Journal of Pediatric Nursing 64 (2022) e15–e23

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Journal of Pediatric Nursing

journal homepage: www.pediatricnursing.org

The roles of parental absence, life skills and personality traits

in mental health status among adolescents in rural China
Ping Mao a, Xuefeng Yang b, Minghui Tan c, Aijing Luo d, Shan Jiang c, Jia Guo, PhD c,⁎, Jing Su e, James Wiley f,
Ping Xu g, Jyu-Lin Chen h
a
Nursing Department of the Third Xiangya Hospital, Central South University, No.138, Tongzipo Road, Yuelu District, Changsha, Hunan, China
b
Department of Oncology, Henan Provincial Key Medicine Laboratory of Nursing, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan 450003, China
c
Xiangya School of Nursing, Central South University, Changsha, Hunan, China
d
Key Laboratory of Medical Information Research (Central South University), College of Hunan Province, China
e
Nursing department, Shantou University Medical College, Shantou, Gungdong, China,
f
School of Medicine, University of California, San Francisco, CA, USA
g
ZiBo hospitals of traditional Chinese and Western medicine, Zibo, Shandong, China
h
School of Nursing, University of California, San Francisco, CA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Problem: Mental health issues in adolescents are public health concerns worldwide including China. However,
Received 23 March 2021 there is a lack of research examining the role of parental absence status, life skills, and personality traits on the
Revised 17 January 2022 mental health of adolescents in rural China.
Accepted 19 January 2022 Method: The purpose of this cross-sectional study was to examine the role of parental absence status, life skills,
and personality traits on the mental health of adolescents in rural China. This study used self-developed demo-
Keywords:
graphic questionnaire, Mental Health Test (MHT), Middle School Student Life Skills Rating Scale, and Eysenck
Adolescents
Life skills
Personality Questionnaire. Binary logistic regression analyses were performed to examine the associated factors
Mental health disorders on different domains of MHT.
Parental absence Results: Adolescents in rural China reported high proportion of mental health disorders (MHDs), including learn-
Personality traits ing anxiety, sensitiveness, self-accusation, and physical symptoms tendency. Although 75.6% experienced paren-
tal absence, this was not associated with MHT after controlling for all other variables. Better mental health was
correlated with life skills including communication skills, interpersonal morality, self-efficacy, and stress coping.
The instability-neuroticism personality trait was positively associated with MHDs.
Discussion: Adolescents in rural China reported high positive rates of MHDs. Communication skills, interpersonal
morality, self-efficacy, ability to cope with stress and Instability-neuroticism were important associated factors of
MHDs.
Application to practice: Life skills and personality are two important factors that should be considered when
assessing the mental health status of adolescents and formulating interventions.
© 2022 Published by Elsevier Inc.

Adolescence is a dynamic period of maturity for biological, psycho- 2020a). In China, 10–30% of adolescents aged 12–16 years old experi-
logical, and social development, but also a period prone to mental health ence MHDs (Tang et al., 2018). Jones (2013) found that over 75% of
disorders (MHDs) (Jones, 2013). MHDs are diseases that are character- adults reported experiencing symptoms of MHD during the adolescent
ized by a combination of abnormal thoughts, perceptions, emotions, be- years. Globally, MHDs account for 16% of injury/illnesses in adolescence
haviors, and relationships with others, such as depression, anxiety, and (WHO, 2020b). Poor mental health has been associated with teenage
bipolar disorder (Ogunniyi, 2020). According to the most recent data, pregnancy, HIV/AIDS, domestic violence, child abuse, physical fights,
about 10–20% of adolescents globally experience MHDs (WHO, crime, homicide, and suicide (Ford et al., 2017; WHO, 2020a). The oc-
currence of MHDs in adolescents is a global health concern that affects
individuals, families, and societies (WHO, 2020b). Considering the
⁎ Corresponding author. high burden of MHDs into account, efforts should be focused on identi-
E-mail addresses: [email protected] (P. Mao), [email protected] (X. Yang),
fying associated factors to prevent their development.
[email protected] (M. Tan), [email protected] (A. Luo),
[email protected] (S. Jiang), [email protected] (J. Guo), [email protected]
The Transactional Model of Stress and Coping offers a compelling
(P. Xu), [email protected] (J.-L. Chen). theoretical framework for understanding people's different appraisalsof

https://doi.org/10.1016/j.pedn.2022.01.011
0882-5963/© 2022 Published by Elsevier Inc.
P. Mao, X. Yang, M. Tan et al. Journal of Pediatric Nursing 64 (2022) e15–e23

