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Year : 2018  |  Volume : 62  |  Issue : 4  |  Page : 311-314  

Depression, anxiety, stress, and stressors among rural adolescents studying in Pune and a rural block of Nanded district of Maharashtra, India

1 Resident, Department of Community Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
2 Professor, Department of Community Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
3 Professor and Head, Department of Community Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India

Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Balan Mahetab Shaikh
B-2, Prathama Arcade, Near Kinara Hotel, Pune-Satara Road, Katraj, Pune - 411 046, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_174_17

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Adolescent population is the major demographic and economic force of a nation. Adolescent mental health not only affects overall health at present but also in future life. In this cross-sectional study, 461 rural adolescent students studying in Pune city and the rural area from a block in Nanded district, Maharashtra, were administered a prevalidated, pretested Marathi depression anxiety and stress scale-21 tool including correlated factors to assess the magnitude of depression, anxiety, and stress and its stressors. The prevalence of depression, anxiety, and stress among these students was 54%, 60%, and 44%, respectively. Rural students in Pune city were having significantly higher levels of stress than the students studying in the rural area. Disturbed family, harsh parenting, past adverse event experiences, negative feeling about academic performance and tobacco use were significantly associated with higher rates. Findings indicate that the mental health status of these students is alarming needing prompt measures.

Keywords: Adolescents, anxiety, depression anxiety and stress scale-21, depression, stress

How to cite this article:
Shaikh BM, Doke P P, Gothankar J S. Depression, anxiety, stress, and stressors among rural adolescents studying in Pune and a rural block of Nanded district of Maharashtra, India. Indian J Public Health 2018;62:311-4

How to cite this URL:
Shaikh BM, Doke P P, Gothankar J S. Depression, anxiety, stress, and stressors among rural adolescents studying in Pune and a rural block of Nanded district of Maharashtra, India. Indian J Public Health [serial online] 2018 [cited 2022 Jan 25];62:311-4. Available from:

Usually, adolescence age is assumed to be healthy age contrary to this WHO reports that 2.6 million young people die each year. About two-thirds of premature deaths and one-third of disease burden has its roots in behavioral pattern in early life. About 20% of adolescents experience some mental health problems.[1] Indigenous stress due to stormy developmental phase gets aggravated by some other environmental factors and plays a very important role in the progression of all mental and social health problems directly or indirectly.[1]

The present fragmentary adolescent health activities in India hardly address the adolescent mental health. Very few studies are carried out about stress/mental health of rural adolescent students and almost nil in Maharashtra. Adolescent students from the rural area are major chunk of adolescent population. Adolescents from rural area studying in metro cities are exposed to even more complex environment. Composite stress is estimated by considering its other forms such as depression and anxiety by using illustrious depression, anxiety, and stress scale (DASS-21) tool.[2] A cross-sectional study was conducted from November 1, 2016, to January 31, 2017, with the objectives to measure the prevalence of depression, anxiety, and stress as well as to assess the stressors among rural adolescent students. The study was conducted at two places.

  1. A secondary and higher secondary school well known for admission of mostly rural students, selected from field practice area of Urban Health Training Center of a medical college in Pune
  2. One school from each randomly selected three villages from Mudkhed block, district Nanded, Maharashtra.

Approval from Ethical Committee was obtained. Considering 51.3% prevalence of depression[3] with 95% confidence level and with allowable error 10% of the expected prevalence; estimated minimum sample size was 365. All eligible students of 8th to 12th standard present in the schools at the time of visit who can read, understand and volunteered to fill the self-assessment forms were included in the study. Excluding total nine students who were unable to understand and fill the self-assessment form. Rural students studying in the school in Pune city recruited in the study were 242. Rural students from rural Mudkhed block, district Nanded, were 219; making a total of 461 students.

We perceived difficulty in understanding original English DASS-21 as well as available elite Marathi version of DASS-21 by all these students from a rural background. Hence, we translated English DASS-21 into simple, comprehensible Marathi language, back-translated by bilingual language expert, validated by a team of bilingual experts in psychiatry and community medicine faculty. The DASS-21 tool and additionally a questionnaire consisting information about sociodemography and stressors such as harsh parental behavioral experiences, adverse events during the past 1 year, disturbed family relations, and addictions were used. The pretesting was carried out in the schools from a similar rural area other than study area in the same district. Following operational definitions were used.

