental health problems of Korean adolescents, to reveal variables affecting their negative mental health and to explore a possible relationship between mental health problems and psychological factors.
3. Method 3.1. Sample After receiving permission from the principals and parents, 2200 students (male: 1146, female: 1054) ranged from 7th to 12th grade who attended junior high and high schools in Seoul, Korea were asked to participate in a survey designed to assess their mental health problems. Out of a possible 2200, 2052 students (male: 1068, female: 984) were invited to participate in the study; 93.3% gave their consent and completed the survey form. Only 6.7% of the subjects declined participation. The non-participants were not significantly different in age or gender from students who participated. The subjects were selected by a random sampling from six schools, geographically located in the northern areas of Seoul. All students in the age cohort were 14–19 years (M ¼ 16:0 years). 3.2. Instruments For the mental health of Korean adolescents, the instrument applied in the study was Korean Symptom Checklist (Kim et al., 1978). This consisted of 4 subdimensions and 38 items (9 items for interpersonal sensitivity, 13 items for depression, 10 items for anxiety, 6 items for hostility). For content validity of the instrument four experts familiar with the health behavior literature were asked to examine each item for congruence with the concept of mental health problems. From their recommendations, 7 items were altered. Through this process, content validity suitable to the purposes of the study was established. The instrument was given to a pilot sample of 156 secondary school students (male: 88, female: 68) of the similar age to the target sample to obtain reliabilities of the instrument. The obtained data were analyzed for internal consistency on the first administration and for stability on a repeat administration to 64 students in the same sample 2 weeks later. This process obtained test– retest r for the four sub-dimensions: 0.80 for interpersonal sensitivity, 0.90 for depression, 0.91 for anxiety and 0.84 for hostility. To assess Korean adolescents’ beliefs, self-reliability and ability to control health and life satisfaction relating to health, the three instruments translated by Kim
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
(1998a) were used: HLC Scale, Self-efficacy Scale and Self-esteem Scale. The Multidimensional HLC Scale, developed by Wallston et al. (1978), was translated into Korean and used in the study. The revised questionnaire consisted of the three sub-scales and 18 items, and alpha reliabilities of each sub-scale were 0.83 for internal HLC, 0.79 for powerful other HLC, and 0.81 for chance HLC. The Self-efficacy Scale, developed by Sherer et al. (1982), was also revised into a Korean version and adopted for the study. Among 17 items, 13 items were reversed requiring the scores to be converted. A Cronbach alpha coefficient of 0.88 was reported for this questionnaire. The Korean version of the Self-esteem Scale, originally developed by Rosenberg (1965) was applied to the study. This questionnaire consisted of 10 items, and five reversed items required scores to be converted. The test– retest reliability method was performed and a reliability of 0.83 was obtained. The psychometric instruments were sent out to four Korean experts familiar with the health psychology and adolescent health to obtain their comments regarding content and construct validity. They were then asked to check and make suggestions for improving the instruments. From their recommendations, the wording of 11 items was changed in the three psychometric instruments. Through this process, content validity, suitable to the purposes of the study, was established. The pilot forms of the psychometric instruments were translated into Korean, and given to a sample of 156 secondary school students to evaluate item clarity and response variance. Examination of frequency distributions indicated that the full range of responses was being used for most items. The students completed the survey with no difficulties in understanding the items. 3.3. Procedures Before the fieldwork, the principal of each selected school was required to agree to the research being carried out in his or her school. Hence, the researcher approached the principal and explained the aims of the research and procedures of data collection. Through this process, the principal’s permission was received. In addition, the researcher was required to obtain permission of the students and their parents. A letter with a permission slip was provided for this purpose. This letter was sent to each parent before the testing sessions. Only students who returned the permission slips signed by themselves and their parents, took part in this study. To correct the data, times were arranged for subjects to complete the battery of instruments. The aims and processes of testing were explained to the students, and each questionnaire was introduced by the researcher.
119
Students were advised that confidentiality would be maintained and voluntary participation was emphasized. After the questionnaires were distributed, time was allowed for the students to ask questions for clarification about any part of the process. After the students had completed the questionnaires they were collected and a control sheet was attached to the front of the top paper to enable coding to be completed.
