Psychological Distress in Adolescents: Prevalence and its Relation to High Risk Behaviors Among Secondary School Students in Uganda.

Psychological Distress in Adolescents: Prevalence and its Relation to High Risk Behaviors Among Secondary School Students in Uganda. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychological Distress in Adolescents: Prevalence and its Relation to High Risk Behaviors Among Secondary School Students in Uganda. Michael U. Anyanwu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-871483/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Jan, 2023 Read the published version in BMC Psychology → Version 1 posted 9 You are reading this latest preprint version Abstract Background Psychological distress is a mental health condition that is common in adolescents. It negatively affects the academic performance of adolescents, relationships with family and friends, and the ability of adolescents to participate fully in the community. Stressful life events in low income countries and risk taking behavior of adolescents have raised concerns on the magnitude and impact of psychological distress among adolescents in Uganda. This study aims to estimate the prevalence of psychological distress and assess the high risk behaviors associated with psychological distress among secondary school students in Uganda. Methods A community based cross-sectional study was conducted among secondary school students in Mbarara Municipality, Uganda. Multistage cluster sampling technique was used to recruit study participants and a total of 921 students participated in the study using a self-reported questionnaire. Psychological distress was assessed by Kessler’s psychological distress scale (K10). To identify high risk behaviors associated with psychological distress, multinomial logistic regression was used with p <0.05 and 95% confidence interval. Results The prevalence of psychological distress was 57%. Risky sexual behavior, alcohol consumption, smoking and substance use were associated with psychological distress. Also, boarding school students, those in mixed schools, students that own mobile phones and adolescents with chronic illness were more likely to report psychological distress. Conclusion The prevalence of psychological distress is high among school going adolescents and risky behaviors were associated with psychological distress. The findings suggest the need to address mental health issues in adolescents. Psychology Psychological distress Risky Behaviors Adolescents Secondary School Students Uganda. Introduction Mental health disorders are among the leading cause of ill-health and disability worldwide. According to World Health Organization (WHO), one in four persons in the world are affected by mental disorder at some point in their lives and around 450 million people suffer from mental disorders ( 1 ). Currently, it is responsible for 1 in 5 years lived with disability globally ( 2 ). About 20% of the world’s adolescent have mental health problems ( 2 ) and mental health disorders account for 16% of the global burden of disease and injury in adolescents ( 3 ). Psychological distress is a non-specific mental health condition that is characterized by anxiety, depression and somatic symptoms ( 4 , 5 ). It involves feelings of vulnerability, sadness, fear, extensive worries, restlessness, negative thoughts and social isolation ( 6 ). Psychological distress is a public health challenge that affects daily activities of adolescents including school and work performance, relationships with family and friends and involvement in the community ( 2 ). Previous surveys have indicated that psychological distress is common in adolescents and a study conducted in Canada reported a prevalence of 35% ( 7 ). Furthermore, about 54% and 40% of students in China and Saudi Arabia respectively showed symptoms of psychological distress ( 8 , 9 ). In low and middle income countries, high prevalence of psychological distress has been reported among adolescents. A cross sectional study of students in India estimated 10.5% mild psychological distress, 5.4% moderate psychological distress and 4.9% severe psychological distress ( 10 ). Also, a study conducted in Zambia showed 15.7% of psychological distress in adolescents ( 11 ), while another study reported 20.6% single psychological distress and 10.3% multiple psychological distress among students in Tanzania ( 12 ). In Uganda, a study conducted among adolescents living with HIV/AIDS reported 51% depression ( 13 ) while another study indicated 21% depression in school-going students ( 14 ). Adolescence is a period characterized with high risk behaviors ( 15 , 16 ). High risk behaviors such as alcohol use, smoking, substance use and risky sexual activities have been linked to psychological distress and other mental problems in adolescents ( 7 , 17 , 18 ). Prior research findings showed that alcohol use among adolescents was associated with psychological distress and suicidal behavior ( 19 , 20 ). Smoking and substance use were also associated with psychological distress among school-going adolescents in studies conducted in Norway, Zambia, Tanzania and Uganda ( 11 , 12 , 14 , 21 ). Moreover, studies have associated risky sexual behavior with psychological distress. Risky sexual behaviors such as early sexual debut, multiple sex partners and inconsistent condom use have been linked to psychological distress in adolescents ( 12 , 18 , 22 , 23 ). Uganda is a low income country where other health issues are prioritized over mental health due to limited resources ( 24 , 25 ). Besides, stressful and undesirable life events continue to raise concerns on the magnitude of mental health problems in the country ( 26 ). Meanwhile, previous studies in Uganda have focused on other mental health problems with no study conducted on psychological distress in adolescents. In addition, prior studies on adolescent mental health were centered on adolescent living with HIV/AIDS, vulnerable and marginalized population ( 13 , 14 , 17 , 27 – 29 ). Hence, this study aimed at estimating the prevalence of psychological distress and its relationship with high risk behaviors among secondary school students in Uganda. Methods Sample and Procedure The participants in this study were part of a research project evaluating gambling disorder among secondary school students in Uganda. The study was a cross-sectional survey conducted in 2019 at Mbarara Municipality, a town located in the South-western part of Uganda and the main administrative and commercial center of Mbarara District. To achieve a representative sample of secondary school students in the Municipality, multistage cluster sampling was used in the study. The first stage involved random selection of two schools from each of the Municipality’s six divisions with each division represented by one public and one private school. At the second stage, students were randomly selected from each class in the secondary school using the class register. A total of 921 secondary school students participated in the study. Secondary schools with both ordinary and advance classes were included in the study and students that have not been in school for at least two months or spent an academic session in the school were excluded in the study. Under the supervision of survey administrators, students completed the self-administered questionnaire in English language in a selected hall during the school period. The study was approved by the Research Ethics Committee of Mbarara University of Science and Technology. Written informed consent was obtained from the participating schools and students before the questionnaire was administered, and students that were not willing to participate in the study were allowed to leave the hall where the survey was conducted. Variable Measurements The survey collected the following students’ characteristics: age, gender, religion, family background, class of student, school type, and caretaker/guardian. Participants also answered questions on owning a mobile phone (yes/no), and ever failed a subject in an exam (yes/no). Psychological Distress Psychological distress was assessed with Kessler’s psychological distress scale (K10), a ten item with a 5 point likert scale that evaluates frequency of depressive and anxiety symptoms over past four weeks. Psychological distress was categorized into normal, mild, moderate, and severe psychological distress. Scores range from 10–50, with score of 0–19 categorized as normal, 20–24 as mild distress, 25–29 as moderate distress and scores from 30 and above categorized as severe psychological distress ( 30 , 31 ). The K10 has been shown to be a reliable and valid tool for screening of adolescents in epidemiological surveys and has been used extensively in Sub-Saharan Africa ( 32 – 36 ). Alcohol Consumption, Smoking and Substance Use Substance use among the students was assessed by alcohol, smoking and substance involvement screening test (ASSIST), a tool validated by World Health Organization for assessing the use of alcohol, tobacco products and other drugs. Substance use was assessed using the second question from ASSIST ( 37 , 38 ). It consists of 10 questions assessing alcohol, smoking and substance use in the past three months, with Never = 0, Once/twice = 2, Monthly = 3, Weekly = 4, and Daily = 5. A score of “0” was classified as “no use” and 2 and above classified as “substance use”. Risky Sexual Behavior The sexual behavior of the participants was assessed with questions on being sexually active, use of condoms and ever being pregnant. It was categorized into two: “No risky behavior” and “Risky Sexual behavior”. Respondent that answered “No” to being sexually active or “Yes” to being sexually active but “No” to her or their sexual partner ever being pregnant and “Yes” to consistent use of condoms was categorized as “No risky behavior”. Chronic Illness The chronic illness or condition of the participants was determined by the question “Do you have a chronic (long lasting) illness or health condition” with yes or no response. Social Support Two questions assessed social support, “Is there advice and support provided by your family and friends for you?” and “Are there elders or community leaders that you can easily go to for support and advice? Social support was classified into “No social support” and “Have Social Support”. Any “Yes” answer to one of the question was categorized as have social support. Analysis Data analysis was done with STATA Version 12.0. All participants that did not complete the questionnaire on psychological distress were excluded. Descriptive statistics was used to show the characteristics of the participants. The prevalence of psychological distress was determined by the scores of the students on Kessler’s psychological distress scale (K10). To identify the high risk behaviors associated with psychological distress, multinomial logistic