stress and how their appraisals affect their coping strategies and indi- neuroticism and extraversion have been strongly correlated with anxi-
vidual outcomes (Lazarus & Folkman, 1984). Specifically, this theory ety and depression in a general population ranging from 20 to 70
posits that personal appraisal is based on the individual's personality, years old (Jylhã & Isometsã, 2010). Gale et al. (2013) found that in the
and their personality affects their coping abilities and emotional well- U.K., neuroticism personality in youth aged 16–26 had a negative effect
being (Wang et al., 2017). Based on this theory, we hypothesize that pa- on mental health, as well as on the well-being of people aged 60–64.
rental absence isconsidered a stressful event in an adolescents' life ex- Meanwhile, in China, a meta-analysis with a total sample of 171,131
periences and personality (personal appraisal) that affects life skills people from the general population reported that neuroticism had the
(coping ability) and MHD development (emotional well-being). Given strongest correlation with MHDs, psychoticism had a moderately posi-
the above, thepurpose of this study is to investigate the effects of paren- tive relationship with them, and extraversion had a negative correlation
tal absence, life skills, personality, and demographic indicators on ado- (Liao et al., 2017). Similarly, research has recognized that the develop-
lescents' mental health. ment of an offspring's personality can be affected by parental absence.
Parents play an important role in adolescents' development of social For example, Shiner et al. (2017) told that parental absence predicted
skills, emotional stability, and mental health. Parental absence is associ- increases in neuroticism. However, it is not clear which dimensions of
ated with several situations, including chronic physical or mental ill- personality traits may be associated with MHDs among adolescents, es-
ness, missing persons, adoption, death, incarceration, alcohol or drug pecially adolescents with parental absence.
problems, and divorce (Boss, 2004). However, previous empirical stud- Several demographic indicators among adolescents are also associ-
ies have been inconsistent about the effect of parental absence on the ated with the development of MHDs. First, the association between
mental health of adolescents. For example, one study claimed that socio-economic status (SES) and mental health is well established in
MHDs had a significantly higher prevalence among U.S. adults who re- Western societies. Earlier research has indicated that socioeconomically
ported experiencing parental divorce during childhood or adolescence disadvantaged children and adolescents were two to three times more
than those who had not (Tebeka et al., 2016). Studies in China found likely to develop mental health problems (Reiss, & Franziska., 2013).
that children and adolescents whose parents were absent due to job re- Adolescents in China were also more likely to have MHDs when SES de-
location were more likely to develop MHDs than their counterparts in creased (Zhou et al., 2018). Comparisons of adolescents' mental health
the group whose parents were present (Wang et al., 2019; Wu et al., in rural China across socio-economic conditions will provide additional
2019). Nevertheless, a cohort study of 1401 middle school students in insights. Adolescents' gender is also an important factor when deter-
China showed no difference in the prevalence of MHDs when compar- mining the state of their mental health. A few studies on gender in Chi-
ing adolescents whose parents were absent due to job relocation and nese adolescents have given contradictory results. Some have found
adolescents in the control group whose parents were present (Luo that girls reported higher levels of anxiety than boys (Bakhla et al.,
et al., 2016). Thus, more empirical studies are needed to explore the 2014; Ge et al., 2015; Ishikawa et al., 2018), whereas others showed
effect of parental absence on the mental health of adolescents. similar MHD development among both genders (Wang et al., 2019;
Life skills are abilities that enable individuals to adapt and exhibit Wang, Zou, et al., 2019). Regarding age, Wu et al. (2019) told that
positive behaviors and thus help them effectively respond to the older children showed higher impulsive tendencies than younger chil-
needs and challenges of daily life. Research has found a significantly dren. In contrast, Hu et al. (2014) reported that younger children have
positive association betweenlife skills and the mental health of adoles- higher levels of psychological and behavioral problems than older chil-
cent boys in India and Iran (Kazemi et al., 2018; Suman & Sanjeev, dren. In addition, another study found that the mental health issues of
2019). WHO (2003) outlined ten core life skill strategies: problem- children were not related to age (Delvecchio et al., 2015; Wang, Zou,
solving, critical thinking, effective communication skills, decision mak- et al., 2019). Thus, additional studies are needed to examine MHDs
ing, creative thinking, interpersonal relationship skills, self-awareness, about gender and age while considering other factors, such as personal-
empathy, and coping with stress and emotions. Sahu and Gupta ity traits.
(2013) found that every domain of life skills is positively related to pos- In sum, understanding the roles of parental absence, life skills, per-
itive mental health development. At the same time, adolescents' life sonality, and demographic indicators on the MHDs of adolescents in
skills development is influenced by their parents. Meland et al. (2020) rural China can supplement research on MHDs in non-Western socio-
proved a sex-specific effect on loss of communication between fathers cultural contexts. Efforts focused on identifying factors associated with
and adolescents after a parental absence. According to their study, the MHDs will help pediatric nurses identify high-risk populations. They
impairment of communication had predictive repercussions on the can also provide a theoretical basis for health care providers to develop
health and self-esteem of adolescents. Unfortunately, existing studies effective programs that incorporate key concepts to promote adoles-
on life skills have been predominately conducted in Western countries cents' mental health and thus prevent MHD development and reduce
(Nasheeda et al., 2019), with very few studies completed in non- the possibility of personal risk behaviors, family disease burden, and ad-
Western contexts. Especially in Chinese culture, parents strongly verse social events.
emphasize their adolescents' scholastic competence since academic The aims of the present study were as follows: To explore the prev-
success is considered an important means of climbing the social ladder. alence of MHDs among adolescents aged 11–18 years in rural China, and
As such, other areas of personal development (such as life skills) are to examine the role of the adolescents' SES, sex, age, parental absence
underestimated (Shek & Siu, 2019). Moreover, life skills research in status, life skills, and personality traits on their mental health.
China more often focuses on the use of life skills training to reduce
left-behind children's behavioral problems (Liu et al., 2016). Accord- Materials and methods
ingly, the level of Chinese rural adolescents' life skills and the role of
life skills in those adolescents' mental health development are still Study design and sample procedure
unclear.
Personality is a dynamic and organized set of characteristics people This study followed a cross-sectional design. The study adopted
possess that uniquely influence their cognition, motivations, and behav- stratified cluster random sampling as well to obtain representative sam-
iors in various situations; these characteristics are relatively stable over ples from all 14 prefecture-level administrative divisions in China's
time and differ among individuals (Jylhã & Isometsã, 2010). Personality Hunan Province. The 14 prefecture-level cities were ranked 1–7 and
traits have a significant impact on individual behavior, emotions, and 8–14 by Gross Domestic Product (GDP) (Hunan Provincial Statistics Bu-
wellness (Mabbe et al., 2016; Stead & Bibby, 2017). Different domains reau, 2018). We chose Zhangjiajie, a city of ethnic minorities and low-
of personality traits have been associated with a range of psychological income areas (14), as a low-income research site. Compared with
problems (Ye et al., 2017; Ying et al., 2014). In Western studies, both Zhangjiajie, the city of Changsha was a non-low-income research site

