Issues in Mental Health Nursing
ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20
Ecological Factors Influencing Emotional/ Behavioral Problems and Self-Concept in Adolescents from Low-Income Families in South Korea Suyon Baek & Haewon Yoo To cite this article: Suyon Baek & Haewon Yoo (2017): Ecological Factors Influencing Emotional/ Behavioral Problems and Self-Concept in Adolescents from Low-Income Families in South Korea, Issues in Mental Health Nursing, DOI: 10.1080/01612840.2017.1325949 To link to this article: http://dx.doi.org/10.1080/01612840.2017.1325949
Published online: 14 Jun 2017.
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Date: 15 August 2017, At: 19:12
ISSUES IN MENTAL HEALTH NURSING https://doi.org/./..
Ecological Factors Influencing Emotional/Behavioral Problems and Self-Concept in Adolescents from Low-Income Families in South Korea Suyon Baek, PhD, RN
a
and Haewon Yoo, PhD, MBA, RNb
a Industry Academy Cooperation Foundation, Inje University, Busan, South Korea; b Global Healthcare Management, Hanyang University, Seoul, Republic of Korea
Downloaded by [Australian Catholic University] at 19:12 15 August 2017
ABSTRACT
In this study, we examined emotional/behavioral problems and self-concept in adolescents from lowincome families in Korea; additionally, we identified ecological factors associated with these traits. This descriptive study employed an ecological model to analyze data from the Korean Children and Youth Panel Survey. A nationwide stratified multistage cluster sampling methodology was used. Overall, 2534 first-year middle school students were included in the survey, and the survey was conducted from 2010 to 2016. Hierarchical multiple regression models were generated. The mean score of emotional/behavioral problem has been changed from 2.20 (2011), 2.15 (2013), to 2.11 (2015) out of 4, and the mean score of self-concept has been changed from 2.73 (2012), 2.73 (2014), to 2.77 (2015) out of 4. Factors that influenced emotional/behavioral problems and self-concept among adolescents were health perception and academic achievement (only associated with self-concept) at the intrapersonal level and parenting style, peer attachment (only associated with self-concept), and relationships with teachers at the interpersonal level. These results may be used to inform the development of interventions designed to decrease emotional/behavioral problems and improve positive self-concept in adolescents from low-income families.
Introduction According to the Organization for Economic Cooperation and Development (OECD, 2014), child poverty has steadily increased worldwide, and in Korea, a greater proportion of children have been observed to meet the definition of poverty, with a poverty rate of 10.3% identified in 2010 and a poverty rate of 12.2% identified in 2012 (Statistics Korea, 2013). Additionally, given the quantitative increase in the number of impoverished children and the fact that one of the major goals of health policy is to alleviate health inequalities, the health of children from lowincome families and vulnerable groups should be prioritized. In this respect, studies on the physical health and quality of life of low-income and vulnerable adolescents have been conducted; however, mental health has rarely been assessed within this population (Byck, Bolland, Dick, Ashbeck, & Mustanski, 2013). Despite the fact that 90% of children and adolescents live in low-income and middle-income countries, only 10% of studies have focused on the mental health of children and adolescents in these countries (Kieling et al., 2011). The results of one longitudinal study indicated that based on parent-reported data, children of low socioeconomic status (SES) were more likely than children of higher SES to experience mental health problems (Wadsworth & Achenbach, 2005). These results demonstrate that we should pay more attention to the mental health problems of children and adolescents in low-income families. Studies previously conducted in Korea have focused on the implementation of interventions targeting adolescents from low-income families. In other words, basic research has not been conducted to determine the types of mental health CONTACT Suyon Baek
whitesy@naver.com
© Taylor & Francis Group, LLC
problems that exist in this population, as prior studies have merely examined mental health before and after interventions by arbitrarily selecting variables such as depression and anxiety. As the emotional/behavioral problems affecting adolescents have been found to vary widely, it may be difficult to define all these traits within the framework of a single theoretical model. However, internalizing problems such as anxiety, depression, and fear are often referred to as emotional problems, and externalizing problems such as distraction, hyperactivity, aggression, and impulsivity are often referred to as behavioral problems (Cho & Lim, 2003; Kauffman & Hallahan, 1981). In addition, Achenbach and Rescorla (2001) classified the behavioral problems of children and adolescents into internalizing and externalizing problems using an empirical approach. Based on this approach, the internalizing problems are comprised anxiety, depression, withdrawal, and somatic symptoms, and the externalizing problems were characterized by aggressive and destructive behaviors. Therefore, the systematic identification and assessment of emotional/behavioral problems affecting adolescents should precede the execution of intervention studies. Most studies on adolescent mental health have focused only on the problematic factors associated with impoverished conditions and overlooked their potentially protective role. If we simply accept that poverty has a negative impact on adolescents, then all adolescents from low-income families should either exhibit maladaptive behaviors or become problematic youth. However, contrary to this hypothesis, some adolescents have been found to exhibit high levels of adaptation and positive
Industry Academy Cooperation Foundation, Inje University, , Bokji-ro, Busanjin-gu, Busan , South Korea.