regression was used with normal psychological distress as the reference. The variables which were significant in univariate analysis were included in the multivariable multinomial regression model. All statistical tests were two sided and all variables with p < 0.05 were considered significant at 95% confidence interval. Results Socio-demographic characteristics of study participants A total of 921 students participated in the study with a response rate of 98.4% (n = 906). However, 15 (1.6%) students were excluded due to missing information on psychological distress. The minimum and maximum age of the participants was 11 years and 25 years respectively and the mean age was 16.9 (standard deviation 2.1). Most of the respondents were male 483 (53.6%), boarding students 673 (75.9%), Catholics 330 (36.7%) and attend mixed (both sex) schools 786 (86.7%). Socio-demographic characteristics of participants are shown in Table 1 . Table 1 Socio-demographic characteristics of participants Variable Normal n (%) Mild n (%) Moderate n (%) Severe n (%) Total N = 906 (%) Age Below 18 years 18 years and above 228 (64.4) 126 (35.6) 115 (56.7) 88 (43.3) 79 (53.4) 69 (46.6) 60 (54.0) 51 (46.0) 482 (59.1) 334 (40.9) Gender Female Male 184 (47.3) 205 (52.7) 4 (42.5) 127 (57.5) 78 (48.2) 84 (51.8) 62 (48.1) 67 (51.9) 418 (46.4) 483 (53.6) Type of Student Boarding Day 280 (73.5) 101 (26.5) 169 (77.2) 50 (22.8) 132 (83.5) 26 (16.5) 92 (71.3) 37 (28.7) 673 (75.9) 214 (24.1) Type of School Private Public Mixed (Both sex) Single-sex 211 (54.1) 179 (45.9) 320 (82.0) 70 (18.0) 123 (55.2) 100 (44.8) 195 (87.4) 28 (12.6) 93 (57.1) 70 (42.9) 150 (92.0) 13 (8.0) 71 (54.6) 59 (45.4) 121 (93.0) 9 (7.0) 498 (55.0) 408 (45.0) 786 (86.7) 120 (13.3) Residence Urban/Town Sub-urban 220 (60.6) 143 (39.4) 111 (54.4) 93 (45.6) 88 (59.1) 61 (40.9) 59 (48.8) 62 (51.2) 478 (57.1) 359 (42.9) Religion Catholic Moslem Protestant Pentecostal Other 123 (31.9) 38 (9.9) 80 (20.8) 89 (23.1) 55 (14.3) 79 (35.4) 25 (11.2) 44 (19.7) 45 (20.2) 30 (13.5) 72 (44.4) 15 (9.3) 25 (15.4) 34 (21.0) 16 (9.9) 56 (43.4) 6 (4.7) 23 (17.8) 32 (24.8) 12 (9.3) 330 (36.7) 84 (9.3) 172 (19.1) 200 (22.3) 113 (12.6) Family Type Both Parent Alive One Parent Alive Orphan 326 (84.9) 47 (12.2) 11 (2.9) 179 (81.4) 34 (15.5) 7 (3.2) 125 (77.2) 29 (17.9) 8 (4.9) 98 (77.2) 24 (18.9) 5 (3.9) 728 (81.5) 134 (15.0) 31 (3.5) Parents Marital Status Married/cohabiting Separated/widowed 315 (86.5) 49 (13.5) 179 (87.3) 26 (12.7) 128 (85.9) 21 (14.1) 112 (88.9) 14 (11.1) 734 (87.0) 110 (13.0) Guardian/Caretaker Parents Others 339 (92.1) 29 (7.9) 195 (91.6) 18 (8.4) 139 (90.8) 14 (9.2) 113 (90.4) 12 (9.6) 786 (91.5) 73 (8.5) Prevalence of psychological distress Out of the 906 students, 390 (43%) students with scores less than 20 on the K10 psychological distress scale were normal. The prevalence of mild psychological distress was 223 (24.6%), moderate psychological distress 163 (18%) and severe psychological distress 130 (14.4%). The overall prevalence of psychological distress among the study participants was 57%. Associations with mild, moderate and severe Psychological Distress Unadjusted multinomial logistic regression showed that type of student, type of school (single/mixed), phone ownership, chronic illness, risky sexual behavior, alcohol consumption, smoking and substance use were significant (Table 2 ). In adjusted multinomial logistic regression, students in mixed schools, those that owns mobile phones, have chronic illness, engages in risky sexual behavior, takes alcohol, smokes and use substances were more likely to have mild psychological distress. However, type of student, type of school, chronic illness, risky sexual behavior, alcohol consumption, smoking and substance use were associated with moderate psychological distress. For severe psychological distress, students in mixed schools, those that have mobiles phone, presence of chronic illness, students that engages in risky sexual behavior, consumes alcohol, smokes or use substances were at a higher risk (Table 3 ). Table 2 Univariate analysis of factors related to psychological distress Variable Crude Relative Risk Ratio (95% CI) P value Mild n (%) Moderate n (%) Severe n (%) Age Below 18 years 18 years and above 1 1.38 (0.97–1.97) 1 1.58 (1.07–2.33) 1 1.54 (0.99–2.37) 0.050 Gender Female Male 1 1.21 (0.87–1.69) 1 0.97 (0.67–1.39) 1 0.97 (0.65–1.45) 0.614 Type of Student Boarding Day 1.22 (0.83–1.79) 1 1.83 (1.14–2.95) 1 0.89 (0.57–1.39) 0.040 Type of School Private Public Mixed (both sex) Single-sex 1.04 (0.75–1.45) 1 1.52 (0.95–2.44) 1 1.13 (0.78–1.63) 1 2.52 (1.35–4.71) 1 1.02 (0.69–1.52) 1 2.94 (1.42–6.07) 1 0.937 < 0.001 Residence Urban/Town Sub-urban 1 1.29 (0.91–1.82) 1 1.07 (0.72–1.57) 1 1.62 (1.07–2.45) 0.108 Religion Catholic Moslem Protestant Pentecostal Other 1.18 (0.69–1.99) 1.21 (0.62–2.36) 1.01 (0.57–1.79) 0.93 (0.52–1.64) 1 2.01 (1.07–3.77) 1.36 (0.59–3.07) 1.07 (0.53–2.19) 1.31 (0.66–2.59) 1 2.09 (1.04–4.20) 0.72 (0.25–2.09) 1.32 (0.61–2.87) 1.65 (0.78–3.47) 1 0.135 Family Type Both Parent Alive One Parent Alive Orphan 1 1.32 (0.82–2.12) 1.16 (0.44–3.04) 1 1.61 (0.97–2.67) 1.89 (0.75–4.83) 1 1.69 (0.98–2.92) 1.51 (0.51–4.46) 0.337 Guardian/Caretaker Parents Others 1 1.08 (0.58–1.99) 1 1.17 (0.60–229) 1 1.24 (0.61–2.51) 0.928 Parents Marital Status Married/cohabiting Separated/widowed 1.07 (0.64–1.78) 1 0.95 (0.55–1.64) 1 1.24 (0.66–2.34) 1 0.883 Phone Ownership No Yes 1 1.55 (1.11–2.17) 1 1.74 (1.20–2.53) 1 2.06 (1.37–3.11) < 0.001 Social Support No Yes 1 1.29 (0.82–2.06) 1 1.22 (0.74–2.03) 1 0.73 (0.45–1.19) 0.201 Exam Failure No Yes 1 1.28 (0.85–1.92) 1 1.52 (0.95–2.44) 1 1.04 (0.65–1.67) 0.273 Chronic Illness No Yes 1 1.59 (1.07–2.35) 1 1.83 (1.19–2.80) 1 2.59 (1.67–4.04) < 0.001 Risky Sex Behavior No Yes 1 1.81 (1.17–2.79) 1 2.12 (1.33–3.37) 1 2.08 (1.26–3.43) 0.001 Substance Use No Yes 1 2.12 (1.49–3.02) 1 2.63 (1.79–3.87) 1 2.76 (1.82–4.18) < 0.001 Table 3 Multivariable analysis of factors related to psychological distress Variable Adjusted Relative Risk Ratio (95% CI) P value Mild n (%) Moderate n (%) Severe n (%) Type of Student Boarding Day 1.24 (0.81–1.89) 1 2.01 (1.20–3.37) 1 0.93 (0.57–1.51) 1 a 0.316 b 0.008** c 0.768 Type of School Mixed (both sex) Single-sex 1.73 (1.04–2.88) 1 3.02 (1.57–5.81) 1 2.93 (1.37–6.31) a 0.036* b 0.001*** c 0.006** Phone Ownership No Yes 1 1.42 (1.00-2.03) 1 1.47 (0.99–2.20) 1 1.93 (1.24–3.01) a 0.049* b 0.058 c 0.003** Chronic Illness No Yes 1 1.62 (1.07–2.43) 1 1.88 (1.20–2.94) 1 2.60 (1.64–4.14) a 0.022* b 0.006** c <0.001*** Risky Sex Behavior No Yes 1 1.68 (1.06–2.68) 1 1.85 (1.12–3.05) 1 1.79 (1.04–3.09) a 0.028* b 0.017* c 0.034* Substance Use No Yes 1 2.01 (1.39–2.92) 1 2.35 (1.55–3.55) 1 2.57 (1.66–4.01) a <0.001*** b <0.001*** c <0.001*** a Mild; b Moderate; c Severe *p < 0.05; **p < 0.01; ***p < 0.001 Discussion The aim of the study was to determine the prevalence of psychological distress and to identify the high risk behaviors associated with psychological distress among secondary school adolescents in Uganda. The overall prevalence of psychological distress was 57% with 24.6% mild psychological distress, 18% moderate psychological distress and 14.4% severe psychological distress. The study identified risky sexual behavior, alcohol consumption, smoking and substance use as high risk behaviors associated with mild, moderate and severe psychological distress. Other covariates identified in this study were chronic illness and type of school which were significantly associated with mild, moderate and severe psychological distress. However, mobile phone ownership was associated with mild and severe psychological distress while type of student residence was significantly associated with moderate psychological distress. The prevalence of psychological distress in this study is consistent with the prevalence rates reported by other studies in Uganda. Generally, previous studies have shown a high prevalence of mental health issues such as anxiety and depression among adolescents in Ugandan. A recent study conducted among high school adolescent girls in Southern Uganda revealed that the prevalence of depressive symptoms ranged from 16–29% among the study participants ( 27 ). Another study conducted among secondary school students in Central Uganda indicated that 21% had significant depression symptoms ( 14 ). Other studies have reported prevalence rates of 26.6% anxiety disorders in children and adolescents ( 29 ), 36% anxiety/depressive symptoms in marginalized adolescent population ( 28 ) and 51% psychological distress in adolescents living with HIV/AIDS ( 13 ). In comparison to studies from other countries, this study finding is similar to the rates reported in Tanzania ( 12 ), Ethiopia ( 33 ), Egypt ( 39 ), Canada ( 7 ) and China ( 8 ), but distinct from rates in Zambia ( 11 ), India ( 10 ) and USA ( 40 ). The differences in the prevalence rates of psychological distress could be due to the diverse environment, culture and economic factors as well as varying study sample, assessment tool and methodology. In this survey, students who drank alcohol, smoked or used substances were more likely to report psychological distress compared to students who do not. This finding is consistent with a study conducted in Uganda where alcohol and drug use was associated with depression in school going adolescents ( 14 ). This association may be due to the use of alcohol as a coping mechanism to stressors or life challenges. Previous studies conducted in Tanzania ( 12 ), Ethiopia ( 33 ), Zambia ( 11 ), India ( 10 ), Norway ( 21 ) and Finland ( 41 ) have shown similar results although a study in Canada reported that alcohol and cannabis use were not associated with psychological distress ( 7 ). This study revealed that adolescents that engage in risky sexual activities were more likely to report psychological distress. The possible explanation for this relationship could be that adolescents become distressed because of engaging in risky sexual behavior or psychological distress may make it difficult for the students to practice safe sex. This is supported by studies conducted among high school students in the US ( 18 , 23 ), school-going adolescents in Tanzania ( 12 ) and adolescents in Sub-Saharan Africa ( 22 ). However, contradictory findings was reported in African American adolescent girls ( 42 ). When examining the covariates of psychological distress, students who report having chronic health conditions were more likely to have psychological distress. This is in line with a research conducted among adolescents in Kampala, Uganda ( 17 ). Other existing studies have also shown similar results ( 43 , 44 ). Phone ownership was significantly associated with psychological distress in our sample. Studies suggest that adolescents that own mobile phones were more likely to have psychological distress compared to their colleagues that do not have mobile devices ( 35 , 45 ). In addition, students in boarding schools and schools with both genders tend to report more cases of psychological distress, nonetheless, this is contrary to another study where students in single-sex schools had higher odds of psychological distress ( 14 ). Contrary to existing studies; gender, social support and academic performance were not associated with psychological distress in this study ( 7 , 10 , 14 , 27 , 33 , 46 , 47 ). This study has limitations that should be considered when interpreting the results. The cross-sectional design of this study does not indicate the cause - effect relationship. Self-reported instrument was used to identify psychological distress with no diagnostic interview conducted to establish the presence of psychological distress. Moreover, there is a tendency of giving social desirable responses by the students and some questions require recall of past history which is prone to recall bias. Conclusions A high prevalence of psychological distress was identified among secondary school students in Uganda. The finding indicates that one in every two school-going adolescent have some symptoms of psychological distress. Besides, the results of this study revealed that risky sexual behavior, alcohol consumption, smoking and substance use were associated with psychological distress. Hence, psychological distress in adolescents may be linked to high rate of HIV/AIDS, sexual transmitted infections, unwanted pregnancies and other negative consequences in this population. Thus, incorporating mental health services with substance and sexual health programs for adolescents is recommended. Also, it is needful to institute counseling and mental health programs for secondary school students. Declarations Ethics approval and consent to participate The study was approved by the Research Ethics Committee of Mbarara University of Science and Technology. Participation was voluntary and informed written consent was obtained from all the participants. All procedures performed were in accordance with the 1964 Helsinki declaration and its later amendments. Consent for publication Not Applicable. Availability of data and materials The datasets used and/or analyzed during this study are available from the corresponding author on reasonable request. Competing Interests The author declares that there is no competing interest. Authors’ Contributions MUA was the sole author involved in the conceptualization, data collection, and writing of this article. Funding None Acknowledgement None References World health Organization. The World Health Report 2001: Mental Disorders affect one in four people. Geneva: WHO, 2001 [cited 2021 June 30], Available from: https://www.who.int/news/items/28-09-2001-the-world-health-report-2001-mental-disorders-affect-one-in-four-people. World Health Organization. Mental Health. 2021 [cited 2021 July, 11], Available from: https://www.who.int/health-topics/mental-health#tab_2. World Health Organization (WHO). Adolescent Mental Health. 2019 [cited 2021 July, 10], Available from: https://www.int/news-room/fact-sheets/detail/adolescent-mental-health. Drapeau A, Marchand A, Beaulieu-Prévost D. Epidemiology of psychological distress. Mental illnesses-Understanding Prediction Control2012. Mirowsky J, Ross C. Measurement for a human science. J Health Soc Behav. 2002,43(2):152-70. International Encyclopedia of the Social and Behavioural Sciences. Psychological Distress. 2015 [cited 2021 July, 11], second:[Available from: https://Sciencedirect.com/topics/psychology/psychological-distress. Arbour-Nicitopoulos KP, Faulkner G, Irving H. Multiple health-risk behavior and psychological distress in adolescence. J Can Acd Child Adolesc Psychiatry. 2012,21(3):171-8. Huang J, Xia W, Sun C, Zhang H, Wu L. Psychological distress and its correlates in Chinese adolescents. Aust N Z J Psychiatry. 2009,43(7):674-81. Saquib N, Saquib J, Wahid A, Ahmed A, Dhuhayr H, Zaghloul M, et al. Video game addiction and psychological distress among expatriate adolescents in Saudi Arabia. Addict Behav Rep. 2017:112-7. Jaisoorya T, Desai G, Beena K, Beena M, Ellangovan K, Thennarasu K. Prevalence and correlates of psychological distress in adolescent students from India. East Asian Arch Psychiatry. 2017,27(2):56-62. Siziya S, Mazaba M. Prevalence and correlates for psychosocial distress among in-school adolescents in Zambia. Frontiers in Public Health. 2015,3(180). Pengpid S, Peltzer K. Psychological distress and its associated factors among school-going adolescents in Tanzania. Psychol Stud. 2020,65:174-81. Musisi S, Kinyanda E. Emotional and behavioral disorders in HIV seropositive adolescents in urban Uganda. East Afr Med J. 2009,86(1):16-24. Nalugya-Sserunjogi J, Rukundo G, Ovuga E, Kiwuwa S, Musisi S, Nakimuli-Mpungu E. Prevalence and factors associated with depression symptoms among school-going adolescents in central Uganda. Child Adolesc Psychiatry Ment Health. 2016,10(1). Dahl R. Adolescent brain developent: a period of vulnerabilities and opportunities. Keynote address. Ann N Y Acad Sci. 2004. Michaud P, Blum R, Ferron C. "Bet you I will" Risk or experimental behavior during adolescence? Archives of Pediatric and Adolescent Medicine. 1998,152(3):224-6. Henry BM, Bakeera-Kitaka S, Lubega K, Snyder AS, LaRussa P, Pfeffer B. Depressive symptoms, sexual activity, and substance use among adolescents in Kampala, Uganda. Afr Health Sci. 2019,19(2):1888-96. Lehrer J, Shrier L, Gortmaker S, Buka S. Depressive symptoms as a longitudinal predictor of sexual risk behaviors among US middle and high school students. Pediatrics 2006. 2006,118(1):189-200. Balogun O, Koyanagi A, Stickley A, Gilmour S, Shibuya K. Alcohol consumption and psychological distress in adolescents: A multi-country study. J Adolesc Health. 2014,54:228-34. Marmorstein N, Lacono W, Malone S. Longitudinal associations between depression and substance dependence from adolescence through early adulthood. Drug Alcohol Depend. 2010,107:154-60. Myklestad I, Røysamb E, Tambs K. Risk and protective factors for psychological distress among adolescents: a family study in the Nord-Trøndelag health study. Soc Psychiatry Psychiatr Epidemiol. 2011. Page RM, Hall CP. Psychological distress and alcohol use as factors in adolescent sexual behavior among Sub-Saharan African adolescents. Journal of school health. 2009,79(8):369-79. Traci LB, Sion KH, Jeannie ST, Elizabeth RW. Association of adolescent risk behavior with mental health symptoms in high school students. J Adolesc Health. 2002,31(3):240-6. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J. Barriers to improvement of mental health services in low income and middle income countries. Lancet. 2007,370:1164-74. Chisholm D, Lund C, Saxena S. Cost of scling up mental healthcare in low-and middle-income countries. Br J Psychiat. 2007,191:S28-S35. Muhwezi W, Ågren H, Neema S, Maganda A, Musisi S. Life events associated with major depression in Uganda Primary Healthcare (PHC) patients: Issues of cultural specifificity. Int J Soc Psychiat. 2008,54:144-64. Nabunya P, Damulira C, Byansi W. Prevalence and correlates of depressive symptoms among high school adolesent girls in southern Uganda. BMC Public Health. 2020,20. McMullen J, O'Callaghan P, Richards J, Eakin J, Rafferty H. Screening for traumatic exposure and psychological distress among war-affected adolescents in post-conflict northern Uganda. Soc Psychiatry Psychiatr Epidemiol. 2012,47(9):1489-98. Abbo C, Kinyanda E, Kizza R, Levin J, Ndyanabangi S, Stein D. Prevalence , comorbidity and predictors of anxiety disorders in children and adolescents in rural north-western Uganda. Child Adolesc Psychiatry Ment Health. 2013,7(1):21. Kessler R, editor. The WHO World Mental Health Survey: Global Perspectives on the Epidemiology of Mental Disorders: Cambridge University Press, 2008. Kessler R, Andrews G, Colpe L, Hiripi E, Mroczek D, Normand S, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002,32:959-76. Myer L, Stein D, Grimsrud A, Seedat S, Williams D. Social determinants of psychological distress in a nationally-rpresentative sample of South African adults. Soc Sci Med. 2008,66:1828-40. Gebremedhin H, Bifftu B, Lebessa M, Weldeyes A, Gebru T, Petrucka P. Prevalence and associated factors of psychological distress among secondary school students in Mekelle City, Tigray Region, Ethiopia: Cross-sectional study. Psychology Research and Behavior Management. 2020,13:473-80. Andrews G, Slade T. Interpreting scores on the Kessler psychological distress scale (K10). Aust N Z J Public Health. 2001,25(6):494-7. Zenebe Y, Kunno K, Mekonnen M, Bewuket A, Birkie M, Necho M, et al. Prevalence and associated factors of internet addiction among undergraduate university students in Ethiopia: a community university-based cross-sectional study. BMC Psychology. 2021,9(4). Canavan M, Sipsma H, Adhvaryu A, Ofori-Atta A, Jack H, Udry C, et al. Psychological distress in Ghana: associations with employment and lost productivity. Int J Ment Health Syst. 2013,7(9). World Health Organisation. Alcohol, Smoking and Substance Involvement Screening Test. Geneva, Switzerland: WHO, [cited 2018 23 August], Available from: http://www.who.int/substance_abuse/activities/assist/en/. WHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002,97(9):1183-94. Diab I, Elweshahi H, Sheshtawy H, Youssef A, Eltayar S, Sharaf A. Screening for psychological distress among high school graduates accepted for enrollment at Alexandria faculty of medicine: academic year 2016/2017. Alexandria J Med. 2017,54(2):155-9. Zhang X, Ra C, Zhang D, Zhang Y, MacLeod K. The impact of school social support and bullying victimization on psychological distress among California adolescents. Californian J Health Promot. 2016,14(2). Savolainen I, Kaakinen M, Sirola A, Oksanen A. Addictive behaviors and psychological distress among adolescents and emerging adults: a mediating role of peer group identification. Addict Behav Rep. 2018,7:75-81. Bachanas P, Morris M, Lewis-Gess J, Sarett-Cuasay J, Sirl K, Ries K, et al. Predictors of risky sexual behavior in African American adolescent girls: implications for prevention interventions. J Pediatr Psychol. 2002,27(6):519-30. Seigel W, Golden N, Gough J, Lashley M, Sacker I. Depression, self-esteem and life events in adolescents with chronic diseases. Journal of Adolescent Health Care. 1990,11(6):501-4. Pinquart M, Shen Y. Depressive symptoms in children and adolescents with chronic physical illness: An updated meta-analysis. Journal of Pediatric Psychology. 2011,36(4). Wang C, Li K, Kim M, Lee S, Seo D-C. Association between psychological distress and elevated use of electronic devices among U.S adolescents:Results from the youth risk behavior surveillance 2009-2017. Addict Behav. 2019,90:112-8. Atorkey P, Owiredua C. Clustering of multiple health risk behaviors and association with socio-demographic characteristics and psychological distress among adolescents in Ghana: A latent class analysis. SSM-Population Health. 