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P. Mao, X. Yang, M. Tan et al. Journal of Pediatric Nursing 64 (2022) e15–e23

selected according to its GDP ranking (1), geographical distribution total of 47 yes/no questions. The internal consistency coefficient has
(east and west), and ethnic distribution (Han and ethnic minorities). been reported as 0.946 for the total scale and 0.626–0.844 for the sub-
A random number generator then randomly selected two rural counties scales. The cumulative variance contribution rate obtained via confir-
from each area. matory factor analysis was previously reported as 54.47% (Zhao et al.,
The data were collected between January 2019 and May 2019. The 2012). The Cronbach's alpha in this study was 0.74 and the split-half re-
exposure group consisted of adolescents with parental absence re- liability 0.77. The cumulative variance contribution rate obtained via
cruited from a list of 343 active cases from the Civil Affairs Department confirmatory factor analysis was 56.65%.
in the chosen counties. The inclusion criteria for this group were
(1) both parents are absent; (2) the adolescents are living with other Personality traits
non-parental caregivers; (3) 11–18 years old; (4) attending middle or The 88 items of the Chinese version of the Eysenck Personality Ques-
high schools in the selected counties; and (5) not diagnosed with any tionnaire (EPQ) were used to assess the personality traits. There is an
MHDs. The inclusion criteria for the comparison group were (1) adoles- adult version (≥16 years old) and a child version (7–15 years old) of
cents living with both biological parents; (2) 11–18 years old; and the EPQ questionnaire (Gong, 1984). The two versions were included
(3) friends or deskmates of the adolescents with parental absence in our study according to the age of participants. And it includes four
who attend the same school. All eligible adolescents were invited to scales: extraversion (E), neuroticism (N), psychoticism (P), and lie (L).
join the study, and trained research assistants explained the purpose The standard score T (T = 50 + 10 × (x − m)/SD) can be converted
of the study to them at the schools. Adolescents who agreed to take from norms to analyze the personality characteristics of the subjects ac-
part in the study returned home with consent forms. Consent was ob- cording to the total score (rough score) obtained by the subjects on each
tained from both the family caregivers and adolescents. Most of the scale. E scores of 43.3–56.7 are used to divide the E scores into extro-
adolescent-specific items on the questionnaires were completed by ad- verted, middle, and introverted personality types; N scores into the ta-
olescents in a private room at their schools. The trained research assis- bles, middle, and unstable mood types; and P scores into obedient,
tants were present at the research sites to answer any questions the considerate, and cooperative traits; middle traits; and psychopathic
participants asked. Family-related information, such as family income and antisocial traits. Lastly, the L score is a validity scale used to test
level, the primary caregiver's health status, and education level, were the subjects' concealment tendency. A score exceeding 70 is invalid.
obtained from the adolescents and their caregivers via questionnaires The retest reliability values for each sub-scale were 0.67, 0.88, 0.80,
completed together at home. The study was approved by the Human and 0.78, respectively in a previous study (Ye et al., 2017). In this
Research Ethics Committee at Xiangya School of Nursing, Central study, Cronbach's alpha values were 0.71, 0.85, and 0.60 for the main
South University, China (No. 2018030). Informed consent from the three sub-scales. The cumulative variance contribution rate obtained
school boards and participants was obtained as well. via confirmatory factor analysis was 64.60%.

Measurements Data analysis

Demographics We conducted descriptive analyses for each variable. Chi-square

The research team developed a demographics survey to obtain infor- tests and analyses of variance and covariance were performed to com-
mation related to the participants' sociodemographic characteristics, in- pare the rate of MHDs among the adolescents with parental absence
cluding the adolescents' age, sex, and ethnicity, as well as their parental and those in the comparison group. Chi-square tests were also used to
absence status. In addition, the survey asked questions about the primary examine differences in mental health by sex and age. Spearman correla-
caregivers' region (low-income or non-low-income), physical health, and tion analyses were performed to explore the association between life
education level. The questionnaire was completed by the adolescents. skills and mental health. The association between personality traits
and mental health was examined with Chi-square tests as well. Addi-
Mental health test tionally, binary logistic regression analyses were performed to examine
The Mental Health Test (MHT) questionnaire, Chinese version factors associated with mental health among adolescents. To ensure suf-
(Zhou, 1991) was used to examine the adolescents' mental health ficient statistical power for detecting true associations in the logistic re-
condition. The MHT includes both anxiety-appointed objects and gression model, we anticipated that a minimum sample size of 180
anxiety-led behaviors. It consists of eight subscales: learning anxiety, samples would satisfy the established minimum of 10 events per vari-
interpersonal relationship anxiety, loneliness tendency, self-accusation able criteria (Peduzzi et al., 1996). No multicollinearity problems with
tendency, sensitiveness tendency, physical symptoms, phobia tendency, the variance inflation factors were detected. All analyses were con-
and impulsive tendency. It also has one validity scale, which considers ducted using SPSS 25.0. All P values were based on two-tailed tests in
the questionnaire invalid if the score is 7 or higher. The MHT features which α = 0.05.
a total of 100 yes/no questions, 10 of which are validity items. Scores
higher than 8 on each sub-scale and a total score above 65 indicate Results
the presence of an MHD. The scale has strong psychometric properties;
previous research specified the split-half reliability of each sub-scale as Demographics
0.84–0.88, the split-half reliability of the total scale as 0.91, and the test- A total of 463 adolescents completed the study questionnaire. How-
retest reliability of the total scale and sub-scales as 0.67–0.86 (Liu et al., ever, 33 students were excluded because they did not pass the reliability
2018). In the current study, the Cronbach's alpha of the total MHT score check in the MHT and EPQ, and 16 students did not meet the inclusion
was 0.80 and ranged from 0.61 to 0.79 for the eight sub-scale scores. The criteria. The final sample for analysis thus included 414 participants,
cumulative variance contribution rate obtained via confirmatory factor representing 89% of the recruited sample. There were no significant dif-
analysis was 61.84%. ferences in the sociodemographic variables between the participants
who were excluded and those who remained.
Life skills According to their parental situation, the adolescents were divided
The Middle School Student Life Skills Rating Scale was developed by into either the parental absence or comparison group. Table 1 presents
Zhao et al. (2012) to assess eight major life skills of children in China: the number and prevalence estimates for each parental situation by
empathy skills, communication skills, self-esteem, sociability skills, in- the group. Among adolescents with parental absence, the main reason
terpersonal morality, self-efficacy, stress coping, and emotion regula- for the father's absence was death and remarriage for the mother's
tion. A higher score is indicative of better skills. This scale consists of a absence.