Downloaded by [Australian Catholic University] at 19:12 15 August 2017
2
S. BAEK AND H. YOO
developmental outcomes despite growing up in poor families. Therefore, it is necessary to identify the characteristics of these adolescents and the factors associated with adapting well to various risks and adversities, including poverty. In addition, if the aim of mental health nursing is to promote the psychological well-being of adolescents, increased attention should be paid to the need to reinforce the protective aspects and reduce the problematic aspects of adolescence. Self-concept refers to an individual’s views and evaluation of him or herself. Self-conceptualization has been reported to have an important effect on mental health (Heine & Lehman, 1999). Correlation studies have examined the relationship between mental health and self-concept and found that having a positive self-concept was an important indicator of psychological health (Barnett & Hunter, 2012), particularly in adolescents (Wu, Jiang, Ho, Duan, & Zhang, 2014, Recitation). Therefore, the purpose of this study was to evaluate emotional/behavioral problems and self-concept in adolescents from low-income families in Korea and to investigate the ecological factors associated with these traits. Ecological approaches take into account the complex and dynamic processes of various environmental systems, such as families, schools, friends, and communities, as well as intrapersonal aspects to develop an understanding of the issues associated with child and adolescent development. The central premise of the ecological model is that multilevel interventions may be the most effective for instigating change (Sallis, Owen, & Fisher, 2009), a hypothesis that has been consistently supported by the results of previous studies of diverse groups and environments (Samuels et al., 2010). Therefore, in this study, we aimed to understand the ecological factors affecting adolescents, thereby emphasizing the importance of creating a healthy environment to facilitate improvements in emotional/behavioral problems and self-concept in adolescents from low-income families. In addition, the use of this approach may provide concrete directions for the development of multilevel intervention programs in the future. Purpose of the study (1) The purpose of this study was to identify emotional/behavioral problems (depression, somatic complaint, social withdrawal, aggression, and attention problem) and self-concept (self-esteem, resilience, and ego-identity) in adolescents from low-income families using longitudinal data. (2) The purpose of this study was to investigate the intrapersonal, interpersonal, and organizational factors associated with emotional/behavioral problems (depression, somatic complaint, social withdrawal, aggression, and attention problem) and self-concept (self-esteem, resilience, and ego-identity) in adolescents from lowincome families using cross-sectional data.
Methodology Study design This was a secondary data analysis study based on the ecological model developed by McLeroy, Bibeau, Steckler, & Glanz (1988).
In this study, intrapersonal factors refer to the individual characteristics of adolescents, whereas interpersonal factors refer to their family structure, parents’ parenting style, peer attachment, and relationships with teachers. Organizational factors refer to the adolescents’ perception of their level of community connectedness. Participants This study used data from the Korean Children and Youth Panel Survey, which is disseminated by the Korea Youth Policy Institute (KYPI). A nationwide stratified multistage cluster sampling methodology was used. These data were collected annually from nationally representative panels of elementary and middle school students between 2010 and 2016. Of the 2534 subjects included in the first-year middle school panel in 2010, 698 subjects were excluded because their caregiver did not respond to the annual household income question more than once during the study period. We averaged the annual household incomes reported over the six-year period from 2010 to 2015 and classified families in the lower 15% of the average annual household incomes as low-income. The average annual household income within this group was 16,966,000 won, which is below the 24,000,000 won that was designated the minimum cost of living for a 4-member family in 2015. As a result, 220 subjects were classified as “adolescents from low-income families.” In this study, data from 2011, 2012, 2013, 2014, and 2015 were included in the final analysis, as the dependent variables were not measured during all study waves. The sociodemographic characteristics of the participants are summarized in Table 1. Measures Emotional/behavioral problems In accordance with the operational definitions used in a previous study (Ban & Oh, 2016), an adolescent’s emotional/behavioral problem score referred to the sum of his or her depression, somatic complaint, social withdrawal, aggression, and attention problem scores. Depression. Ten items from the Symptom Checklist-90Revised (Kim, Kim, & Won, 1984) were used. Item responses Table . Sociodemographic and ecological factor-related characteristics of the participants (N = ). Characteristics Gender Annual household income (, won) Family structure
Health perception Academic achievement Parenting style Peer attachment Relationship with teacher Community connectedness
Distribution Male Female
N (%)
M(SD)
Range
(.) (.) .(.)
Two-parent Single-parent Grandparent Other Positive Negative
(.) (.) (.) (.) .(.) .(.) .(.) .(.) .(.) .(.) .(.)
– – – – – – –
ISSUES IN MENTAL HEALTH NURSING
were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I am uninterested in everything.” All items were reverse-coded so that higher scores indicated higher levels of depression. The Cronbach’s alpha for these items was .88 in the current study.