2021,13. Shao R, He P, Ling B, Tan L, Xu L, Hou Y, et al. Prevalence of depression, anxiety, and correlations between depression, anxiety, family functioning, social support and coping styles among Chinese medical students. BMC Psychology. 2020,8(38). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Jan, 2023 Read the published version in BMC Psychology → Version 1 posted Editorial decision: Major revision 08 Oct, 2021 Reviews received at journal 04 Oct, 2021 Reviewers agreed at journal 28 Sep, 2021 Reviewers agreed at journal 18 Sep, 2021 Reviewers invited by journal 14 Sep, 2021 Editor assigned by journal 06 Sep, 2021 Editor invited by journal 06 Sep, 2021 Submission checks completed at journal 06 Sep, 2021 First submitted to journal 03 Sep, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-871483","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":50242207,"identity":"5f01d7bf-ce90-4232-aa11-e84ca5f0ef67","order_by":0,"name":"Michael U. Anyanwu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYLCChAI2IJl8AEhIyBCjgbEhwYAPSKclgLTwEKeFwUAOSOcYgHiEtejOSH/+4IGBmV0/e87nVzdqLHgY2A8f3YBPi9mNHEOgw9KSZ/a83WadcwzoMJ60tBsEtID8cizZ4EbuNuMcNqAWCR4zAlrSHwK1/AdqyXlmnPOPKC0JIIex2QG1MD/ObSNGy5k3hjOAWhIke56ZMef2SfCwEfTL8fQHH39UsNnzsyc//pzzrU6On/3wMbxaYCCxgYGBTQLEYiNGOQjYAzHzB2JVj4JRMApGwcgCADs8Shjl3nqfAAAAAElFTkSuQmCC","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Michael","middleName":"U.","lastName":"Anyanwu","suffix":""}],"badges":[],"createdAt":"2021-09-03 07:44:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-871483/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-871483/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40359-023-01039-z","type":"published","date":"2023-01-09T18:18:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44716477,"identity":"56491e72-3798-48b2-afbb-0f81a780cc04","added_by":"auto","created_at":"2023-10-16 18:26:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":351068,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-871483/v1/94a589c3-e930-4ae3-abc8-45a8ddfef9ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePsychological Distress in Adolescents: Prevalence and its Relation to High Risk Behaviors Among Secondary School Students in Uganda.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental health disorders are among the leading cause of ill-health and disability worldwide. According to World Health Organization (WHO), one in four persons in the world are affected by mental disorder at some point in their lives and around 450\u0026nbsp;million people suffer from mental disorders (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Currently, it is responsible for 1 in 5 years lived with disability globally (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). About 20% of the world\u0026rsquo;s adolescent have mental health problems (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and mental health disorders account for 16% of the global burden of disease and injury in adolescents (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Psychological distress is a non-specific mental health condition that is characterized by anxiety, depression and somatic symptoms (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). It involves feelings of vulnerability, sadness, fear, extensive worries, restlessness, negative thoughts and social isolation (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Psychological distress is a public health challenge that affects daily activities of adolescents including school and work performance, relationships with family and friends and involvement in the community (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious surveys have indicated that psychological distress is common in adolescents and a study conducted in Canada reported a prevalence of 35% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Furthermore, about 54% and 40% of students in China and Saudi Arabia respectively showed symptoms of psychological distress (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In low and middle income countries, high prevalence of psychological distress has been reported among adolescents. A cross sectional study of students in India estimated 10.5% mild psychological distress, 5.4% moderate psychological distress and 4.9% severe psychological distress (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Also, a study conducted in Zambia showed 15.7% of psychological distress in adolescents (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), while another study reported 20.6% single psychological distress and 10.3% multiple psychological distress among students in Tanzania (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In Uganda, a study conducted among adolescents living with HIV/AIDS reported 51% depression (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) while another study indicated 21% depression in school-going students (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdolescence is a period characterized with high risk behaviors (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). High risk behaviors such as alcohol use, smoking, substance use and risky sexual activities have been linked to psychological distress and other mental problems in adolescents (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Prior research findings showed that alcohol use among adolescents was associated with psychological distress and suicidal behavior (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Smoking and substance use were also associated with psychological distress among school-going adolescents in studies conducted in Norway, Zambia, Tanzania and Uganda (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Moreover, studies have associated risky sexual behavior with psychological distress. Risky sexual behaviors such as early sexual debut, multiple sex partners and inconsistent condom use have been linked to psychological distress in adolescents (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUganda is a low income country where other health issues are prioritized over mental health due to limited resources (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Besides, stressful and undesirable life events continue to raise concerns on the magnitude of mental health problems in the country (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Meanwhile, previous studies in Uganda have focused on other mental health problems with no study conducted on psychological distress in adolescents. In addition, prior studies on adolescent mental health were centered on adolescent living with HIV/AIDS, vulnerable and marginalized population (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Hence, this study aimed at estimating the prevalence of psychological distress and its relationship with high risk behaviors among secondary school students in Uganda.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eSample and Procedure\u003c/p\u003e \u003cp\u003eThe participants in this study were part of a research project evaluating gambling disorder among secondary school students in Uganda. The study was a cross-sectional survey conducted in 2019 at Mbarara Municipality, a town located in the South-western part of Uganda and the main administrative and commercial center of Mbarara District. To achieve a representative sample of secondary school students in the Municipality, multistage cluster sampling was used in the study. The first stage involved random selection of two schools from each of the Municipality\u0026rsquo;s six divisions with each division represented by one public and one private school. At the second stage, students were randomly selected from each class in the secondary school using the class register. A total of 921 secondary school students participated in the study. Secondary schools with both ordinary and advance classes were included in the study and students that have not been in school for at least two months or spent an academic session in the school were excluded in the study. Under the supervision of survey administrators, students completed the self-administered questionnaire in English language in a selected hall during the school period. The study was approved by the Research Ethics Committee of Mbarara University of Science and Technology. Written informed consent was obtained from the participating schools and students before the questionnaire was administered, and students that were not willing to participate in the study were allowed to leave the hall where the survey was conducted.\u003c/p\u003e \u003cp\u003eVariable Measurements\u003c/p\u003e \u003cp\u003eThe survey collected the following students\u0026rsquo; characteristics: age, gender, religion, family background, class of student, school type, and caretaker/guardian. Participants also answered questions on owning a mobile phone (yes/no), and ever failed a subject in an exam (yes/no).\u003c/p\u003e \u003cp\u003ePsychological Distress\u003c/p\u003e \u003cp\u003ePsychological distress was assessed with Kessler\u0026rsquo;s psychological distress scale (K10), a ten item with a 5 point likert scale that evaluates frequency of depressive and anxiety symptoms over past four weeks. Psychological distress was categorized into normal, mild, moderate, and severe psychological distress. Scores range from 10\u0026ndash;50, with score of 0\u0026ndash;19 categorized as normal, 20\u0026ndash;24 as mild distress, 25\u0026ndash;29 as moderate distress and scores from 30 and above categorized as severe psychological distress (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The K10 has been shown to be a reliable and valid tool for screening of adolescents in epidemiological surveys and has been used extensively in Sub-Saharan Africa (\u003cspan additionalcitationids=\"CR33 CR34 CR35\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlcohol Consumption, Smoking and Substance Use\u003c/p\u003e \u003cp\u003eSubstance use among the students was assessed by alcohol, smoking and substance involvement screening test (ASSIST), a tool validated by World Health Organization for assessing the use of alcohol, tobacco products and other drugs. Substance use was assessed using the second question from ASSIST (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). It consists of 10 questions assessing alcohol, smoking and substance use in the past three months, with Never\u0026thinsp;=\u0026thinsp;0, Once/twice\u0026thinsp;=\u0026thinsp;2, Monthly\u0026thinsp;=\u0026thinsp;3, Weekly\u0026thinsp;=\u0026thinsp;4, and Daily\u0026thinsp;=\u0026thinsp;5. A score of \u0026ldquo;0\u0026rdquo; was classified as \u0026ldquo;no use\u0026rdquo; and 2 and above classified as \u0026ldquo;substance use\u0026rdquo;.