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P. Mao, X. Yang, M. Tan et al. Journal of Pediatric Nursing 64 (2022) e15–e23

Table 1 Table 3
The parental situation of adolescents. Comparison of mental health problems between adolescents with parental absence and
comparison group.
Types of parent Father Mother
(n, %) (n, %) Variables All Parental Comparisons χ2 p
adolescents absence (n = 101)
Parental absence Severe illness 15(4.8) Severe illness 10(3.2)
(n = 414) (n = 313) (n, %)
(n = 313) Severe disability 25(8.0) Severe disability 10(3.2)
(n, %) (n, %)
Missing 29(9.3) Missing 42(13.4)
Incarnation 20(6.4) Incarnation 1(0.3) Learning anxiety 288(69.6) 224(71.6) 64(63.4) 2.43 0.119
Substance abuse 2(0.6) Remarriage 142(45.4) Interpersonal
45(10.9) 39(12.5) 6(5.9) 3.35 0.067
Death 133(42.5) Death 19(6.1) relationship anxiety
Job relocation 89(28.4) Job relocation 89(28.4) Loneliness tendency 27(6.5) 26(8.3) 1(1.0) 6.71 0.010
Comparison Presence 101(100) Presence 101(100) Self-accusation tendency 127(30.7) 103(32.9) 24(23.8) 3.00 0.083
(n = 101) Sensitiveness tendency 161(38.9) 130(41.5) 31(30.7) 3.78 0.052
Physical symptoms 107(25.8) 88(28.1) 19(18.8) 3.45 0.063
Phobia tendency 51(12.3) 44(14.1) 7(6.9) 3.59 0.058
Impulsive tendency 17(4.1) 15(4.8) 2(2.0) 1.53 0.216
Regarding demographics, the mean age of the participants included Total MHT 17(4.1) 17(4.1) 0(0.0) 5.72 0.017
in the analysis was 13.9 years (SD = 1.5), 211 (51.0%) were female, and
224 (54.1%) had an ethnic minority background. About 68% of the par-
ticipants were from low-income regions. In the parental absence −0.10) with several MHT sub-scales. These study results suggest that
group, the primary caregivers reported lower physical health and had stronger life skills are associated with better mental health in adoles-
less education than those in the comparison group. Table 2 shows the cents.
demographic characteristics of the adolescents in the two groups.

MHDs in adolescents based on parental absence status, sex, and age Relationship between personality traits and mental health among all
About 70% of all study participants self-reported learning anxiety, adolescents
40% reported a tendency for sensitiveness, 30% expressed a tendency Adolescents with the unstable neuroticism personality trait reported
for self-accusation, and 26% exhibited physical symptoms (Table 3). a higher rate of MHDs, as well as had higher scores in the total MHT and
The total score rates for the MHT (4.1% vs. 0%, p = 0.017) and the lone- all its sub-scales than those with the stable and middle neuroticism per-
liness sub-scale (8.3% vs. 1.0%, p = 0.010) were significantly higher in sonality traits (χ2 = 6.61–62.87,p = 0.000–0.037; Table 6).
the parental absence group than in the comparison group. Although
there were no significant differences in the rates of the remaining
MHT dimensions, the rates of the parental absence group were similarly Binary logistic regression analysis of factors associated with adolescent
higher than in the control group. As shown in Table 4, no significant dif- mental health
ference in MHD occurrence emerged based on sex and age. We included several potential demographic factors, life skills, and
personality traits in a binary logistic regression analysis of all the MHT
Relationship between MHDs and Life Skills among Adolescents dimensions. The analysis found that the instability-neuroticism person-
In general, for all participants, the life skills score negatively corre- ality trait, communication skills, interpersonal morality, self-efficacy,
lated with MHDs. The total MHT score was negatively associated (r = and emotion regulation were related to several MHT sub-scales
−0.26 to −0.20) with communication skills, self-esteem, self-efficacy, (Table 7).
emotion regulation, and total life skills score (Table 5). These life skills In terms of life skills, higher communication skills were significantly
sub-scales were also significantly negatively associated (r = −0.29 to associated with decreased sensitiveness tendency, physical symptoms,
and impulsive tendency (odds ratio [OR] = 0.53–0.83, p < 0.05). Ado-
lescents who had higher interpersonal morality were at a significantly
Table 2
Demographics. higher risk of also having learning anxiety and self-accusation tendency
(OR = 1.30 and OR = 1.64, respectively; p < 0.05), but a decreased rate
Variables All Parental Comparisons Statistics p
of impulsive tendency (OR = 0.49, p < 0.05). Adolescents who reported
adolescents absence (n = 101) (t/χ2)
(n = 414) (n = 313) higher self-efficacy skills were at a significantly lower risk of having
learning anxiety, interpersonal relationship anxiety, and self-
Age (years) - M (SD) 13.9 (1.5) 13.9 (1.4) 14.2 (1.7) 1.76 0.414
Gender 0.32 0.571
accusation tendency. The OR for these subscales ranged from 0.80 to
Male - n (%) 203(49.0) 151(48.2) 52(51.5) 0.86 (p < 0.05).
Female - n (%) 211(51.0) 162(51.8) 49(48.5) Adolescents who reported greater stress coping were at a signifi-
Ethnicity 0.70 0.402 cantly lower risk of having learning anxiety (OR = 0.79, p < 0.05) and
Han ethnic - n (%) 190(45.9) 140(44.7) 50(49.5)
self-accusation tendency (OR = 0.72, p < 0.01), but they exhibited a
Minority ethnic - 224(54.1) 173(55.3) 51(50.5)
n (%) higher rate of impulsive tendency (OR = 2.04, p < 0.05). Adolescents
Income 3.43 0.064 who had greater emotion regulation were at lower risk of interpersonal
Non-low-income - 133(32.1) 93(29.7) 40(39.6) relationship anxiety, physical symptoms, phobia tendency, and impul-
n (%) sive tendency, with the ORs of these sub-scales ranging from 0.50 to
Low-income 281(67.9) 220(70.3) 61(60.4)
Caregiver's physical health 57.78 0.000
0.77 (p < 0.05).
Poor - n (%) 106(25.6) 102(32.6) 4(4.0) Lastly, the results indicate that adolescents with instability and mid-
Fair - n (%) 155(37.4) 125(39.9) 30(29.7) dle neuroticism had a significantly higher likelihood of developing
Good - n (%) 153(37.0) 86(27.5) 67(66.3) MHDs than those with stable personalities. Adolescents with middle
Caregiver's education 49.81 0.000
and/or instability-neuroticism demonstrated a significantly higher like-
Primary school and 197(47.6) 178(56.9) 19(18.8)
below - n (%) lihood of having higher learning anxiety, self-accusation tendency, pho-
Middle school - n (%) 172(41.5) 113(36.1) 59(58.4) bia tendency, sensitiveness tendency, and physical symptoms
High school and 45(10.9) 22(7.0) 23(22.8) compared with adolescents who had stable personality traits (OR =
above - n (%) 3.68–22.15, p < 0.01).