4. Results 4.1. Mental health of Korean adolescents in this study Table 1 shows the result of frequency analysis concerning Korean adolescents’ mental health problems. Korean adolescents with 74.3% responded that they have frequently experienced ‘interpersonal sensitivity’ and 56.9% of adolescents have felt ‘depression’, 48.8% for ‘anxiety’ and 41.6% for ‘hostility’ owing to a variety of daily stresses including school. Considering the high prevalence in all sub-dimensions, negative mental health in the Korean adolescents is a crucial factor that might adversely affect their overall health. In addition, there were significant mean differences between male and female adolescents in all subdimensions of mental health problems. Female adolescents reported that they have higher scores on ‘interpersonal sensitivity’ (t ¼ 16:40), ‘depression’ (t ¼ 15:62), ‘anxiety’ (t ¼ 9:89) than males; meanwhile, males have more frequently experienced ‘hostility’ (t ¼ 8:92),
Table 1 Prevalence of mental health problems among respondents Mental health problems Interpersonal sensitivity
Depression
Anxiety
Hostility
Total
Case (N)
Percent (%)
Experienced
1524
74.3
Never experienced Experienced Never experienced Experienced Never experienced Experienced Never experienced
528
25.7
1167 962
56.9 43.1
1001 1051
48.8 51.2
853 1199
41.6 58.4
2052
100.0
Cut-off point: Never experienced: not al all (1). Experienced: Seldom (2), occasionally (3), often (4) and repeatedly (5).
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
120
compared with their female counterparts (all po0:001) (see Table 2). Table 3 shows the mean differences in the subdimensions of mental health problems by age (F ¼ 14:63 for interpersonal sensitivity, F ¼ 6:59 for depression, all po0:001). Adolescents aged 18–19 years reported that they have most frequently experienced ‘interpersonal sensitivity’ and ‘depression’ in the three age groups, although there were no statistical differences in ‘anxiety’ and ‘hostility’ by age (Tables 4 and 5).
4.2. Correlation between mental health and psychological variables Correlation analysis was conducted to identify the relationships of psychological variables to the subdimensions of adolescents’ mental health. Results revealed that all the sub-domains of psychological variable were significantly correlated with almost all sub-dimensions of mental health. Among them, IHLC was strongly correlated with ‘depression’ (r ¼ 0:44), ‘interpersonal sensitivity’ (r ¼ 0:35) and ‘anxiety’ (r ¼ 0:35). PHLC also had substantial correlations with ‘interpersonal sensitivity’ and ‘anxiety’ (r ¼ 0:24 and 0.15, respectively), meanwhile CHLC was significantly correlated with ‘hostility’ (r ¼ 0:21). Furthermore, the results indicated that the self-efficacy construct was strongly correlated with ‘depression’ (r ¼ 0:43), ‘anxiety’ (r ¼ 0:37) and ‘hostility’ (r ¼ 0:26).
Table 2 Mean and SD of mental health problems by gender Variable
Interpersonal sensitivity Depression Anxiety Hostility n
Male
t
Female
M
SD
M
SD
3.23 3.30 3.49 3.32
0.73 0.79 0.65 0.49
3.89 4.02 3.76 3.03
0.79 0.83 0.57 0.62
16.40n 15.62n 9.89n 8.92n
po0.001.