\u003c/p\u003e \u003cp\u003eRisky Sexual Behavior\u003c/p\u003e \u003cp\u003eThe sexual behavior of the participants was assessed with questions on being sexually active, use of condoms and ever being pregnant. It was categorized into two: \u0026ldquo;No risky behavior\u0026rdquo; and \u0026ldquo;Risky Sexual behavior\u0026rdquo;. Respondent that answered \u0026ldquo;No\u0026rdquo; to being sexually active or \u0026ldquo;Yes\u0026rdquo; to being sexually active but \u0026ldquo;No\u0026rdquo; to her or their sexual partner ever being pregnant and \u0026ldquo;Yes\u0026rdquo; to consistent use of condoms was categorized as \u0026ldquo;No risky behavior\u0026rdquo;.\u003c/p\u003e \u003cp\u003eChronic Illness\u003c/p\u003e \u003cp\u003eThe chronic illness or condition of the participants was determined by the question \u0026ldquo;Do you have a chronic (long lasting) illness or health condition\u0026rdquo; with yes or no response.\u003c/p\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003cp\u003eTwo questions assessed social support, \u0026ldquo;Is there advice and support provided by your family and friends for you?\u0026rdquo; and \u0026ldquo;Are there elders or community leaders that you can easily go to for support and advice? Social support was classified into \u0026ldquo;No social support\u0026rdquo; and \u0026ldquo;Have Social Support\u0026rdquo;. Any \u0026ldquo;Yes\u0026rdquo; answer to one of the question was categorized as have social support.\u003c/p\u003e \u003cp\u003eAnalysis\u003c/p\u003e \u003cp\u003eData analysis was done with STATA Version 12.0. All participants that did not complete the questionnaire on psychological distress were excluded. Descriptive statistics was used to show the characteristics of the participants. The prevalence of psychological distress was determined by the scores of the students on Kessler\u0026rsquo;s psychological distress scale (K10). To identify the high risk behaviors associated with psychological distress, multinomial logistic regression was used with normal psychological distress as the reference. The variables which were significant in univariate analysis were included in the multivariable multinomial regression model. All statistical tests were two sided and all variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered significant at 95% confidence interval.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSocio-demographic characteristics of study participants\u003c/p\u003e\n\u003cp\u003eA total of 921 students participated in the study with a response rate of 98.4% (n\u0026thinsp;=\u0026thinsp;906). However, 15 (1.6%) students were excluded due to missing information on psychological distress. The minimum and maximum age of the participants was 11 years and 25 years respectively and the mean age was 16.9 (standard deviation 2.1). Most of the respondents were male 483 (53.6%), boarding students 673 (75.9%), Catholics 330 (36.7%) and attend mixed (both sex) schools 786 (86.7%). Socio-demographic characteristics of participants are shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\" style=\"margin-right: calc(0%); width: 100%;\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSocio-demographic characteristics of participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;906 (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003eBelow 18 years\u003c/p\u003e\n \u003cp\u003e18 years and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e228 (64.4)\u003c/p\u003e\n \u003cp\u003e126 (35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e115 (56.7)\u003c/p\u003e\n \u003cp\u003e88 (43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e79 (53.4)\u003c/p\u003e\n \u003cp\u003e69 (46.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e60 (54.0)\u003c/p\u003e\n \u003cp\u003e51 (46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e482 (59.1)\u003c/p\u003e\n \u003cp\u003e334 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e184 (47.3)\u003c/p\u003e\n \u003cp\u003e205 (52.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e4 (42.5)\u003c/p\u003e\n \u003cp\u003e127 (57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e78 (48.2)\u003c/p\u003e\n \u003cp\u003e84 (51.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e62 (48.1)\u003c/p\u003e\n \u003cp\u003e67 (51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e418 (46.4)\u003c/p\u003e\n \u003cp\u003e483 (53.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of Student\u003c/p\u003e\n \u003cp\u003eBoarding\u003c/p\u003e\n \u003cp\u003eDay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e280 (73.5)\u003c/p\u003e\n \u003cp\u003e101 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e169 (77.2)\u003c/p\u003e\n \u003cp\u003e50 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e132 (83.5)\u003c/p\u003e\n \u003cp\u003e26 (16.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e92 (71.3)\u003c/p\u003e\n \u003cp\u003e37 (28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e673 (75.9)\u003c/p\u003e\n \u003cp\u003e214 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of School\u003c/p\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003cp\u003eMixed (Both sex)\u003c/p\u003e\n \u003cp\u003eSingle-sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e211 (54.1)\u003c/p\u003e\n \u003cp\u003e179 (45.9)\u003c/p\u003e\n \u003cp\u003e320 (82.0)\u003c/p\u003e\n \u003cp\u003e70 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e123 (55.2)\u003c/p\u003e\n \u003cp\u003e100 (44.8)\u003c/p\u003e\n \u003cp\u003e195 (87.4)\u003c/p\u003e\n \u003cp\u003e28 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e93 (57.1)\u003c/p\u003e\n \u003cp\u003e70 (42.9)\u003c/p\u003e\n \u003cp\u003e150 (92.0)\u003c/p\u003e\n \u003cp\u003e13 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e71 (54.6)\u003c/p\u003e\n \u003cp\u003e59 (45.4)\u003c/p\u003e\n \u003cp\u003e121 (93.0)\u003c/p\u003e\n \u003cp\u003e9 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e498 (55.0)\u003c/p\u003e\n \u003cp\u003e408 (45.0)\u003c/p\u003e\n \u003cp\u003e786 (86.7)\u003c/p\u003e\n \u003cp\u003e120 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003cp\u003eUrban/Town\u003c/p\u003e\n \u003cp\u003eSub-urban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e220 (60.6)\u003c/p\u003e\n \u003cp\u003e143 (39.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e111 (54.4)\u003c/p\u003e\n \u003cp\u003e93 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e88 (59.1)\u003c/p\u003e\n \u003cp\u003e61 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e59 (48.8)\u003c/p\u003e\n \u003cp\u003e62 (51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e478 (57.1)\u003c/p\u003e\n \u003cp\u003e359 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003cp\u003eMoslem\u003c/p\u003e\n \u003cp\u003eProtestant\u003c/p\u003e\n \u003cp\u003ePentecostal\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e123 (31.9)\u003c/p\u003e\n \u003cp\u003e38 (9.9)\u003c/p\u003e\n \u003cp\u003e80 (20.8)\u003c/p\u003e\n \u003cp\u003e89 (23.1)\u003c/p\u003e\n \u003cp\u003e55 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e79 (35.4)\u003c/p\u003e\n \u003cp\u003e25 (11.2)\u003c/p\u003e\n \u003cp\u003e44 (19.7)\u003c/p\u003e\n \u003cp\u003e45 (20.2)\u003c/p\u003e\n \u003cp\u003e30 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e72 (44.4)\u003c/p\u003e\n \u003cp\u003e15 (9.3)\u003c/p\u003e\n \u003cp\u003e25 (15.4)\u003c/p\u003e\n \u003cp\u003e34 (21.0)\u003c/p\u003e\n \u003cp\u003e16 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e56 (43.4)\u003c/p\u003e\n \u003cp\u003e6 (4.7)\u003c/p\u003e\n \u003cp\u003e23 (17.8)\u003c/p\u003e\n \u003cp\u003e32 (24.8)\u003c/p\u003e\n \u003cp\u003e12 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e330 (36.7)\u003c/p\u003e\n \u003cp\u003e84 (9.3)\u003c/p\u003e\n \u003cp\u003e172 (19.1)\u003c/p\u003e\n \u003cp\u003e200 (22.3)\u003c/p\u003e\n \u003cp\u003e113 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily Type\u003c/p\u003e\n \u003cp\u003eBoth Parent Alive\u003c/p\u003e\n \u003cp\u003eOne Parent Alive\u003c/p\u003e\n \u003cp\u003eOrphan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e326 (84.9)\u003c/p\u003e\n \u003cp\u003e47 (12.2)\u003c/p\u003e\n \u003cp\u003e11 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e179 (81.4)\u003c/p\u003e\n \u003cp\u003e34 (15.5)\u003c/p\u003e\n \u003cp\u003e7 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e125 (77.2)\u003c/p\u003e\n \u003cp\u003e29 (17.9)\u003c/p\u003e\n \u003cp\u003e8 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e98 (77.2)\u003c/p\u003e\n \u003cp\u003e24 (18.9)\u003c/p\u003e\n \u003cp\u003e5 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e728 (81.5)\u003c/p\u003e\n \u003cp\u003e134 (15.0)\u003c/p\u003e\n \u003cp\u003e31 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents Marital Status\u003c/p\u003e\n \u003cp\u003eMarried/cohabiting\u003c/p\u003e\n \u003cp\u003eSeparated/widowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e315 (86.5)\u003c/p\u003e\n \u003cp\u003e49 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e179 (87.3)\u003c/p\u003e\n \u003cp\u003e26 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e128 (85.9)\u003c/p\u003e\n \u003cp\u003e21 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e112 (88.9)\u003c/p\u003e\n \u003cp\u003e14 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e734 (87.0)\u003c/p\u003e\n \u003cp\u003e110 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGuardian/Caretaker\u003c/p\u003e\n \u003cp\u003eParents\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4814%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e339 (92.1)\u003c/p\u003e\n \u003cp\u003e29 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 12.9159%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e195 (91.6)\u003c/p\u003e\n \u003cp\u003e18 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 14.4578%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e139 (90.8)\u003c/p\u003e\n \u003cp\u003e14 (9.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 13.0809%;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e113 (90.4)\u003c/p\u003e\n \u003cp\u003e12 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e786 (91.5)\u003c/p\u003e\n \u003cp\u003e73 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ePrevalence of psychological distress\u003c/p\u003e\n\u003cp\u003eOut of the 906 students, 390 (43%) students with scores less than 20 on the K10 psychological distress scale were normal. The prevalence of mild psychological distress was 223 (24.6%), moderate psychological distress 163 (18%) and severe psychological distress 130 (14.4%). The overall prevalence of psychological distress among the study participants was 57%.