  1. Harsh parental behavior experience: Experiencing often or almost always harsh scolding/verbal abusing/beating/physical attack by father or mother or both the parents or guardian
  2. Perception about academic performance:

    1. Positive feeling: Feeling excellent/good/satisfactory about marks scored in the last annual examination
    2. Negative feeling: Feeling unsatisfactory/bad/very bad about marks scored in the past annual examination.

  3. Adverse event experiences: Death/major accident/major illness/major dispute in the family during the past 1 year
  4. Disturbed intrafamily relationships: Often/almost always fighting parents or other family members/separated parents
  5. Smoking: Smoking/ever smoked more than once cigarette/bidi/hookah, etc.
  6. Tobacco chewing: Chewing/ever chewed for more than once tobacco or any tobacco containing product
  7. Alcohol consumption: Consumes/ever consumed more than once any form of alcohol
  8. Sexual intercourse experience: Ever had penetrative sexual intercourse with male/female.

On day one, after introduction, informed consent forms were distributed to the students to seek the consent of the parents/local guardians/custodians and assent from the student was obtained. On day two, the DASS-21 tool along with the structured questionnaire was administered after giving instructions about filling the self-assessment form. Self-assessment forms filled by the students were collected through multiple visits.

Severity rating depending upon the score points for depression, anxiety, and stress items was done as per illustrious DASS-21 as normal, mild, moderate, severe, and extremely severe.[2]

Data were analyzed using SPSS 20.0 statistical software; the prevalence was measured per 100 students and expressed as a percentage. Chi-square test was used to find out the association between prevalence and related factors/stressors; a P < 0.05 was considered statistically significant.

Among participated study individuals 267 (58%) were boys and 194 (42%) girls. The mean age of participants was 16 years (+0.92 standard deviation). Of total 461 students, 126 (27.3%) were of normal mental health. The rest were having either single or multiple mental conditions, i.e., depression, anxiety, and stress of various grades, i.e., mild, moderate, severe, and extremely severe. Among them 85 (18.4%) were having the single condition, 110 (23.9%) were having two conditions and 140 (30.4%) students were having all of three conditions.

[Table 1] depicts the proportion of students having depression anxiety and stress, gender and school location wise. There was no gender wise and school location wise significant difference except stress. Stress was significantly high among rural students studying in urban schools.
Table 1: Depression, anxiety, and stress among rural adolescent students

Click here to view

[Table 2] depicts that all students did not respond to questions pertaining to all stressors. It shows number of students responded to questions pertaining to various stressors, proportion of students with different stressors and proportion of these students having depression, anxiety, and stress with stressors. Students experiencing stressors such as harsh parental behavior experience, negative feeling about own academic performance, adverse events experienced during the past 1 year and disturbed family relationships were found to be significantly more depressed, more anxious, and more stressed as shown in [Table 2]. Students smoking cigarettes or chewing tobacco were having significantly higher levels of depression, anxiety, and stress. Alcohol drinking and students who experienced sexual intercourse had significantly higher levels of anxiety.
Table 2: Depression, anxiety, and stress association with stressors

Click here to view

Stress, anxiety, and depression are correlated with each other. Anxiety is the reactive expression of stress whereas depression is manifestation of long-standing stress.[1] Although it is not a clinical assessment; the proportion of students with depression (53.9%), anxiety (59.7%), and stress (43.8%) detected in this study is alarmingly high. These rates are similar to few past studies carried out using DASS tool; depression (18.5%–51.3%), anxiety (24.4%–66.9%), and stress (20%–53%).[3],[4],[5],[6] Most of the studies were having lower rates than the present study, but some studies noticed higher rates than the present study using different instruments such as the Beck Depression Inventory Scale for depression (71.25%),[7] stress (87.6%) using Perceived Stress Scale.[8] Almost all the above studies were conducted in urban or affluent adolescent population. This study highlights that mental health of the rural adolescent students is more adversely affected contrary to the popular presumption about rural and urban adolescents' mental health. Gender-wise prevalence of depression, anxiety, and stress is controversial. Some studies reported no significant difference in gender-wise rates as found in the present study[4],[8] but in contrast to this study observation, some studies noticed significant higher rates among females.[3],[5],[6],[7] This study does not substantiate the assumption of higher rates among girls due to exposure to more stressful environment in our gender biased society.