In the case of self-esteem, there were significantly correlations with ‘depression’, ‘anxiety’ and ‘hostility’, ‘interpersonal sensitivity’ (r ¼ 0:39; 0.39, 0.29 and 0.26, respectively). 4.3. Effect of psychological factors on mental health To examine the effect of sub-dimensions of psychological factor on mental health problems, multiple regression analysis using the analysis of moment of structure (AMOS) program was applied. According to the standardized regression coefficients and squared multiple correlation coefficients, all of the psychological variables had a statistically significant impact on almost all mental health problems. 31% of the total psychological variables accounted for ‘interpersonal sensitivity’ (R2 ¼ 0:31) and among five psychological variables PHLC (b ¼ 0:34) had the strongest effect on ‘interpersonal sensitivity’. In addition, 49% of total psychological variables explained ‘depression’ (R2 ¼ 0:49), and self-efficacy, self-esteem, IHLC and PHLC had a substantial effect on ‘depression’ (b ¼ 0:45; 0.42, 0.41 and 0.15, respectively). Furthermore, 36% of total psychological variables accounted for ‘anxiety’ (R2 ¼ 0:36), and among psychological variables, self-esteem (b ¼ 0:39), self-efficacy (b ¼ 0:37), IHLC (b ¼ 0:36), PHLC (b ¼ 0:24) and CHLC (b ¼ 0:18) had a significant linear relation with ‘anxiety’. The results indicated that 21% of total psychological variables explained ‘hostility’ (R2 ¼ 0:21), and CHLC, self-efficacy and self-esteem statistically substantial effect on ‘hostility’ (b ¼ 0:32; 0.18, and 0.16, respectively). The use of the AMOS program allowed the observed variables in mental health (e.g., depression and anxiety, etc.) and psychological variable (e.g., IHLC and selfefficacy, etc.) to be treated as one factor (Arbuckle, 1997). The AMOS program, then analyzed the possible correlation between the latent variables (e.g., mental health and psychological factors). As a result, a correlation coefficient between mental health and psychological factors was obtained (r ¼ 0:43).
Table 3 Mean and SD of mental health problems by age Variable
Interpersonal sensitivity Depression Anxiety Hostility n
po0.001.
14–15 (year)
16–17 (year)
F
18–19 (year)
M
SD
M
SD
M
SD
3.43 3.40 3.55 2.89
0.68 0.71 0.77 0.62
3.62 3.53 3.54 2.87
0.55 0.80 0.74 0.59
3.92 3.71 3.54 3.01
0.73 0.76 0.75 0.60
14.63n 6.59n 2.10 0.88
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
121
Table 4 Correlation among all variables Variable
IS
D
An
H
IHLC
PHLC
CHLC
SEf
SEs
IS D An H IHLC PHLC CHLC SEf SEs M SD
1.00 0.42** 0.33** 0.34** 0.35** 0.24** 0.04 0.05 0.26** 3.13 0.72
1.00 0.36** 0.56** 0.44** 0.06 0.06 0.43** 0.39** 3.45 0.76
1.00 0.14* 0.35** 0.15* 0.08 0.37** 0.39** 3.58 0.80
1.00 0.07 0.08 0.21** 0.26** 0.29** 3.15 0.62
1.00 0.05 0.08 0.21** 0.24** 4.55 0.79
1.00 0.36** 0.11* 0.16* 3.38 0.69
1.00 0.15* 0.05 3.36 0.65
1.00 0.58** 8.32 1.57
1.00 2.83 0.48
*po0.05; **po0.001. IS: Interpersonal sensitivity; D: Depression; An: Anxiety; H: Hostility; IHLC: Internal health locus of control; PHLC: Powerful other health locus of control; CHLC: Chance health locus of control; SEf: Self-efficacy; SEs: Self-esteem.
Table 5 The Standardized regression coefficient and squared multiple correlation coefficient between mental health problems and psychological factors Variable
Mental health problems IS
Psychological Factor IHLC 0.33** PHLC 0.34** CHLC 0.06 SEf 0.07 Ses 0.27**
D
An
H
0.41** 0.15* 0.04 0.45** 0.42**
0.36** 0.24** 0.18* 0.37** 0.39**
0.07 0.08 0.32** 0.18* 0.16*
R2 0.31 0.49 0.36 Correlation between latent variables: r ¼ 0:43
0.21
*po0.05; **po0.001. IS: Interpersonal sensitivity; D: Depression; An: Anxiety; H: Hostility; IHLC: Internal health locus of control; PHLC: Powerful other health locus of control; CHLC: Chance health locus of control; SEf: Self-efficacy; SEs: Self-esteem.