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P. Mao, X. Yang, M. Tan et al. Journal of Pediatric Nursing 64 (2022) e15–e23

Table 4
Adolescents mental health by sex and age (n = 414).

Variables Sex χ2 P Age χ2 p

Male Female ≤15 ≥16

(n, %) (n, %) (n, %) (n, %)

Learning anxiety 138(68.0) 150(71.1) 0.47 0.492 245(70.8) 43(63.2) 1.54 0.215
Interpersonal relationship anxiety 19(9.4) 26(12.3) 0.94 0.333 41(11.8) 4(5.9) 2.09 0.148
Loneliness tendency 18(8.9) 9(4.3) 3.59 0.058 23(6.6) 4(5.9) 0.06 0.815
Self-accusation tendency 61(30.0) 66(31.3) 0.07 0.786 107(30.9) 20(29.4) 0.06 0.805
Sensitiveness tendency 76(37.4) 85(40.3) 0.35 0.553 132(38.2) 29(42.6) 0.48 0.487
Physical symptoms 52(25.6) 55(26.1) 0.01 0.917 91(26.3) 16(23.5) 0.23 0.633
Phobia tendency 29(14.3) 22(10.4) 1.43 0.232 43(12.4) 8(11.8) 0.02 0.879
Impulsive tendency 7(3.4) 10(4.7) 0.44 0.508 14(4.0) 3(4.4) 0.02 0.890
Total MHT 11(5.4) 6(5.8) 1.74 0.187 16(4.6) 1(1.5) 1.44 0.231

Table 5
Correlations between mental health and life skills of all adolescents (n = 414).

Empathy Communication Self-esteem Sociability Interpersonal Self-efficacy Stress Emotion The total score of life
skills skills morality coping regulation skills

Total MHT −0.00 −0.24⁎⁎ −0.23⁎⁎ −0.11⁎ −0.08 −0.26⁎⁎ −0.12⁎ −0.20⁎⁎ −0.26⁎⁎
Learning anxiety 0.01 −0.09 −0.12⁎ −0.02 0.01 −0.23⁎⁎ −0.14⁎⁎ −0.05 −0.14⁎⁎
Interpersonal relationship 0.02 −0.14⁎⁎ −0.06 −0.08 −0.03 −0.16⁎⁎ 0.01 −0.17⁎⁎ −0.12⁎
anxiety
Loneliness tendency −0.01 −0.13⁎⁎ −0.10⁎ −0.19⁎⁎ −0.11⁎ −0.14⁎⁎ −0.03 −0.02 −0.15⁎⁎
Self-accusation Tendency −0.02 −0.10⁎ −0.14⁎⁎ −0.08 0.08 −0.26⁎⁎ −0.17⁎⁎ −0.04 −0.17⁎⁎
Sensitiveness −0.00 −0.22⁎⁎ −0.20⁎⁎ −0.05 −0.04 −0.25⁎⁎ −0.10⁎ −0.15⁎⁎ −0.21⁎⁎
Tendency
Physical symptoms −0.06 −0.28⁎⁎ −0.22⁎⁎ −0.09 −0.09 −0.26⁎⁎ −0.08 −0.21⁎⁎ −0.27⁎⁎
Phobia tendency −0.03 −0.20⁎⁎ −0.24⁎⁎ −0.07 −0.13⁎⁎ −0.17⁎⁎ −0.08 −0.21⁎⁎ −0.23⁎⁎
Impulsivetendency 0.05 −0.29⁎⁎ −0.13⁎⁎ −0.03 −0.13⁎⁎ −0.10⁎ 0.04 −0.18⁎⁎ −0.15⁎⁎
⁎⁎ p < 0.01
⁎ p < 0.05

Table 6
Comparison of personality traits and mental health differences of all adolescents (n = 414).

Extraversion(E) Psychoticism (P) Neuroticism (N)

Extraversion Middle type Introversion Lower- Middle type High- Stability Middle type Instability
(n, %) (n, %) (n, %) Psychoticism (n, %) Psychoticism (n, %) (n, %) (n, %)
(n, %) (n, %)