\u003c/p\u003e\n\u003cp\u003eAssociations with mild, moderate and severe Psychological Distress\u003c/p\u003e\n\u003cp\u003eUnadjusted multinomial logistic regression showed that type of student, type of school (single/mixed), phone ownership, chronic illness, risky sexual behavior, alcohol consumption, smoking and substance use were significant (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn adjusted multinomial logistic regression, students in mixed schools, those that owns mobile phones, have chronic illness, engages in risky sexual behavior, takes alcohol, smokes and use substances were more likely to have mild psychological distress. However, type of student, type of school, chronic illness, risky sexual behavior, alcohol consumption, smoking and substance use were associated with moderate psychological distress. For severe psychological distress, students in mixed schools, those that have mobiles phone, presence of chronic illness, students that engages in risky sexual behavior, consumes alcohol, smokes or use substances were at a higher risk (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eUnivariate analysis of factors related to psychological distress\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eCrude Relative Risk Ratio (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003eBelow 18 years\u003c/p\u003e\n \u003cp\u003e18 years and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.38 (0.97\u0026ndash;1.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.58 (1.07\u0026ndash;2.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.54 (0.99\u0026ndash;2.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.21 (0.87\u0026ndash;1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.97 (0.67\u0026ndash;1.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.97 (0.65\u0026ndash;1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.614\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of Student\u003c/p\u003e\n \u003cp\u003eBoarding\u003c/p\u003e\n \u003cp\u003eDay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.22 (0.83\u0026ndash;1.79)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.83 (1.14\u0026ndash;2.95)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.89 (0.57\u0026ndash;1.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of School\u003c/p\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003cp\u003eMixed (both sex)\u003c/p\u003e\n \u003cp\u003eSingle-sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.04 (0.75\u0026ndash;1.45)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.52 (0.95\u0026ndash;2.44)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.13 (0.78\u0026ndash;1.63)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.52 (1.35\u0026ndash;4.71)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.02 (0.69\u0026ndash;1.52)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.94 (1.42\u0026ndash;6.07)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.937\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003cp\u003eUrban/Town\u003c/p\u003e\n \u003cp\u003eSub-urban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.29 (0.91\u0026ndash;1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.07 (0.72\u0026ndash;1.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.62 (1.07\u0026ndash;2.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003cp\u003eMoslem\u003c/p\u003e\n \u003cp\u003eProtestant\u003c/p\u003e\n \u003cp\u003ePentecostal\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.18 (0.69\u0026ndash;1.99)\u003c/p\u003e\n \u003cp\u003e1.21 (0.62\u0026ndash;2.36)\u003c/p\u003e\n \u003cp\u003e1.01 (0.57\u0026ndash;1.79)\u003c/p\u003e\n \u003cp\u003e0.93 (0.52\u0026ndash;1.64)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2.01 (1.07\u0026ndash;3.77)\u003c/p\u003e\n \u003cp\u003e1.36 (0.59\u0026ndash;3.07)\u003c/p\u003e\n \u003cp\u003e1.07 (0.53\u0026ndash;2.19)\u003c/p\u003e\n \u003cp\u003e1.31 (0.66\u0026ndash;2.59)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2.09 (1.04\u0026ndash;4.20)\u003c/p\u003e\n \u003cp\u003e0.72 (0.25\u0026ndash;2.09)\u003c/p\u003e\n \u003cp\u003e1.32 (0.61\u0026ndash;2.87)\u003c/p\u003e\n \u003cp\u003e1.65 (0.78\u0026ndash;3.47)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily Type\u003c/p\u003e\n \u003cp\u003eBoth Parent Alive\u003c/p\u003e\n \u003cp\u003eOne Parent Alive\u003c/p\u003e\n \u003cp\u003eOrphan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.32 (0.82\u0026ndash;2.12)\u003c/p\u003e\n \u003cp\u003e1.16 (0.44\u0026ndash;3.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.61 (0.97\u0026ndash;2.67)\u003c/p\u003e\n \u003cp\u003e1.89 (0.75\u0026ndash;4.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.69 (0.98\u0026ndash;2.92)\u003c/p\u003e\n \u003cp\u003e1.51 (0.51\u0026ndash;4.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGuardian/Caretaker\u003c/p\u003e\n \u003cp\u003eParents\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.08 (0.58\u0026ndash;1.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.17 (0.60\u0026ndash;229)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.24 (0.61\u0026ndash;2.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.928\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParents Marital Status\u003c/p\u003e\n \u003cp\u003eMarried/cohabiting\u003c/p\u003e\n \u003cp\u003eSeparated/widowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.07 (0.64\u0026ndash;1.78)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.95 (0.55\u0026ndash;1.64)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.24 (0.66\u0026ndash;2.34)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.883\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhone Ownership\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.55 (1.11\u0026ndash;2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.74 (1.20\u0026ndash;2.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.06 (1.37\u0026ndash;3.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial Support\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.29 (0.82\u0026ndash;2.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.22 (0.74\u0026ndash;2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.73 (0.45\u0026ndash;1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.201\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExam Failure\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.28 (0.85\u0026ndash;1.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.52 (0.95\u0026ndash;2.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.04 (0.65\u0026ndash;1.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.273\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronic Illness\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.59 (1.07\u0026ndash;2.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.83 (1.19\u0026ndash;2.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.59 (1.67\u0026ndash;4.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRisky Sex Behavior\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.81 (1.17\u0026ndash;2.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.12 (1.33\u0026ndash;3.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.08 (1.26\u0026ndash;3.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubstance Use\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.12 (1.49\u0026ndash;3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.63 (1.79\u0026ndash;3.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.76 (1.82\u0026ndash;4.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMultivariable analysis of factors related to psychological distress\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eAdjusted Relative Risk Ratio (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of Student\u003c/p\u003e\n \u003cp\u003eBoarding\u003c/p\u003e\n \u003cp\u003eDay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.24 (0.81\u0026ndash;1.89)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2.01 (1.20\u0026ndash;3.37)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e0.93 (0.57\u0026ndash;1.51)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e0.316\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e0.008**\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ec\u003c/sup\u003e0.768\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of School\u003c/p\u003e\n \u003cp\u003eMixed (both sex)\u003c/p\u003e\n \u003cp\u003eSingle-sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1.73 (1.04\u0026ndash;2.88)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e3.02 (1.57\u0026ndash;5.81)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e2.93 (1.37\u0026ndash;6.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e0.036*\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e0.001***\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ec\u003c/sup\u003e0.006**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhone Ownership\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.42 (1.00-2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.47 (0.99\u0026ndash;2.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.93 (1.24\u0026ndash;3.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e0.049*\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e0.058\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ec\u003c/sup\u003e0.003**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronic Illness\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.62 (1.07\u0026ndash;2.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.88 (1.20\u0026ndash;2.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.60 (1.64\u0026ndash;4.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e0.022*\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e0.006**\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ec\u003c/sup\u003e\u0026lt;0.001***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRisky Sex Behavior\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.68 (1.06\u0026ndash;2.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.85 (1.12\u0026ndash;3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.79 (1.04\u0026ndash;3.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e0.028*\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e0.017*\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ec\u003c/sup\u003e0.034*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubstance Use\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.01 (1.39\u0026ndash;2.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.35 (1.55\u0026ndash;3.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.57 (1.66\u0026ndash;4.