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Somatic complaint. Eight items from the Emotional or Behavioral Problems Scale (Cho & Lim, 2003) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I often have a headache.” All items were reverse-coded so that higher scores indicated worse somatic complaints. The Cronbach’s alpha for these items was .85 in the current study. Social withdrawal. Five items from the Behavior Problem Scale for Children and Adolescence (Kim & Kim, 1998) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I hate to be in front of people.” All items were reverse-coded so that higher scores indicated higher levels of social withdrawal. The Cronbach’s alpha for these items was .89 in the current study. Aggression. Six items from the Emotional or Behavioral Problems Scale (Cho & Lim, 2003) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “Sometimes I feel angry all day.” All items were reverse-coded so that higher scores indicated higher levels of aggression. The Cronbach’s alpha for these items was .80 in the current study. Attention problem. Seven items from the Emotional or Behavioral Problems Scale (Cho & Lim, 2003) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I tend to miss out on the letters.” All items were reverse-coded so that higher scores indicated worse attention problems. The Cronbach’s alpha for these items was .76 in the current study. Self-concept In this study, self-concept referred to the sum of the adolescents’ self-esteem, resilience, and ego-identity scores. Each variable was measured as follows. Self-esteem. Ten items from the Rosenberg Self-Esteem Scale (Rosenberg, 1965) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I have a positive attitude toward myself.” Six items were reverse-coded so that higher scores indicated higher levels of self-esteem. The Cronbach’s alpha for these items was .85 in the current study.
3
Resilience. Fourteen items from the Ego-Resiliency Scale (Block & Kreman, 1996) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I am regarded as a very energetic person.” All items were reverse-coded so that higher scores indicated higher levels of resilience. The Cronbach’s alpha for these items was .85 in the current study. Ego-identity. Eight items from the Korean Adolescent Egoidentity Scale (Park, 2003) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I have set clear goals in life.” Three items were reverse-coded so that higher scores indicated higher levels of ego-identity. The Cronbach’s alpha for these items was .71 in the current study. Intrapersonal factors Health perception. This item was assessed using one question. Responses to this item were reported on a 4-point Likert scale (1 = very healthy to 4 = not very healthy). This item was reverse-coded so that higher scores indicated positive health perception. Academic achievement. This item was assessed using one question. Responses to this item were reported on a 4-point Likert scale (1 = very satisfied to 4 = not very satisfied). This item was reverse-coded so that higher scores indicated higher levels of satisfaction with academic achievement. Interpersonal factors Parenting style. Twenty-one items from the Parenting Behavior Inventory (Heo, 2004) were used. The measure consisted of six subscales, including supervision, affection, reasonable explanation, inconsistency, over-expectation, and over-involvement. In this study, positive parenting styles were assessed by calculating the sum of the mean scores for supervision, affection, and reasonable explanation. In addition, negative parenting styles were assessed by calculating the sum of the mean scores for inconsistency, over-expectation, and over-involvement. We used three items for supervision, four items for affection, three items for reasonable explanation, three items for inconsistency, four items for over-expectation, and four items for overinvolvement. Item responses were reported on a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). All items were reverse-coded so that higher scores indicated higher levels of positive and negative parenting styles. Cronbach’s alpha for positive parenting styles was .73, and Cronbach’s alpha for negative parenting styles was .84. Peer attachment. Nine items from the Inventory of Parent and Peer Attachment (Armsden & Greenberg, 1987) were used. The measure consists of three subscales, including communication, mutual trust, and isolation. Each subscale consisted of three items. Item responses were reported on a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). All items were reverse-coded so that higher scores indicated higher levels of
4
S. BAEK AND H. YOO
peer attachment. Cronbach’s alpha for these items was .85 in the current study.
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Relationships with teachers. Six items from the School Adjustment Scale (Min, 1991) were used. Item responses were reported on a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). All items were reverse-coded so that higher scores indicated good relationship with teacher. Cronbach’s alpha for these items was .85 in the current study. Organizational factors Community connectedness: Six items from the National Longitudinal Study of Adolescent to Adult Health (Carolina Population Center, 2009), as translated by the KYPI (2010), were used. Item responses were reported on a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). All items were reversecoded so that higher scores indicated higher levels of community connectedness. Cronbach’s alpha for these items was .69 in the current study. Analysis Statistical Package for the Social Sciences (SPSS) version 21.0 was used for the data analyses. All data were checked to ensure their accuracy after entry and that the assumptions of the utilized statistical tests were met. The participants’ emotional/behavioral problem and self-concept scores and general characteristics were analyzed using descriptive statistics, and a hierarchical multiple regression analysis was employed to investigate the ecological factors associated with emotional/behavioral problem and self-concept scores among participating adolescents.