The total score of MHT 10(8.6) 5(2.8) 2(1.6) 2(1.8) 10(4.7) 5(5.7) 0(0.0) 0(0.0) 17(13.7)
χ2 8.61 2.38 41.46
P 0.014 0.304 0.000
Learning anxiety 88(75.9) 124(70.5) 76(62.3) 71(62.3) 159(74.6) 58(66.7) 48(44.4) 142(78.0) 98(79.0)
χ2 5.28 5.80 43.59
P 0.071 0.055 0.000
Interpersonal
12(10.3) 24(13.6) 9(7.4) 6(5.3) 26(12.2) 13(14.9) 7(6.5) 14(7.7) 24(19.4)
relationship anxiety
χ2 2.96 5.58 13.26
P 0.228 0.061 0.001
Loneliness tendency 13(11.2) 12(6.8) 2(1.6) 3(2.6) 18(8.5) 6 (6.9) 5(4.6) 8(4.4) 14(11.3)
χ2 8.97 4.15 6.61
P 0.011 0.126 0.037
Self-accusation tendency 40(34.5) 53(30.1) 34(27.9) 31(27.2) 70(32.9) 26(29.9) 17(15.7) 50(27.5) 60(48.4)
χ2 1.27 1.16 30.50
P 0.531 0.561 0.000
Sensitiveness tendency 52(44.8) 71(40.3) 38(31.1) 30(26.3) 86(40.4) 45(51.7) 13(12.0) 70(38.5) 78(62.9)
χ2 4.95 13.81 62.87
P 0.084 0.001 0.000
Physical symptoms 36(31.0) 39(22.2) 32(26.2) 19(16.7) 60(28.2) 28(32.2) 5(4.6) 32(17.6) 70(56.5)
χ2 2.89 7.44 92.45
P 0.236 0.024 0.000
Phobia tendency 20(17.2) 22(12.5) 9(7.4) 9(7.9) 27(12.7) 15(17.2) 2(1.9) 14(7.7) 35(28.2)
χ2 5.37 4.04 43.61
P 0.068 0.132 0.000
Impulsive tendency 7(6.0) 5(2.8) 5(4.1) 1(0.9) 9(4.2) 7(8.0) 1(0.9) 3(1.6) 13(10.5)
χ2 1.81 6.46 18.38
P 0.404 0.040 0.000

19
P. Mao, X. Yang, M. Tan et al. Journal of Pediatric Nursing 64 (2022) e15–e23

Table 7
Binary Logistic regression analysis on influencing factors associated with mental health among all adolescents (n = 414).

Learning Interpersonal Loneliness Self-accusation Sensitiveness Physical Phobia Impulsive

anxiety relationship anxiety tendency tendency tendency symptoms tendency tendency
(B, 95% CI) (B, 95% CI) (B, 95% CI) (B, 95% CI) (B, 95% CI) (B, 95% CI) (B, 95% CI) (B, 95% CI)

Gender
Male 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Female 1.33 1.43(0.70,2.90) 0.39 1.03(0.64,1.66) 1.19(0.75,1.89) 1.04 0.89(0.45,1.79) 2.17
(0.82,2.15) (0.15,1.04) (0.61,1.80) (0.52,9.14)
Age group
≤15 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
≥16 0.64 0.11(0.03,0.48)⁎⁎ 0.53 1.22(0.49,3.05) 0.53(0.22,1.31) 0.54 0.38(0.11,1.32) 0.33
(0.25,1.60) (0.09,3.22) (0.19,1.54) (0.05,2.43)
Ethnicity
Han 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Minority 1.39 0.82(0.31,2.18) 0.38 1.20(0.61,2.36) 1.60(0.82,3.15) 0.72 0.92(0.38,2.23) 1.93
(0.67,2.88) (0.12,1.19) (0.34,1.51) (0.29,12.72)
Income
No-low income 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Low income 1.24 1.44(0.50,4.14) 5.13 0.68(0.33,1.41) 0.44(0.21,0.91) 1.63 2.44(0.88,6.79) 1.33
(0.58,2.63) (1.29,20.43)⁎ (0.73,3.63) (0.15,11.71)
Parental absence
No 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Yes 0.91 2.06(0.74,5.74) 5.50 1.35(0.73,2.53) 1.23(0.68,2.25) 1.00 1.82(0.66,5.01) 1.30
(0.50,1.66) (0.62,48.55) (0.49,2.07) (0.20,8.51)
Caregiver's education
Elementary school and 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
below
Middle school 1.01 1.62(0.74,3.52) 0.80 1.30(0.76,2.22) 1.26(0.74,2.14) 0.86 1.84(0.85,3.99) 0.93