5. Discussion This study makes a unique contribution to the existing knowledge about Korean adolescents. Adolescent mental health in Korea is not a prime focus for educators, health workers, government bureaucrats or politicians. Indeed, mental health care is in its infancy and only just emerging as a social educational issue. Along with such a socially undervalued context, there has been very limited research into adolescent mental health and psychology in Korea. Before discussing the implications of the findings, it is important to consider the methodological limitations of
this study. This study did not focus on obtaining data from the lower socioeconomic, rural or out-of-school adolescents. Therefore, data obtained from the adolescents in the midrange socioeconomic status region of Kyunggi-do cannot be considered representative of the eligible population of all Korean adolescents. One of the frequently questioned methodological limitations in survey research is how to apply the adopted instruments developed in other countries. However, the validity of the instruments used in this study has been proved by the similarity between behavioral and psychological findings obtained by other Korean studies with the same instruments (Kim, 1998a, 1998b, 1999; Hyun, 2001). This study adopted only age and gender as the demographic factors which can possibly affect adolescents’ mental health problems. Hence, it cannot identify the potential influence of other demographic factors such as family income and parents’ education on the mental health problems of adolescents. The primary focus of this study was to explore the possible relationship between adolescents’ mental health problems and some psychological variables. Therefore, interaction effects between mental health problems and demographic factors have not been considered. In spite of such methodological limitations, this study provides much needed information about Korean adolescents in terms of their mental health issues and aspects of psychological constructs which relate directly to negative mental health. It further explored the relationship of these constructs to negative mental health, all of which are the foci of this research. The study identified that Korean adolescents in this study had a problem with their mental health. Almost half of adolescents experienced depression, anxiety and hostility. It might be possible to explain that such mental health problems are because of too much stress about
122
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
study, parents’ excessive expectation and demand and exclusion from a peer group. 74.3% of respondents reported that they have experienced interpersonal sensitivity. It could be possible to interpret that many adolescents alone in modern society have tended to spend considerable time with computers and as a result, they are likely to be egocentric and fail in building meaningful interpersonal relationships. This could not be substantiated from literature and thus, there is a need for further study to see whether it is an aspect of Korean culture. Many Western studies support this study’s findings. According to Nancarrow (1993), a large volume of students was concerned with general mental heath problems. The results showed that an estimated 53% of students were concerned about feeling depressed; 50% were concerned about emotional upsets; and, 48% had negative feeling about themselves or aspects of their life. Such negative issues in adolescent mental health are not confined in one society, but applied in all societies around the world. These findings should provide effective data to promote adolescents’ mental health in school health education and community-based health care. From the findings, there were significant differences between male and female adolescents in all dimensions of mental health problems. Compared with their male counterparts female adolescents scored highly in interpersonal sensitivity, depression and anxiety. It is generally recognized that female adolescents in or over puberty tend to have an emotional disposition and hence are likely to be sensitive to the common events in everyday life. This result was supported by the findings of McCauley et al. (1999) and Hishinuma et al. (2000), indicating that female adolescents were more likely to be anxious and depressed than males. In addition, adolescent’ mental health was in part different between the three age groups. Of the three groups, adolescents aged 18–19 years reported that they have most frequently experienced interpersonal sensitivity and depression. It is not unexpected that older adolescents have a higher possibility of experiencing mental health problems than younger adolescents. Mental health itself is a complex concept, and the specific components of mental health are elusive and intangible elements. In addition, these mental health problems depend on people’ perceptions and behaviors through their interactions in and with their environment. In this regard, the result about age difference can be explained that in a developmental viewpoint, older adolescents, in general, have experienced a variety of negative and uncomfortable events through their lifetime than adolescents in early and middle adolescence. This could not be substantiated from the literature and thus, there is a need for further study to see whether it is an aspect of Korean culture.
From a large number of previous studies it has been concluded that psychological variables are significantly related to mental health problems of adolescents and identifying such a relation was a key focus of this study. Regarding a relationship of mental health problems with psychological variables in adolescence, this study revealed that the three psychological variables had direct effects on almost all of the domains of mental health problems. The results were supported by evidence presented in previous research (Copper et al., 1998; Strauss, 2000; Takakura and Sakihara, 2000; Muris et al., 2001b), and in practical terms reinforced the argument for consideration of psychological aspects in the development of mental health programs. These identified correlations allowed for further exploration of possible relationships between the subdimensions in negative mental health and the constructed psychological factor. Clearly, the correlation model proposed in this study was an adequate fit to explore possible links expressed numerically in terms of correlations, and equally and clearly the relationships between mental health problem and the psychological factor were significant. Such findings of the existence of significant relationships suggest understanding could be increased if further studies were to be undertaken to look at relationships between psychological factors and other specific dimensions of adolescent health. On the basis of these findings, this study provides significant information not previously obtained on psychological factors related to Korean adolescents’ mental health problems. In Korea, the field of adolescent mental health is just beginning to develop, and there is a lack of research, which describes adolescents’ risk behavior and health psychology. In a perspective of exploratory research, it is important to share the results because there are virtually no studies of the relationships between mental health and psychological constructs in Korea. For Korea, this study has the potential to influence the development of better mental health care and mental health promotion programs for adolescents. More importantly, the findings of this study suggest that nurses should take a more assertive role in promoting and designing risk reduction interventions congruent with the values and perceptions of Korean adolescents. The ideas and issues identified through this study are in line with the results of previous research in the field on adolescent mental health. Some questions have been answered, and underlying premises have been confirmed. There are, however, additional issues that require further elaboration and investigation. A further study should be considered using more sophisticated techniques to measure mental health problems of Korean adolescents. It is important to adequately prepare, better equip and encourage health workers to
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
deal with the physical, psychological and social needs of adolescents of different demographic and ethnic backgrounds.