Research findings Sociodemographic and ecological factor-related characteristics of the participants The sociodemographic and ecological factor-related characteristics of the participants are presented in Table 1. The ratio of male to female participants was relatively equal. Two-parent families were the most commonly observed family structure, but 40.9% of the adolescents were members of single-parent families. The average annual household income of the low-income families was 16,966,000 won. Emotional/behavioral problems and self-concept in adolescents from low-income families This study identified emotional/behavioral problems and selfconcept in adolescents from low-income families using longitudinal data from 2011 to 2015. The longitudinal trajectories of the outcome variables are depicted in Figure 1. The participants’ depression and somatic symptoms scores tended to decrease between the time point of the first survey (2011) and that of the last survey included herein (2015). However, the changes observed across all study time points were not statistically significant (depression: F = .864, p = .422; somatic symptoms: F = 1.913, p = .149). Social withdrawal scores tended to increase during this time period;
however, this increase was not statistically significant (social withdrawal: F = 1.022, p = .360). Aggression and attention problem scores significantly decreased between 2011 and 2015 (aggression: F = 7.347, p = .001; attention problems: F = 12.263, p ࣘ .000). A reduction was observed between 2011 and 2015 in the overall emotional/behavioral problem scores, which were calculated as the sum of the depression, somatic complaint, social withdrawal, aggression, and attention problem scores. However, the changes observed in emotional/behavioral problem scores across all study time points were not statistically significant (F = 2.467, p = .086). The participants’ self-esteem scores tended to increase between the time point of the first survey (2012) and that of the last survey included herein (2015); however, this difference was not statistically significant (F = 2.455, p = .087). Resilience scores significantly increased between 2012 and 2015 (F = 3.644, p = .027). While ego-identity scores decreased between 2012 and 2015, this difference was not statistically significant (F = .174, p = .840). Self-concept scores, which were calculated as the sum of the self-esteem, resilience, and ego-identity scores, were increased between 2012 and 2015 but not significantly (F = .969, p = .380). Ecological factors influencing emotional/behavioral problems in adolescents from low-income families In this study, we identified ecological factors influencing emotional/behavioral problems in adolescents from low-income families using cross-sectional data from 2015. To examine the factors that affected emotional/behavioral problems, a hierarchical regression analysis was performed, with gender, health perception, and academic achievement assessed in the intrapersonal domain (Model 1); family structure, positive patenting style, negative parenting style, peer attachment, and relationships with teachers assessed in the interpersonal domain (Model 2); and community connectedness assessed in the organizational domain (Model 3). Prior to performing the hierarchical multiple regression analysis, variables influencing emotional/behavioral problems were assessed for multicollinearity by examining their tolerance and variance inflation factor (VIF) values. As the results of these assessments indicated that the VIF value was less than three and the tolerance value was over 0.3 for all the variables, we determined that multicollinearity was not an issue. These results are shown in Table 2. The explanatory power was 11.5% (p ࣘ .001) for Model 1, which included only factors in the intrapersonal domain, indicating that having a positive perception of one’s health condition and academic achievement was associated with fewer emotional/behavioral problems. In Model 2, which also included factors in the interpersonal domain, the explanatory power increased by 12.6% (p ࣘ .001) relative to the explanatory power of Model 1, achieving an explanatory power of 24.1% (p ࣘ .001) and suggesting that having a positive perception of one’s health condition, higher levels of positive parenting, lower levels of negative parenting, and positive relationships with teachers were associated with fewer emotional/behavioral problems. In Model 3, which also included factors in the organizational domain, the explanatory power was 24.4% (p ࣘ .001). This value indicated a 0.3% increase over the explanatory power of Model 2 output;
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ISSUES IN MENTAL HEALTH NURSING
Figure . Emotional/behavioral problems and self-concept in adolescent from low-income families. (a). Depression, (b) somatic complaint, (c) social withdrawal, (d) aggression, (e) attention problem, (f) emotional/behavioral problems, (g) self-esteem, (h) resilience, (i) ego-identity, and (j) self-concept.
however, this difference was not significant (p = .317). In addition, academic achievement (p = .059) was significant at the .10 level. Ecological factors influencing self-concept in adolescents from low-income families In this study, we identified ecological factors influencing self-concept in adolescents from low-income families using
cross-sectional data from 2015. To examine factors associated with self-concept in adolescents from low-income families, a hierarchical regression analysis was conducted, with gender, health perception, and academic achievement assessed in the intrapersonal domain (Model 1); family structure, positive patenting style, negative parenting style, peer attachment, and relationships with teachers assessed in the interpersonal domain (Model 2); and community connectedness assessed
6
S. BAEK AND H. YOO
Table . Ecological factors influencing emotional/behavioral problems in adolescents from low-income families (n = ). Model β Intrapersonal
Interpersonal
Downloaded by [Australian Catholic University] at 19:12 15 August 2017
Organizational
Gender
Constant Male Female
Health perception Academic achievement Family structure Two-parent Single-parent Grandparent Other Parenting style Positive Negative Peer attachment Relationship with teacher Community connectedness F (p) R R change (p)
Model
t
β
p
t
. Ref. . − . − . Ref.
Model β
p
t
.
. − . − .
.
ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20
Ecological Factors Influencing Emotional/ Behavioral Problems and Self-Concept in Adolescents from Low-Income Families in South Korea Suyon Baek & Haewon Yoo To cite this article: Suyon Baek & Haewon Yoo (2017): Ecological Factors Influencing Emotional/ Behavioral Problems and Self-Concept in Adolescents from Low-Income Families in South Korea, Issues in Mental Health Nursing, DOI: 10.1080/01612840.2017.1325949 To link to this article: http://dx.doi.org/10.1080/01612840.2017.1325949
Published online: 14 Jun 2017.
Submit your article to this journal
Article views: 21
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imhn20 Download by: [Australian Catholic University]
Date: 15 August 2017, At: 19:12
ISSUES IN MENTAL HEALTH NURSING https://doi.org/./..
Ecological Factors Influencing Emotional/Behavioral Problems and Self-Concept in Adolescents from Low-Income Families in South Korea Suyon Baek, PhD, RN
a
and Haewon Yoo, PhD, MBA, RNb
a Industry Academy Cooperation Foundation, Inje University, Busan, South Korea; b Global Healthcare Management, Hanyang University, Seoul, Republic of Korea
Downloaded by [Australian Catholic University] at 19:12 15 August 2017
ABSTRACT
In this study, we examined emotional/behavioral problems and self-concept in adolescents from lowincome families in Korea; additionally, we identified ecological factors associated with these traits. This descriptive study employed an ecological model to analyze data from the Korean Children and Youth Panel Survey. A nationwide stratified multistage cluster sampling methodology was used. Overall, 2534 first-year middle school students were included in the survey, and the survey was conducted from 2010 to 2016. Hierarchical multiple regression models were generated. The mean score of emotional/behavioral problem has been changed from 2.20 (2011), 2.15 (2013), to 2.11 (2015) out of 4, and the mean score of self-concept has been changed from 2.73 (2012), 2.73 (2014), to 2.77 (2015) out of 4. Factors that influenced emotional/behavioral problems and self-concept among adolescents were health perception and academic achievement (only associated with self-concept) at the intrapersonal level and parenting style, peer attachment (only associated with self-concept), and relationships with teachers at the interpersonal level. These results may be used to inform the development of interventions designed to decrease emotional/behavioral problems and improve positive self-concept in adolescents from low-income families.
Introduction According to the Organization for Economic Cooperation and Development (OECD, 2014), child poverty has steadily increased worldwide, and in Korea, a greater proportion of children have been observed to meet the definition of poverty, with a poverty rate of 10.3% identified in 2010 and a poverty rate of 12.2% identified in 2012 (Statistics Korea, 2013). Additionally, given the quantitative increase in the number of impoverished children and the fact that one of the major goals of health policy is to alleviate health inequalities, the health of children from lowincome families and vulnerable groups should be prioritized. In this respect, studies on the physical health and quality of life of low-income and vulnerable adolescents have been conducted; however, mental health has rarely been assessed within this population (Byck, Bolland, Dick, Ashbeck, & Mustanski, 2013). Despite the fact that 90% of children and adolescents live in low-income and middle-income countries, only 10% of studies have focused on the mental health of children and adolescents in these countries (Kieling et al., 2011). The results of one longitudinal study indicated that based on parent-reported data, children of low socioeconomic status (SES) were more likely than children of higher SES to experience mental health problems (Wadsworth & Achenbach, 2005). These results demonstrate that we should pay more attention to the mental health problems of children and adolescents in low-income families. Studies previously conducted in Korea have focused on the implementation of interventions targeting adolescents from low-income families. In other words, basic research has not been conducted to determine the types of mental health CONTACT Suyon Baek
whitesy@naver.com
© Taylor & Francis Group, LLC
problems that exist in this population, as prior studies have merely examined mental health before and after interventions by arbitrarily selecting variables such as depression and anxiety. As the emotional/behavioral problems affecting adolescents have been found to vary widely, it may be difficult to define all these traits within the framework of a single theoretical model. However, internalizing problems such as anxiety, depression, and fear are often referred to as emotional problems, and externalizing problems such as distraction, hyperactivity, aggression, and impulsivity are often referred to as behavioral problems (Cho & Lim, 2003; Kauffman & Hallahan, 1981). In addition, Achenbach and Rescorla (2001) classified the behavioral problems of children and adolescents into internalizing and externalizing problems using an empirical approach. Based on this approach, the internalizing problems are comprised anxiety, depression, withdrawal, and somatic symptoms, and the externalizing problems were characterized by aggressive and destructive behaviors. Therefore, the systematic identification and assessment of emotional/behavioral problems affecting adolescents should precede the execution of intervention studies. Most studies on adolescent mental health have focused only on the problematic factors associated with impoverished conditions and overlooked their potentially protective role. If we simply accept that poverty has a negative impact on adolescents, then all adolescents from low-income families should either exhibit maladaptive behaviors or become problematic youth. However, contrary to this hypothesis, some adolescents have been found to exhibit high levels of adaptation and positive
Industry Academy Cooperation Foundation, Inje University, , Bokji-ro, Busanjin-gu, Busan , South Korea.