(0.58,1.76) (0.29,2.21) (0.47,1.58) (0.22,3.97)
High school diploma or 0.35 2.66(0.75,9.39) 1.02 0.44(0.17,1.18) 0.53(0.22,1.27) 0.39 1.39(0.38,5.13) 1.85
equivalent (0.16,0.79)⁎ (0.11,9.58) (0.13,1.16) (0.21,16.53)
Caregiver's physical
health
Poor 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Fair 0.91 1.24(0.50,3.07) 0.54 1.47(0.80,2.69) 0.79(0.44,1.41) 0.81 1.98(0.83,4.75) 0.76
(0.48,1.73) (0.18,1.62) (0.41,1.60) (0.16,3.74)
Good 0.98 0.97(0.35,2.69) 0.54 1.31(0.65,2.62) 0.83(0.43,1.59) 0.92 1.05(0.37,2.94) 0.72
(0.49,1.96) (0.14,1.99) (0.43,1.97) (0.13,3.99)
Empathy skills 1.10 1.15(0.94,1.41) 1.24 1.00(0.87,1.15) 1.05(0.91,1.20) 0.95 1.09(0.89,1.34) 1.30
(0.96,1.28) (0.94,1.64) (0.81,1.11) (0.92,1.82)
Communication skills 1.02 0.93(0.72,1.20) 0.92 0.92(0.76,1.11) 0.83(0.69,1.00) ⁎ 0.80 0.91(0.72,1.16) 0.53
(0.83,1.25) (0.68,1.26) (0.66,0.99)⁎ (0.34,0.82)⁎⁎
Self-esteem 0.92 1.20(0.97,1.48) 1.01 0.98(0.85,1.13) 0.93(0.81,1.07) 1.00 0.88(0.73,1.07) 1.04
(0.79,1.08) (0.77,1.31) (0.85,1.17) (0.74,1.47)
Sociability 1.19 0.91(0.69,1.20) 0.64 1.08(0.90,1.30) 1.21(1.01,1.45)⁎ 1.10 1.16(0.89,1.52) 1.37
(0.98,1.44) (0.46,0.91)⁎ (0.89,1.35) (0.74,2.55)
Interpersonal morality 1.30 1.10(0.76,1.58) 0.71 1.64(1.26,2.15)⁎⁎ 1.22(0.96,1.55) 1.07 0.89(0.63,1.26) 0.49
(1.01,1.68)⁎ (0.47,1.09) (0.81,1.41) (0.25,0.95)⁎
Self-efficacy 0.86 0.80(0.64,0.99)* 0.84 0.80(0.69,0.92)⁎⁎ 0.94(0.82,1.08) 0.96 1.07(0.87,1.32) 1.14
(0.74,0.99)⁎ (0.63,1.12) (0.81,1.13) (0.80,1.64)
Stress coping 0.79 1.14(0.81,1.62) 1.26 0.72(0.57,0.91)⁎⁎ 0.88(0.71,1.10) 1.05 1.01(0.72,1.41) 2.04
(0.63,1.00)⁎ (0.79,2.03) (0.81,1.36) (1.04,4.00)⁎
Emotion regulation 1.04 0.57(0.41,0.79)⁎⁎ 1.26 1.04(0.83,1.30) 0.91(0.73,1.14) 0.77 0.74 0.50
(0.82,1.31) (0.78,2.03) (0.60,1.00)⁎ (0.55,1.00)⁎ (0.30,0.85)⁎
Extraversion(E)
Extraversion 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Middle type 0.74 1.71(0.64,4.57) 0.90 1.07(0.57,2.01) 0.83(0.45,1.51) 0.74 0.64(0.26,1.56) 0.26
(0.38,1.45) (0.27,2.94) (0.04,1.74)
Intraversion 0.46 0.74(0.22,2.46) 0.24 1.05(0.49,2.24) 0.60(0.29,1.26) 1.44 0.37(0.12,1.15) 0.34
(0.21,1.01) (0.04,1.52) (0.04,2.70)
Psychoticism(P)
Lower-Psychoticism 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Middle type 1.45 2.25(0.82,6.13) 2.44 1.08(0.60,1.93) 1.35(0.76,2.40) 0.96 0.96(0.38,2.44) 1.87
(0.82,2.58) (0.61,9.73) (0.48,1.94) (0.18,19.83)
High-Psychoticism 0.81 5.95(1.58,22.45)⁎⁎ 2.79 0.64(0.25,1.65) 2.68(1.07,6.74)⁎ 1.43 1.93(0.55,6.76) 5.78
(0.31,2.13) (0.37,21.07) (0.50,4.11) (0.38,86.81)
Neuroticism (N)
Stability 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Middle type 4.29 0.53(0.17,1.59) 0.41 1.77(0.90,3.48) 3.66 3.72 3.48 0.58
(2.35,7.82)⁎⁎ (0.11,1.60) (1.80,7.43)⁎⁎ (1.32,10.51)⁎ (0.72,16.93) (0.04,8.87)
Instability 3.90 1.29(0.40,4.13) 0.57 3.68(1.69,8.00)⁎⁎ 7.92 22.15 14.06 5.15
(1.81,8.41)⁎⁎ (0.13,2.56) (3.52,17.82)⁎⁎ (7.28,67.33)⁎⁎ (2.75,71.94)⁎⁎yy (0.40,66.14)
⁎⁎ p< 0.01
⁎ p< 0.05