The proportion of students smoking (3.7%) and tobacco chewing (5.2%) was similar to a study of adolescents in urban Patna city;[9] whereas alcohol drinking (6.3%) was higher than this Patna study.[9] The observed proportion of students having sexual intercourse experiences (7.3%) in this study was higher than a previous study in Pune city in 2012 (1%–6.3%)[10] and indicates notable increase in a span of 5 years. Some previous studies also reported the association of some stressors such as disturbed family relationship,[7],[8] academic situations,[3],[8] tobacco use,[3],[6] and alcohol consumption[3] with these mental health ailments as found in the present study.

The study results would help public health planners and private health sectors as well the education sector to take prompt and appropriate measures to address the mental health of the adolescents. High prevalence of depression, anxiety, and stress among rural adolescent students points out the need of strengthening adolescent mental health initiatives in rural areas also. High levels of stress among rural adolescents studying in the urban area facing and acclimatizing different new environment may be considered at high risk to address this special situational problem. Stressors associated with high levels of ailments should be tackled by proper counseling of students as well as of parents. Addictions and high-risk behavior can be averted by taking the required steps at this foundation stage of life.

The findings of this may not applicable to urban as well as general rural adolescents including nonschool going adolescents. This study cannot be used as a clinical diagnosis of depression, anxiety, and stress as it is only screening and self-assessment of the mental conditions.


The authors would like to thank all the students and the institutes participated in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

World Health Organization. Adolescent Health, Adolescent Mental Health; 2013. Available from: [Last accessed on 2016 Nov 02].  Back to cited text no. 1
Fernando Gomez. Guide to the Depression, Anxiety and Stress Scale (DASS 21). Available from: [Last accessed on 2016 Oct 14].  Back to cited text no. 2
Iqbal S, Gupta S, Venkatarao E. Stress, anxiety and depression among medical undergraduate students and their socio-demographic correlates. Indian J Med Res 2015;141:354-7.  Back to cited text no. 3
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Al-Gelban KS. Depression, anxiety and stress among Saudi adolescent school boys. J R Soc Promot Health 2007;127:33-7.  Back to cited text no. 4
Kumar KS, Akoijam BS. Depression, anxiety and stress among higher secondary school students of imphal, Manipur. Indian J Community Med 2017;42:94-6.  Back to cited text no. 5
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Sahoo S, Khess CR. Prevalence of depression, anxiety, and stress among young male adults in India: A dimensional and categorical diagnoses-based study. J Nerv Ment Dis 2010;198:901-4.  Back to cited text no. 6
Kumar GS, Jain A, Hegde S. Prevalence of depression and its associated factors using beck depression inventory among students of a medical college in Karnataka. Indian J Psychiatry 2012;54:223-6.  Back to cited text no. 7
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Watode BK, Kishore J, Kohli C. Prevalence of stress among school adolescents in Delhi. Indian J Youth Adolesc Health 2015;2:34-8.  Back to cited text no. 8
Kumar P, Kumar D, Ranjan A, Singh CM, Pandey S, Agarwal N, et al. Prevalence of hypertension and its risk factors among school going adolescents of Patna, India. J Clin Diagn Res 2017;11:SC01-4.  Back to cited text no. 9
Shashikumar R, Das RC, Prabhu HR, Srivastava K, Bhat PS, Prakash J, et al. A cross-sectional study of factors associated with adolescent sexual activity. Indian J Psychiatry 2012;54:138-43.  Back to cited text no. 10
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  [Table 1], [Table 2]

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