Downloaded by [Australian Catholic University] at 19:12 15 August 2017
2
S. BAEK AND H. YOO
developmental outcomes despite growing up in poor families. Therefore, it is necessary to identify the characteristics of these adolescents and the factors associated with adapting well to various risks and adversities, including poverty. In addition, if the aim of mental health nursing is to promote the psychological well-being of adolescents, increased attention should be paid to the need to reinforce the protective aspects and reduce the problematic aspects of adolescence. Self-concept refers to an individual’s views and evaluation of him or herself. Self-conceptualization has been reported to have an important effect on mental health (Heine & Lehman, 1999). Correlation studies have examined the relationship between mental health and self-concept and found that having a positive self-concept was an important indicator of psychological health (Barnett & Hunter, 2012), particularly in adolescents (Wu, Jiang, Ho, Duan, & Zhang, 2014, Recitation). Therefore, the purpose of this study was to evaluate emotional/behavioral problems and self-concept in adolescents from low-income families in Korea and to investigate the ecological factors associated with these traits. Ecological approaches take into account the complex and dynamic processes of various environmental systems, such as families, schools, friends, and communities, as well as intrapersonal aspects to develop an understanding of the issues associated with child and adolescent development. The central premise of the ecological model is that multilevel interventions may be the most effective for instigating change (Sallis, Owen, & Fisher, 2009), a hypothesis that has been consistently supported by the results of previous studies of diverse groups and environments (Samuels et al., 2010). Therefore, in this study, we aimed to understand the ecological factors affecting adolescents, thereby emphasizing the importance of creating a healthy environment to facilitate improvements in emotional/behavioral problems and self-concept in adolescents from low-income families. In addition, the use of this approach may provide concrete directions for the development of multilevel intervention programs in the future. Purpose of the study (1) The purpose of this study was to identify emotional/behavioral problems (depression, somatic complaint, social withdrawal, aggression, and attention problem) and self-concept (self-esteem, resilience, and ego-identity) in adolescents from low-income families using longitudinal data. (2) The purpose of this study was to investigate the intrapersonal, interpersonal, and organizational factors associated with emotional/behavioral problems (depression, somatic complaint, social withdrawal, aggression, and attention problem) and self-concept (self-esteem, resilience, and ego-identity) in adolescents from lowincome families using cross-sectional data.
Methodology Study design This was a secondary data analysis study based on the ecological model developed by McLeroy, Bibeau, Steckler, & Glanz (1988).
In this study, intrapersonal factors refer to the individual characteristics of adolescents, whereas interpersonal factors refer to their family structure, parents’ parenting style, peer attachment, and relationships with teachers. Organizational factors refer to the adolescents’ perception of their level of community connectedness. Participants This study used data from the Korean Children and Youth Panel Survey, which is disseminated by the Korea Youth Policy Institute (KYPI). A nationwide stratified multistage cluster sampling methodology was used. These data were collected annually from nationally representative panels of elementary and middle school students between 2010 and 2016. Of the 2534 subjects included in the first-year middle school panel in 2010, 698 subjects were excluded because their caregiver did not respond to the annual household income question more than once during the study period. We averaged the annual household incomes reported over the six-year period from 2010 to 2015 and classified families in the lower 15% of the average annual household incomes as low-income. The average annual household income within this group was 16,966,000 won, which is below the 24,000,000 won that was designated the minimum cost of living for a 4-member family in 2015. As a result, 220 subjects were classified as “adolescents from low-income families.” In this study, data from 2011, 2012, 2013, 2014, and 2015 were included in the final analysis, as the dependent variables were not measured during all study waves. The sociodemographic characteristics of the participants are summarized in Table 1. Measures Emotional/behavioral problems In accordance with the operational definitions used in a previous study (Ban & Oh, 2016), an adolescent’s emotional/behavioral problem score referred to the sum of his or her depression, somatic complaint, social withdrawal, aggression, and attention problem scores. Depression. Ten items from the Symptom Checklist-90Revised (Kim, Kim, & Won, 1984) were used. Item responses Table . Sociodemographic and ecological factor-related characteristics of the participants (N = ). Characteristics Gender Annual household income (, won) Family structure
Health perception Academic achievement Parenting style Peer attachment Relationship with teacher Community connectedness
Distribution Male Female
N (%)
M(SD)
Range
(.) (.) .(.)
Two-parent Single-parent Grandparent Other Positive Negative
(.) (.) (.) (.) .(.) .(.) .(.) .(.) .(.) .(.) .(.)
– – – – – – –
ISSUES IN MENTAL HEALTH NURSING
were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I am uninterested in everything.” All items were reverse-coded so that higher scores indicated higher levels of depression. The Cronbach’s alpha for these items was .88 in the current study.