20
P. Mao, X. Yang, M. Tan et al. Journal of Pediatric Nursing 64 (2022) e15–e23

Discussion relationship between grandparents and adolescents is critical for the

latter's mental health (Wen & Lin, 2012). Furthermore, the social sup-
This study is the first to explore the prevalence of mental health port of other adults in an extended family or community in the Chinese
problems among adolescents with and without parental absence in family-based sociocultural context might serve as a positive protective
rural China and examine the role of their SES, sex, age, parental absence factor for adolescents whose parents are not present. Studies have sug-
status, life skills, and personality traits on their mental health. This study gested that MHDs are positively correlated with social support; the ab-
has several important findings. First, adolescents in rural China reported sence of parents may then have a smaller impact on adolescents
high positive rates of MHDs related to learning anxiety, sensitiveness, because they are usually cared for by relatives who can cushion the neg-
self-accusation, and physical symptoms. Second, there were no signifi- ative effects of parental absence (Xu et al., 2019). Therefore, it is very
cant differences between the adolescents' positive rate of MHDs and pa- likely that adolescents have adequate support from a trusted adult
rental absence, gender, or age. Finally, better communication skills, regardless of parental presence.
interpersonal morality, self-efficacy, and ability to cope with stress de- Our study found that MHDs did not differ based on the adolescents'
creased the risk of MHDs, whereas the instability-neuroticism personal- sex or age. Other studies in China also found no differences in MHDs be-
ity trait increased this risk. tween girls and boys (Wang, Zou, et al., 2019). However, some studies
In our study, the high prevalence of learning anxiety, sensitiveness from India, China, and Japan have determined that girls report higher
tendency, self-accusation tendency, and physical symptoms related to anxiety levels than boys (Bakhla et al., 2014; Ishikawa et al., 2018; Wu
anxiety was consistent with other studies from China (Liu et al., et al., 2019). Differences in these studies' findings may be due to the par-
2018). Our analyses indicated that, of all dimensions of the MHT, learn- ticipants' age and how the researchers measured MHDs. In our study,
ing anxiety was the most prevalent (70%) in this population. This rate is the adolescents' MHDs were not related to age, which is consistent
similar to that found in studies conducted in China and other Asian pop- with findings for Chinese and Italian adolescents (Delvecchio et al.,
ulations (Mary et al., 2014; Sun, 2012), whereas the global average was 2015). The similarity in anxiety levels between sex and age in our
56% (Howard, 2020). The high prevalence of learning anxiety may result study may also be due to the fact that the Chinese government has is-
from the intense competition for higher education and the high expec- sued a policy related to child custody, daily life, education, medical
tations set by Chinese schools. Notably, students in China must take a care, psychological services, and other social matters that emphasizes
competitive entrance exam to begin high school or college. Some nega- support and care at the county, township, and village levels (People's
tive outcomes have been found in association with prolonged learning Government of Hunan Province, 2016). Therefore, all adolescents, re-
anxiety, such as adverse consequences for cardiovascular, airway, and gardless of sex, age, SES, or parental absence status, receive guidance
immune health (Trueba et al., 2013). Thus, identifying factors associated and help from different programs under these official guidelines.
with learning anxiety is critical. Our study's findings also suggest that fewer MHDs are associated
Sensitiveness tendency was the second most common problem with better life skills, especially better communication skills, interper-
among adolescents with a detection rate of 40%. Adolescence enhances sonal morality, self-efficacy, and ability to cope with stress. First, com-
the social stimulus function and triggers stress responses under condi- munication skills involve ability to express feelings, give feedback,
tions of social evaluation (Blakemore & Choudhury, 2006). Adolescents manage conflict, and listen to and understand others' needs. Developing
are sensitive to the evaluations and opinions of others, which leads to this skillset enables adolescents to be accepted in society and provides
strong emotional reactions such as anger, frustration, and humiliation the foundation for their adult social behavior (WHO, 2021), which can
due to peer exclusion (Warrington & Younger, 2011). When adolescents handle interpersonal anxiety. Turiel (1983) defined morality as “pre-
act, they often think that someone is observing them or consider the pos- scriptive judgments of justice, rights, and welfare about how people
sible reactions of others. As such, they produce cognitive and hormonal ought to relate to each other.” Morally competent people act after con-
responses related to stress. The high detection of self-blaming tendency sidering the consequences for others. It appears that interpersonal mo-
in our study may be related to the fact that self-blame is a mediator of de- rality also has an impact on interpersonal anxiety. Next, self-efficacys
pression symptoms (David-Ferdon & Kaslow, 2008). The detection rate of positive effect on mental health has been proved in two ways. First,
physical symptoms in our study was also over 26%. Physical changes dur- self-efficacy can alleviate the burden of stress and promote positive
ing adolescence may cause students to worry about their physical condi- mental health (Maddux, 2002). Second, high self-efficacy can improve
tion. Previous studies have found that mental anxiety can cause a range of efficacy when coping with anxiety (Liu, 2012). Finally, ability to cope
problems for children and adolescents, hinder their normal physical de- with stress via positive thinking has shown the strong association
velopment, and be accompanied by a series of physical symptoms, such with health in several studies. For example, Melato et al. (2017) found
as difficulty falling asleep, racing heartbeat, sweating, insomnia, and fa- a significantly negative relationship between positive coping strategies
tigue (Hauken et al., 2017; Willis & Gregory, 2015). and MHDs. Meanwhile, the absence of appropriate skills to cope with
Regarding the effect of parental absence on MHDs, there was an in- unique life changes during adolescence can cause many physical and
consistency between the univariate analysis and multiple logistic re- behavioral difficulties (Gerami et al., 2015).
gression. This is not uncommon in medical publications because an Our results indicated that instability-neuroticism was the primary
outcome may have multiple confounding covariates (Liu et al., 2017). personality trait that increased the risk for MHDs. This result is consistent
For example, treatment effects are confounded by differences between with the findings of Gale et al. (2013), which indicated that neuroticism
treatment groups, including age, drug use, and comorbidities. However, has a long-term effect on mental well-being. There is evidence suggesting
these covariates were not considered in the univariate analysis. There- that personality traits, particularly neuroticism, have important links to
fore, the results of our multiple logistic regression showed that MHDs psychopathology. They are also important vulnerability factors for anxiety
were similar among adolescents regardless of parental absence status, disorders, as people with high levels of anxiety and stress typically have
which is consistent with other studies conducted in China (Luo et al., high neuroticism scores (Jylhã & Isometsã, 2010; Ye et al., 2017). Individ-
2016). However,Several studies revealed that there were significant as- uals with high neuroticism are characteristically stubborn, lonely, un-
sociations between parental absence and mental health among Norway, friendly, poorly adapted to external circumstances, and lack empathy,
Palestinian, and Indian adolescents (Eide et al., 2020; Ghosh, 2016; which increases their risk of developing MHDs (Ying et al., 2014).
Shehadeh et al., 2016). The following reasons may explain our findings.
Although not all adolescents' parents were present, all adolescents iden- Practical implications
tified a primary caregiver. In the context of shared child-rearing, chil-
dren and adolescents in China who have two absent parents are Our study underscores the fact that MHDs are common among rural
primarily taken care of by their grandparents, and a positive Chinese adolescents. This requires urgent attention from multiple

21
P. Mao, X. Yang, M. Tan et al. Journal of Pediatric Nursing 64 (2022) e15–e23

entities that involve adolescents, including schools and healthcare sys- David-Ferdon, C., & Kaslow, N. J. (2008). Evidence-based psychosocial treatments for child
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common MHD among adolescents, and they usually spend the most symptoms in community-based Chinese and Italian adolescents. Journal of Child and
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Funding Liu, H., Shi, Y., Auden, E., & Rozelle, S. (2018). Anxiety in rural Chinese children and ado-
lescents: Comparisons across provinces and among subgroups. International Journal
of Environmental Research and Public Health, 15(10), 2087. https://doi.org/10.3390/
This work was supported by the Innovation Platform Open Founda- ijerph15102087.
tion, Innovation Platform Development Project of Hunan Provincial Liu, J., Liu, S., Yan, J., Lee, E., & Mayes, L. (2016). The impact of life skills training on behav-
Education Department, 2017–2019 [grant numbers 17 K104]. ior problems in left-behind children in rural China: A pilot study. School Psychology
International, 37(1), 73–84. https://doi.org/10.1177/0143034315618442.
Liu, X. X. (2012). Relationship among personality,self-efficacy and mental health in left-
Declaration of Competing Interest behind junior high school students. Chinese Journal of Public Health, 28(9),
1210–1212.
Luo, Y., Wang, H., Lei, X., Guo, X., Huang, K., & Liu, Q. (2016). Resilience in rural left-behind
none. middle school students in Yunyang county of the three gorges area in China: A pro-
spective cohort study. BMC Psychiatry, 16(1), 77. https://doi.org/10.1186/s12888-
016-0781-1.
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