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003e\u0026lt;0.001***\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003e\u0026lt;0.001***\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ec\u003c/sup\u003e\u0026lt;0.001***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e Mild; \u003csup\u003eb\u003c/sup\u003e Moderate; \u003csup\u003ec\u003c/sup\u003e Severe\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of the study was to determine the prevalence of psychological distress and to identify the high risk behaviors associated with psychological distress among secondary school adolescents in Uganda. The overall prevalence of psychological distress was 57% with 24.6% mild psychological distress, 18% moderate psychological distress and 14.4% severe psychological distress. The study identified risky sexual behavior, alcohol consumption, smoking and substance use as high risk behaviors associated with mild, moderate and severe psychological distress. Other covariates identified in this study were chronic illness and type of school which were significantly associated with mild, moderate and severe psychological distress. However, mobile phone ownership was associated with mild and severe psychological distress while type of student residence was significantly associated with moderate psychological distress.\u003c/p\u003e \u003cp\u003eThe prevalence of psychological distress in this study is consistent with the prevalence rates reported by other studies in Uganda. Generally, previous studies have shown a high prevalence of mental health issues such as anxiety and depression among adolescents in Ugandan. A recent study conducted among high school adolescent girls in Southern Uganda revealed that the prevalence of depressive symptoms ranged from 16\u0026ndash;29% among the study participants (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Another study conducted among secondary school students in Central Uganda indicated that 21% had significant depression symptoms (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Other studies have reported prevalence rates of 26.6% anxiety disorders in children and adolescents (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), 36% anxiety/depressive symptoms in marginalized adolescent population (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and 51% psychological distress in adolescents living with HIV/AIDS (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In comparison to studies from other countries, this study finding is similar to the rates reported in Tanzania (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), Ethiopia (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), Egypt (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), Canada (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and China (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), but distinct from rates in Zambia (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), India (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and USA (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The differences in the prevalence rates of psychological distress could be due to the diverse environment, culture and economic factors as well as varying study sample, assessment tool and methodology.\u003c/p\u003e \u003cp\u003eIn this survey, students who drank alcohol, smoked or used substances were more likely to report psychological distress compared to students who do not. This finding is consistent with a study conducted in Uganda where alcohol and drug use was associated with depression in school going adolescents (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This association may be due to the use of alcohol as a coping mechanism to stressors or life challenges. Previous studies conducted in Tanzania (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), Ethiopia (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), Zambia (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), India (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), Norway (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and Finland (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) have shown similar results although a study in Canada reported that alcohol and cannabis use were not associated with psychological distress (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This study revealed that adolescents that engage in risky sexual activities were more likely to report psychological distress. The possible explanation for this relationship could be that adolescents become distressed because of engaging in risky sexual behavior or psychological distress may make it difficult for the students to practice safe sex. This is supported by studies conducted among high school students in the US (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), school-going adolescents in Tanzania (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and adolescents in Sub-Saharan Africa (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). However, contradictory findings was reported in African American adolescent girls (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen examining the covariates of psychological distress, students who report having chronic health conditions were more likely to have psychological distress. This is in line with a research conducted among adolescents in Kampala, Uganda (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Other existing studies have also shown similar results (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Phone ownership was significantly associated with psychological distress in our sample. Studies suggest that adolescents that own mobile phones were more likely to have psychological distress compared to their colleagues that do not have mobile devices (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). In addition, students in boarding schools and schools with both genders tend to report more cases of psychological distress, nonetheless, this is contrary to another study where students in single-sex schools had higher odds of psychological distress (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Contrary to existing studies; gender, social support and academic performance were not associated with psychological distress in this study (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study has limitations that should be considered when interpreting the results. The cross-sectional design of this study does not indicate the cause - effect relationship. Self-reported instrument was used to identify psychological distress with no diagnostic interview conducted to establish the presence of psychological distress. Moreover, there is a tendency of giving social desirable responses by the students and some questions require recall of past history which is prone to recall bias.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eA high prevalence of psychological distress was identified among secondary school students in Uganda. The finding indicates that one in every two school-going adolescent have some symptoms of psychological distress. Besides, the results of this study revealed that risky sexual behavior, alcohol consumption, smoking and substance use were associated with psychological distress. Hence, psychological distress in adolescents may be linked to high rate of HIV/AIDS, sexual transmitted infections, unwanted pregnancies and other negative consequences in this population. Thus, incorporating mental health services with substance and sexual health programs for adolescents is recommended. Also, it is needful to institute counseling and mental health programs for secondary school students.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Research Ethics Committee of Mbarara University of Science and Technology. Participation was voluntary and informed written consent was obtained from all the participants. All procedures performed were in accordance with the 1964 Helsinki declaration and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that there is no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMUA was the sole author involved in the conceptualization, data collection, and writing of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld health Organization. The World Health Report 2001: Mental Disorders affect one in four people. Geneva: WHO, 2001 [cited 2021 June 30], Available from: https://www.who.int/news/items/28-09-2001-the-world-health-report-2001-mental-disorders-affect-one-in-four-people.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Mental Health. 2021 [cited 2021 July, 11], Available from: https://www.who.int/health-topics/mental-health#tab_2.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Adolescent Mental Health. 2019 [cited 2021 July, 10], Available from: https://www.int/news-room/fact-sheets/detail/adolescent-mental-health.\u003c/li\u003e\n\u003cli\u003eDrapeau A, Marchand A, Beaulieu-Pr\u0026eacute;vost D. Epidemiology of psychological distress. Mental illnesses-Understanding Prediction Control2012.\u003c/li\u003e\n\u003cli\u003eMirowsky J, Ross C. Measurement for a human science. J Health Soc Behav. 2002,43(2):152-70.\u003c/li\u003e\n\u003cli\u003eInternational Encyclopedia of the Social and Behavioural Sciences. Psychological Distress. 2015 [cited 2021 July, 11], second:[Available from: https://Sciencedirect.com/topics/psychology/psychological-distress.\u003c/li\u003e\n\u003cli\u003eArbour-Nicitopoulos KP, Faulkner G, Irving H. Multiple health-risk behavior and psychological distress in adolescence. J Can Acd Child Adolesc Psychiatry. 2012,21(3):171-8.\u003c/li\u003e\n\u003cli\u003eHuang J, Xia W, Sun C, Zhang H, Wu L. Psychological distress and its correlates in Chinese adolescents. Aust N Z J Psychiatry. 2009,43(7):674-81.\u003c/li\u003e\n\u003cli\u003eSaquib N, Saquib J, Wahid A, Ahmed A, Dhuhayr H, Zaghloul M, et al. Video game addiction and psychological distress among expatriate adolescents in Saudi Arabia. Addict Behav Rep. 2017:112-7.\u003c/li\u003e\n\u003cli\u003eJaisoorya T, Desai G, Beena K, Beena M, Ellangovan K, Thennarasu K. Prevalence and correlates of psychological distress in adolescent students from India. East Asian Arch Psychiatry. 2017,27(2):56-62.\u003c/li\u003e\n\u003cli\u003eSiziya S, Mazaba M. Prevalence and correlates for psychosocial distress among in-school adolescents in Zambia. Frontiers in Public Health. 2015,3(180).\u003c/li\u003e\n\u003cli\u003ePengpid S, Peltzer K. Psychological distress and its associated factors among school-going adolescents in Tanzania. Psychol Stud. 2020,65:174-81.\u003c/li\u003e\n\u003cli\u003eMusisi S, Kinyanda E. Emotional and behavioral disorders in HIV seropositive adolescents in urban Uganda. East Afr Med J. 2009,86(1):16-24.\u003c/li\u003e\n\u003cli\u003eNalugya-Sserunjogi J, Rukundo G, Ovuga E, Kiwuwa S, Musisi S, Nakimuli-Mpungu E. Prevalence and factors associated with depression symptoms among school-going adolescents in central Uganda. Child Adolesc Psychiatry Ment Health. 2016,10(1).\u003c/li\u003e\n\u003cli\u003eDahl R. Adolescent brain developent: a period of vulnerabilities and opportunities. Keynote address. Ann N Y Acad Sci. 2004.\u003c/li\u003e\n\u003cli\u003eMichaud P, Blum R, Ferron C. \u0026quot;Bet you I will\u0026quot; Risk or experimental behavior during adolescence? Archives of Pediatric and Adolescent Medicine. 1998,152(3):224-6.