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Somatic complaint. Eight items from the Emotional or Behavioral Problems Scale (Cho & Lim, 2003) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I often have a headache.” All items were reverse-coded so that higher scores indicated worse somatic complaints. The Cronbach’s alpha for these items was .85 in the current study. Social withdrawal. Five items from the Behavior Problem Scale for Children and Adolescence (Kim & Kim, 1998) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I hate to be in front of people.” All items were reverse-coded so that higher scores indicated higher levels of social withdrawal. The Cronbach’s alpha for these items was .89 in the current study. Aggression. Six items from the Emotional or Behavioral Problems Scale (Cho & Lim, 2003) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “Sometimes I feel angry all day.” All items were reverse-coded so that higher scores indicated higher levels of aggression. The Cronbach’s alpha for these items was .80 in the current study. Attention problem. Seven items from the Emotional or Behavioral Problems Scale (Cho & Lim, 2003) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I tend to miss out on the letters.” All items were reverse-coded so that higher scores indicated worse attention problems. The Cronbach’s alpha for these items was .76 in the current study. Self-concept In this study, self-concept referred to the sum of the adolescents’ self-esteem, resilience, and ego-identity scores. Each variable was measured as follows. Self-esteem. Ten items from the Rosenberg Self-Esteem Scale (Rosenberg, 1965) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I have a positive attitude toward myself.” Six items were reverse-coded so that higher scores indicated higher levels of self-esteem. The Cronbach’s alpha for these items was .85 in the current study.
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Resilience. Fourteen items from the Ego-Resiliency Scale (Block & Kreman, 1996) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I am regarded as a very energetic person.” All items were reverse-coded so that higher scores indicated higher levels of resilience. The Cronbach’s alpha for these items was .85 in the current study. Ego-identity. Eight items from the Korean Adolescent Egoidentity Scale (Park, 2003) were used. Item responses were reported on a 4-point Likert scale (1 = very true of me to 4 = not at all true of me). The following statement is an example of the items assessed in this study: “I have set clear goals in life.” Three items were reverse-coded so that higher scores indicated higher levels of ego-identity. The Cronbach’s alpha for these items was .71 in the current study. Intrapersonal factors Health perception. This item was assessed using one question. Responses to this item were reported on a 4-point Likert scale (1 = very healthy to 4 = not very healthy). This item was reverse-coded so that higher scores indicated positive health perception. Academic achievement. This item was assessed using one question. Responses to this item were reported on a 4-point Likert scale (1 = very satisfied to 4 = not very satisfied). This item was reverse-coded so that higher scores indicated higher levels of satisfaction with academic achievement. Interpersonal factors Parenting style. Twenty-one items from the Parenting Behavior Inventory (Heo, 2004) were used. The measure consisted of six subscales, including supervision, affection, reasonable explanation, inconsistency, over-expectation, and over-involvement. In this study, positive parenting styles were assessed by calculating the sum of the mean scores for supervision, affection, and reasonable explanation. In addition, negative parenting styles were assessed by calculating the sum of the mean scores for inconsistency, over-expectation, and over-involvement. We used three items for supervision, four items for affection, three items for reasonable explanation, three items for inconsistency, four items for over-expectation, and four items for overinvolvement. Item responses were reported on a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). All items were reverse-coded so that higher scores indicated higher levels of positive and negative parenting styles. Cronbach’s alpha for positive parenting styles was .73, and Cronbach’s alpha for negative parenting styles was .84. Peer attachment. Nine items from the Inventory of Parent and Peer Attachment (Armsden & Greenberg, 1987) were used. The measure consists of three subscales, including communication, mutual trust, and isolation. Each subscale consisted of three items. Item responses were reported on a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). All items were reverse-coded so that higher scores indicated higher levels of
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peer attachment. Cronbach’s alpha for these items was .85 in the current study.
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Relationships with teachers. Six items from the School Adjustment Scale (Min, 1991) were used. Item responses were reported on a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). All items were reverse-coded so that higher scores indicated good relationship with teacher. Cronbach’s alpha for these items was .85 in the current study. Organizational factors Community connectedness: Six items from the National Longitudinal Study of Adolescent to Adult Health (Carolina Population Center, 2009), as translated by the KYPI (2010), were used. Item responses were reported on a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). All items were reversecoded so that higher scores indicated higher levels of community connectedness. Cronbach’s alpha for these items was .69 in the current study. Analysis Statistical Package for the Social Sciences (SPSS) version 21.0 was used for the data analyses. All data were checked to ensure their accuracy after entry and that the assumptions of the utilized statistical tests were met. The participants’ emotional/behavioral problem and self-concept scores and general characteristics were analyzed using descriptive statistics, and a hierarchical multiple regression analysis was employed to investigate the ecological factors associated with emotional/behavioral problem and self-concept scores among participating adolescents.