References Arbuckle, J., 1997. AMOS Users’ Guide: Version 3.6. SmallWaters Corporation, Chicago. Bandura, A., 1977. Self-efficacy: toward a unifying theory of behavioral change. Psychological Review 84, 191–215. Bandura, A., 1982. The assessment and predictive generality of self-perception of efficacy. Journal of Behavioral Theory and Experimental Psychiatry 13 (3), 195–199. Bandura, A., 1986. Social Foundation of Thought and Action: A Social Cognitive Theory. Prentice-Hall, Englewood Cliffs NJ. Bennett, D., 1982. Problems for adolescent and youth in the community. New Doctor, March 19–21. Bolognini, M., Plancherel, B., Bettechart, W., Halfon, O., 1996. Self-esteem and mental health in early adolescence. Journal of Adolescence 19, 233–245. Byrne, B., 2000. Relationship between anxiety, fear, self-esteem and coping strategies in adolescence. Adolescence 35 (137), 215–301. Committee of Adolescent Protection, 1995. A National Health Survey for Korean 1994. Government Publishing Services, Seoul. Copper, M.L., Shaver, P.R., Collins, N.L., 1998. Attachment styles, emotion regulation and adjustment in adolescence. Journal of Personality and Social Psychology 74 (5), 1380– 1397. Donnelly, M., 1995. Depression among adolescents in Northern Ireland. Adolescence 30, 339–350. Heaven, P.C.L., 1996. Adolescent Health: The Role of Individual Differences. Routledge, London. Hishinuma, E.S., Miyamoto, R.H., Nishimura, S.T., Nahulu, S.B., 2000. Differences in state-trait anxiety inventory scores for ethnically diverse adolescent in Hawaii. Cultural Diverse Ethnic Minority Psychology 6 (1), 73–83. Hogarth, C., 1991. Adolescent Psychiatric Nursing. Mosby Year Book, St. Louis. Hurrelmann, K., Losel, F., 1990. Health hazards in adolescence. De Gruyter, Berlin. Hyun, S.K., 2001. The effect of physical activity on health related psychological constructs in the old females. Master Thesis, HanYang University, Korea. Unpublished. Jensen, P., 1991. Mental health and disorder in children and adolescents: current status and research needs. Community Health 14 (3), 1–11. Kalliopuska, M., 1990. Self-esteem and empathy as related to participation in the arts or sports activities. In: L. Oppenheimer (Ed.), The Self-concept, European Perspectives on its Development, Aspects and Application. Springer, New York, pp. 120–123. Kashani, J.H., Beck, N., Hoeper, E.W., Fallahi, C., Corcoran, C.M., MaAllister, J.A., Rosenberg, T.K., Reid, J.C., 1987. Psychiatric disorders in a community sample of adolescents. Adolescent Journal of Psychiatry 144, 584–589.