\u003c/li\u003e\n\u003cli\u003eHenry BM, Bakeera-Kitaka S, Lubega K, Snyder AS, LaRussa P, Pfeffer B. Depressive symptoms, sexual activity, and substance use among adolescents in Kampala, Uganda. Afr Health Sci. 2019,19(2):1888-96.\u003c/li\u003e\n\u003cli\u003eLehrer J, Shrier L, Gortmaker S, Buka S. Depressive symptoms as a longitudinal predictor of sexual risk behaviors among US middle and high school students. Pediatrics 2006. 2006,118(1):189-200.\u003c/li\u003e\n\u003cli\u003eBalogun O, Koyanagi A, Stickley A, Gilmour S, Shibuya K. Alcohol consumption and psychological distress in adolescents: A multi-country study. J Adolesc Health. 2014,54:228-34.\u003c/li\u003e\n\u003cli\u003eMarmorstein N, Lacono W, Malone S. Longitudinal associations between depression and substance dependence from adolescence through early adulthood. Drug Alcohol Depend. 2010,107:154-60.\u003c/li\u003e\n\u003cli\u003eMyklestad I, R\u0026oslash;ysamb E, Tambs K. Risk and protective factors for psychological distress among adolescents: a family study in the Nord-Tr\u0026oslash;ndelag health study. Soc Psychiatry Psychiatr Epidemiol. 2011.\u003c/li\u003e\n\u003cli\u003ePage RM, Hall CP. Psychological distress and alcohol use as factors in adolescent sexual behavior among Sub-Saharan African adolescents. Journal of school health. 2009,79(8):369-79.\u003c/li\u003e\n\u003cli\u003eTraci LB, Sion KH, Jeannie ST, Elizabeth RW. Association of adolescent risk behavior with mental health symptoms in high school students. J Adolesc Health. 2002,31(3):240-6.\u003c/li\u003e\n\u003cli\u003eSaraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J. Barriers to improvement of mental health services in low income and middle income countries. Lancet. 2007,370:1164-74.\u003c/li\u003e\n\u003cli\u003eChisholm D, Lund C, Saxena S. Cost of scling up mental healthcare in low-and middle-income countries. Br J Psychiat. 2007,191:S28-S35.\u003c/li\u003e\n\u003cli\u003eMuhwezi W, \u0026Aring;gren H, Neema S, Maganda A, Musisi S. Life events associated with major depression in Uganda Primary Healthcare (PHC) patients: Issues of cultural specifificity. Int J Soc Psychiat. 2008,54:144-64.\u003c/li\u003e\n\u003cli\u003eNabunya P, Damulira C, Byansi W. Prevalence and correlates of depressive symptoms among high school adolesent girls in southern Uganda. BMC Public Health. 2020,20.\u003c/li\u003e\n\u003cli\u003eMcMullen J, O\u0026apos;Callaghan P, Richards J, Eakin J, Rafferty H. Screening for traumatic exposure and psychological distress among war-affected adolescents in post-conflict northern Uganda. Soc Psychiatry Psychiatr Epidemiol. 2012,47(9):1489-98.\u003c/li\u003e\n\u003cli\u003eAbbo C, Kinyanda E, Kizza R, Levin J, Ndyanabangi S, Stein D. Prevalence , comorbidity and predictors of anxiety disorders in children and adolescents in rural north-western Uganda. Child Adolesc Psychiatry Ment Health. 2013,7(1):21.\u003c/li\u003e\n\u003cli\u003eKessler R, editor. The WHO World Mental Health Survey: Global Perspectives on the Epidemiology of Mental Disorders: Cambridge University Press, 2008.\u003c/li\u003e\n\u003cli\u003eKessler R, Andrews G, Colpe L, Hiripi E, Mroczek D, Normand S, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002,32:959-76.\u003c/li\u003e\n\u003cli\u003eMyer L, Stein D, Grimsrud A, Seedat S, Williams D. Social determinants of psychological distress in a nationally-rpresentative sample of South African adults. Soc Sci Med. 2008,66:1828-40.\u003c/li\u003e\n\u003cli\u003eGebremedhin H, Bifftu B, Lebessa M, Weldeyes A, Gebru T, Petrucka P. Prevalence and associated factors of psychological distress among secondary school students in Mekelle City, Tigray Region, Ethiopia: Cross-sectional study. Psychology Research and Behavior Management. 2020,13:473-80.\u003c/li\u003e\n\u003cli\u003eAndrews G, Slade T. Interpreting scores on the Kessler psychological distress scale (K10). Aust N Z J Public Health. 2001,25(6):494-7.\u003c/li\u003e\n\u003cli\u003eZenebe Y, Kunno K, Mekonnen M, Bewuket A, Birkie M, Necho M, et al. Prevalence and associated factors of internet addiction among undergraduate university students in Ethiopia: a community university-based cross-sectional study. BMC Psychology. 2021,9(4).\u003c/li\u003e\n\u003cli\u003eCanavan M, Sipsma H, Adhvaryu A, Ofori-Atta A, Jack H, Udry C, et al. Psychological distress in Ghana: associations with employment and lost productivity. Int J Ment Health Syst. 2013,7(9).\u003c/li\u003e\n\u003cli\u003eWorld Health Organisation. Alcohol, Smoking and Substance Involvement Screening Test. Geneva, Switzerland: WHO, [cited 2018 23 August], Available from: http://www.who.int/substance_abuse/activities/assist/en/.\u003c/li\u003e\n\u003cli\u003eWHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002,97(9):1183-94.\u003c/li\u003e\n\u003cli\u003eDiab I, Elweshahi H, Sheshtawy H, Youssef A, Eltayar S, Sharaf A. Screening for psychological distress among high school graduates accepted for enrollment at Alexandria faculty of medicine: academic year 2016/2017. Alexandria J Med. 2017,54(2):155-9.\u003c/li\u003e\n\u003cli\u003eZhang X, Ra C, Zhang D, Zhang Y, MacLeod K. The impact of school social support and bullying victimization on psychological distress among California adolescents. Californian J Health Promot. 2016,14(2).\u003c/li\u003e\n\u003cli\u003eSavolainen I, Kaakinen M, Sirola A, Oksanen A. Addictive behaviors and psychological distress among adolescents and emerging adults: a mediating role of peer group identification. Addict Behav Rep. 2018,7:75-81.\u003c/li\u003e\n\u003cli\u003eBachanas P, Morris M, Lewis-Gess J, Sarett-Cuasay J, Sirl K, Ries K, et al. Predictors of risky sexual behavior in African American adolescent girls: implications for prevention interventions. J Pediatr Psychol. 2002,27(6):519-30.\u003c/li\u003e\n\u003cli\u003eSeigel W, Golden N, Gough J, Lashley M, Sacker I. Depression, self-esteem and life events in adolescents with chronic diseases. Journal of Adolescent Health Care. 1990,11(6):501-4.\u003c/li\u003e\n\u003cli\u003ePinquart M, Shen Y. Depressive symptoms in children and adolescents with chronic physical illness: An updated meta-analysis. Journal of Pediatric Psychology. 2011,36(4).\u003c/li\u003e\n\u003cli\u003eWang C, Li K, Kim M, Lee S, Seo D-C. Association between psychological distress and elevated use of electronic devices among U.S adolescents:Results from the youth risk behavior surveillance 2009-2017. Addict Behav. 2019,90:112-8.\u003c/li\u003e\n\u003cli\u003eAtorkey P, Owiredua C. Clustering of multiple health risk behaviors and association with socio-demographic characteristics and psychological distress among adolescents in Ghana: A latent class analysis. SSM-Population Health. 2021,13.\u003c/li\u003e\n\u003cli\u003eShao R, He P, Ling B, Tan L, Xu L, Hou Y, et al. Prevalence of depression, anxiety, and correlations between depression, anxiety, family functioning, social support and coping styles among Chinese medical students. BMC Psychology. 2020,8(38).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Psychological distress, Risky Behaviors, Adolescents, Secondary School, Students, Uganda.","lastPublishedDoi":"10.21203/rs.3.rs-871483/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-871483/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\u003cp\u003ePsychological distress is a mental health condition that is common in adolescents. It negatively affects the academic performance of adolescents, relationships with family and friends, and the ability of adolescents to participate fully in the community. Stressful life events in low income countries and risk taking behavior of adolescents have raised concerns on the magnitude and impact of psychological distress among adolescents in Uganda. This study aims to estimate the prevalence of psychological distress and assess the high risk behaviors associated with psychological distress among secondary school students in Uganda. \u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e\u003cp\u003eA community based cross-sectional study was conducted among secondary school students in Mbarara Municipality, Uganda. Multistage cluster sampling technique was used to recruit study participants and a total of 921 students participated in the study using a self-reported questionnaire. Psychological distress was assessed by Kessler’s psychological distress scale (K10). To identify high risk behaviors associated with psychological distress, multinomial logistic regression was used with p \u0026lt;0.05 and 95% confidence interval. \u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003eThe prevalence of psychological distress was 57%. Risky sexual behavior, alcohol consumption, smoking and substance use were associated with psychological distress. Also, boarding school students, those in mixed schools, students that own mobile phones and adolescents with chronic illness were more likely to report psychological distress. \u003c/p\u003e\u003cp\u003eConclusion\u003c/p\u003e\u003cp\u003eThe prevalence of psychological distress is high among school going adolescents and risky behaviors were associated with psychological distress. The findings suggest the need to address mental health issues in adolescents.\u003c/p\u003e","manuscriptTitle":"Psychological Distress in Adolescents: Prevalence and its Relation to High Risk Behaviors Among Secondary School Students in Uganda.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-08 22:30:01","doi":"10.21203/rs.3.rs-871483/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-10-08T07:48:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-10-04T19:18:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2af60aa3-6d8c-4d66-9f07-19adfe24a5c8","date":"2021-09-28T22:32:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31788d00-a34f-44a6-9afc-c6da74d07d09","date":"2021-09-18T16:39:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-09-14T15:16:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-09-06T14:17:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-09-06T06:03:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-09-06T06:00:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2021-09-03T07:41:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6edb6b9c-be1f-4f2d-8b43-cc136178efe4","owner":[],"postedDate":"September 8th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":7016913,"name":"Psychology"}],"tags":[],"updatedAt":"2023-10-16T18:22:34+00:00","versionOfRecord":{"articleIdentity":"rs-871483","link":"https://doi.org/10.1186/s40359-023-01039-z","journal":{"identity":"bmc-psychology","isVorOnly":false,"title":"BMC Psychology"},"publishedOn":"2023-01-09 18:18:30","publishedOnDateReadable":"January 9th, 2023"},"versionCreatedAt":"2021-09-08 22:30:01","video":"","vorDoi":"10.1186/s40359-023-01039-z","vorDoiUrl":"https://doi.org/10.1186/s40359-023-01039-z","workflowStages":[]},"version":"v1","identity":"rs-871483","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-871483","identity":"rs-871483","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}