Research findings Sociodemographic and ecological factor-related characteristics of the participants The sociodemographic and ecological factor-related characteristics of the participants are presented in Table 1. The ratio of male to female participants was relatively equal. Two-parent families were the most commonly observed family structure, but 40.9% of the adolescents were members of single-parent families. The average annual household income of the low-income families was 16,966,000 won. Emotional/behavioral problems and self-concept in adolescents from low-income families This study identified emotional/behavioral problems and selfconcept in adolescents from low-income families using longitudinal data from 2011 to 2015. The longitudinal trajectories of the outcome variables are depicted in Figure 1. The participants’ depression and somatic symptoms scores tended to decrease between the time point of the first survey (2011) and that of the last survey included herein (2015). However, the changes observed across all study time points were not statistically significant (depression: F = .864, p = .422; somatic symptoms: F = 1.913, p = .149). Social withdrawal scores tended to increase during this time period;
however, this increase was not statistically significant (social withdrawal: F = 1.022, p = .360). Aggression and attention problem scores significantly decreased between 2011 and 2015 (aggression: F = 7.347, p = .001; attention problems: F = 12.263, p ࣘ .000). A reduction was observed between 2011 and 2015 in the overall emotional/behavioral problem scores, which were calculated as the sum of the depression, somatic complaint, social withdrawal, aggression, and attention problem scores. However, the changes observed in emotional/behavioral problem scores across all study time points were not statistically significant (F = 2.467, p = .086). The participants’ self-esteem scores tended to increase between the time point of the first survey (2012) and that of the last survey included herein (2015); however, this difference was not statistically significant (F = 2.455, p = .087). Resilience scores significantly increased between 2012 and 2015 (F = 3.644, p = .027). While ego-identity scores decreased between 2012 and 2015, this difference was not statistically significant (F = .174, p = .840). Self-concept scores, which were calculated as the sum of the self-esteem, resilience, and ego-identity scores, were increased between 2012 and 2015 but not significantly (F = .969, p = .380). Ecological factors influencing emotional/behavioral problems in adolescents from low-income families In this study, we identified ecological factors influencing emotional/behavioral problems in adolescents from low-income families using cross-sectional data from 2015. To examine the factors that affected emotional/behavioral problems, a hierarchical regression analysis was performed, with gender, health perception, and academic achievement assessed in the intrapersonal domain (Model 1); family structure, positive patenting style, negative parenting style, peer attachment, and relationships with teachers assessed in the interpersonal domain (Model 2); and community connectedness assessed in the organizational domain (Model 3). Prior to performing the hierarchical multiple regression analysis, variables influencing emotional/behavioral problems were assessed for multicollinearity by examining their tolerance and variance inflation factor (VIF) values. As the results of these assessments indicated that the VIF value was less than three and the tolerance value was over 0.3 for all the variables, we determined that multicollinearity was not an issue. These results are shown in Table 2. The explanatory power was 11.5% (p ࣘ .001) for Model 1, which included only factors in the intrapersonal domain, indicating that having a positive perception of one’s health condition and academic achievement was associated with fewer emotional/behavioral problems. In Model 2, which also included factors in the interpersonal domain, the explanatory power increased by 12.6% (p ࣘ .001) relative to the explanatory power of Model 1, achieving an explanatory power of 24.1% (p ࣘ .001) and suggesting that having a positive perception of one’s health condition, higher levels of positive parenting, lower levels of negative parenting, and positive relationships with teachers were associated with fewer emotional/behavioral problems. In Model 3, which also included factors in the organizational domain, the explanatory power was 24.4% (p ࣘ .001). This value indicated a 0.3% increase over the explanatory power of Model 2 output;
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ISSUES IN MENTAL HEALTH NURSING
Figure . Emotional/behavioral problems and self-concept in adolescent from low-income families. (a). Depression, (b) somatic complaint, (c) social withdrawal, (d) aggression, (e) attention problem, (f) emotional/behavioral problems, (g) self-esteem, (h) resilience, (i) ego-identity, and (j) self-concept.
however, this difference was not significant (p = .317). In addition, academic achievement (p = .059) was significant at the .10 level. Ecological factors influencing self-concept in adolescents from low-income families In this study, we identified ecological factors influencing self-concept in adolescents from low-income families using
cross-sectional data from 2015. To examine factors associated with self-concept in adolescents from low-income families, a hierarchical regression analysis was conducted, with gender, health perception, and academic achievement assessed in the intrapersonal domain (Model 1); family structure, positive patenting style, negative parenting style, peer attachment, and relationships with teachers assessed in the interpersonal domain (Model 2); and community connectedness assessed
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Table . Ecological factors influencing emotional/behavioral problems in adolescents from low-income families (n = ). Model β Intrapersonal
Interpersonal
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Organizational
Gender
Constant Male Female
Health perception Academic achievement Family structure Two-parent Single-parent Grandparent Other Parenting style Positive Negative Peer attachment Relationship with teacher Community connectedness F (p) R R change (p)
Model
t
β
p
t
. Ref. . − . − . Ref.
Model β
p
t
.
. − . − .
.