123
Kazdin, A., 1993. Adolescent mental health: prevention and treatment programs. American Psychologist 48, 127–141. Kenny, D.T., Job, R.F.S., 1995. Australia’s Adolescent: a health psychology perspective. University of New England Press, Armidale, Australia. Kim, Y.H., 1998a. Adolescents’ perceptions with regard to health risks, health profile and the relationship of these variables to a psychological factor—a study across gender and different cultural settings. Ph.D. Thesis, University of Wollongong, Australia, unpublished. Kim, Y.H., 1998b. Health related psychological constructs in adolescence: differences in gender and culture. Korean Journal of Sport for All 11, 563–571. Kim, Y.H., 1999. Adolescents’ risk perception to health and its relationship with psychological variables. Third International Congress Asian-South Pacific Association of Sport Psychology(ASPASP), Wuhan, China. Kim, G.I., Won, H.T., Lee, J.H., Kim, G.Y., 1978. A Korean version study of symptom checklist: the response nature of normal person. Journal of Neuro psychological Medicine 17 (4), 449–487. Levenson, H., 1981. Differentiating among internality, powerful others and chance. In: Lefcourt, H.M. (Ed.), Research With the Locus of Control Construct, Vol. 1. Academic Press, New York. McCauley, O.C., Lerner, R.M., Lerner, J.V., Von E, .A., 1999. Does self-competence predict gender differences in adolescent depression and anxiety? Journal of Adolescence 22 (3), 397–411. Michalos, A.C., 1991. Global Report on Student Well-being, Vol. 1: Life Satisfaction and Happiness. Springer, London. Muris, P., Bogie, N., Hoogsteader, A., 2001a. Effects of an early intervention group program for anxious and depressed adolescents: a pilot study. Psychological Report 88 (2), 481–482. Muris, P., Schmidt, H., Lambrichs, R., Meesters, C., 2001b. Protective and vulnerability factors of depression in normal adolescents. Behavioral Research and Therapy 39 (5), 555–565. Nada-Raja, S., McGee, R., Williams, S., 1994. Health beliefs among New Zealand adolescents. Journal of Pediatric of Child Health 30, 523–529. Nancarrow, M., 1993. Adolescent health in hunter region: a survey of student perception and concerns. Thesis, University of Wollongong, Australia, unpublished. Neto, F., Barros, J., 2000. Psychosocial concomitants of loneliness among students of Cape Verde and Portugal. Journal of Psychology 134 (5), 503–514. Raphael, B., 1993. Adolescent resilience: the potential impact of personal development in school. Journal of Pediatric and Child Health 29 (Suppl. 1), 31–36. Rivas Torres, R.M., Fernandez, P., 1995. Self-esteem and value of health as determinants of adolescent health behavior. Journal of Adolescent Health 16, 60–63. Rosenberg, M., 1965. Society and Adolescent Self-image. Princeton University Press, Princeton. Rosenberg, M., 1985. Self-concept and psychological well-being in adolescence. In: Leary, P.L. (Ed.), The Development of the Self. Academic Press, New York. Rottor, J.B., 1954. Social Learning and Clinical Psychology. Prentice Hall, Englewood Cliffs, NJ.
124
Y.-H. Kim / International Journal of Nursing Studies 40 (2003) 115–124
Rottor, J.B., 1966. Generalized expectancies for internal and external control of reinforcement. Psychological Monographs: General and Applied 80, 1–28. Schlenker, B.R., Soraci, S., McCarthy, B., 1976. Self-esteem and group performance as determinants of ego-centric perceptions in cooperative groups. Human Relations 29, 1163–1176. Sherer, M., Maddux, J.E., Mercandane, B., Prentice-Dunn, S., Jacobs, B., Rogers, R.W., 1982. The self-efficacy scale: construction and validation. Psychological Reports 51, 663–671. Strauss, R.S., 2000. Child obesity and self-esteem. Pediatrics 105 (1), 15–16. Takakura, M., Sakihara, S., 2000. Gender differences in the association between psychological factors and depressive
symptoms in Japanese junior high school students. Journal of Epidemiology 10 (6), 383–391. The Ministry of Health and Welfare, 1998. Annual Report for Health, Government Printing Service, Seoul, Korea. US Department of Health and Human Services, 1990. National Plan for Research on Child and Adolescent Mental Disorders, National Institute of Mental Health. US Government Printing Service, Washington DC. Wallston, K.A., Wallston, R.S., DeVellis, R., 1978. Development of the multidimensional health locus of control scale. Health Education Monograph 6, 160–170. Waters, B.C., 1991. Emerging issues in adolescent mental health. Behavioral Medicine Conference, University of Sydney, Sydney.