The association between psychosocial factors, protective factors, and its associated triggers with psychological distress among Bolivian adolescents

The purpose of this study is to investigate the association between psychosocial factors, protective factors, and its associated triggers with psychological distress among Bolivian adolescents. This cross-sectional study was conducted by investigating the 2018 Bolivia global school-based student health survey (GSHS). The total number of students who participated in this survey was 7931, and the final sample was 7377. The mean age of the participants was 15.3 years (SD = 1.4). Psychological distress was assessed with a 2-item screener (loneliness and worry induced sleep disturbance). In all 22.3% of participants reported experiencing psychological distress, with 18.1% among adolescent males and 26.2% among adolescent females. In adjusted logistic regression analysis (AOR, 95% CI), there are two significant directions of association. One is the negative association, such as parental involvement as a protective factor. School adolescents who had more parental involvement were less likely to experience psychological distress. Parents understand problems or worries (0.64, 0.54–0.75, p < .001) and parents disregard privacy (0.69, 0.58–0.82, p < .001). On the other hand, many psycho-social factors are significantly positively associated with psychological distress. School adolescents who experience more psychosocial factors are more likely to experience psychological distress. Physical assault in the previous year (1.83, 1.59–2.11, p < .001), being bullied at school (1.27, 1.07–1.52, p < .01), being bullied outside of school (1.36, 1.15–1.61, p < .001), and being cyberbullied (1.60, 1.37–1.88, p < .001), were all significantly associated with psychological distress. Healthy relationships in a family, and interventions to reduce violence and bullying, should be encouraged and promoted.

Loneliness is one of the psychological consequences that affects people of all ages, including adolescents and school-age children 1 .Between 2012 and 2018, the global phenomenon of school loneliness increased in 36 out of 37 countries 2 .Loneliness is indicated as a mediator of anxiety, depression, and social expression 3 .Furthermore, loneliness, along with negative emotions, is a significant component of psychological distress that contributes to negative mental health outcomes, particularly depressive symptoms and suicidality 4 .Many studies have revealed the factors related to psychological distress.For example, a study using the 2015 Brazil National School Health Survey found that protective and risk factors for psychological health were the relationship with parents and the school context, including school-violent behaviors 5 .Loneliness was one of the aspects of psychological distress that was used to test as a psychological outcome in a group of adolescent-based studies in a global survey 6 .Loneliness has been reported to be a bond linked to anxiety and related symptoms that are emotional or affective circumstances 7 .The questions were used to be a latent variable of loneliness such as "How often you do feel lonely?" or "How many times have you been unable to sleep at night because of worry?" 6 .Moreover, the two questions were used as a screener for psychological distress among adolescents in different countries, with a involved selecting schools, and the second step involved selecting students aged 11-18 years from the classes within those schools.The inclusion criteria were all students present in the selected classrooms regardless of age.The students subsequently provided their answers to each question on a computer-readable answer sheet by themselves.The study was carried out using the publicly available data recorded on the World Health Organization (WHO) website.The total number of students who participated in this survey was 7931 (total response rate was close to 80%) 34 .Of the total sample of 7931, 564 had missing values on the outcome variable (psychological distress), which were removed resulting in our study sample of 7377.

Measures.
The GSHS measurement is similar to the CDC Youth Risk Behavior Survey 35 , with test and re-test reliability known.Furthermore, the GSHS showed that "the average agreement between the test and the re-test is 77%, and the Cohen kappa is 0.47" 36 .This study used the Bolivia GSHS questionnaire 34 that is consisted of three core modules, including (1) psychological distress (loneliness, sleep disturbances, anxiousness); (2) protective factors (the relationship with parents and having close friends), and (3) psychosocial factors (interpersonal violence, being bullied).

Outcome variable.
Psychological distress variables were measured with two items, including (1) "During the past 12 months, how often have you felt lonely?" and (2) "During the past 12 months, how often have you been so worried about something that you could not sleep at night?" Response options were "Never = 1, Rarely = 2, Sometimes = 3, Most of the time = 4, Always = 5", and were coded as "Never = 0, Rarely = 1, Sometimes = 1, Most of the time = 2, Always = 3. " Scores of the two items were summed, and scores of three or more were defined as psychological distress.Coding and scoring of this 2-item psychological distress measure followed previous studies 9,10 .Cronbach alpha for the 2-item psychological distress measure was 0.61.The interitem correlation was 0.44.

Co-variables. Sociodemographic factors included sex and age group.
Protective factors included four items on parental involvement and one item on having close friends.The four parental involvement items are the following: (1) parents check homework: "During the past 30 days, how often did your parents or guardians check to see if your homework was done?" (2) parents understood problems and worries: "During the past 30 days, how often did your parents or guardians understand your problems and worries?" (3) parents know what you were doing with your free time: "During the past 30 days, how often did your parents or guardians really know what you were doing with your free time?" (4) parents go through your things without your approval: "During the past 30 days, how often did your parents or guardians go through your things without your approval?"Response options were "Never = 1, Rarely = 2, Sometimes = 3, Most of the time = 4, Always = 5".Items 1-3 were coded most of the time or always = 1 and never, rarely, or sometimes = 0, and item 4 never or rarely = 1 and sometimes, most of the times or always = 0.
Having close friends.("How many close friends do you have?") (number).
Psycho-social factors included the number of students experiencing three components: (1) interpersonal violence included two items; physically attacked ("During the past 12 months, how many times were you physically attacked?"with coded 0 = 0 times, 1 = 1-12 or more times) and physical fighting in the past 12 months ("During the past 12 months, how many times were you in a physical fight?" with coded 0 = 0 times, 1 = 1-12 or more times) (2) being bullied included three items (response in yes, no questions); being bullied at school ("During the past 12 months, have you ever been bullied on school property?"),being bullied outside school ("During the past 12 months, have you ever been bullied when you were not on school property?"),and being cyberbullied in the last 12 months ("During the past 12 months, have you ever been cyberbullied?").

Data analysis.
Descriptive statistics were performed using frequencies to describe categorical variables.
Testing differences in proportions were calculated using Pearson's chi-square tests.Logistic regression was utilized to present the effects measured among variables by presenting crude and adjusted odds ratios, and 95% confidence intervals.Missing values were not included in the analysis.The statistical software that we used in this study is Stata version 16.0 (Stata Corporation, College Station, TX, USA), taking the multi-stage sampling and weighting of the data into account.
Ethical considerations.The study protocol was approved by the Ministry of Health, Bolivia, and a national ethics committee.The necessary approvals and permits, including informed consent, were obtained from the participating schools, the parents, and the students before the survey was administered.This study used publicly available data from the website of the World Health Organization (WHO), which contains anonymous individual information; hence institutional review board approval was not obtained.All methods were carried out in accordance with relevant guidelines and regulations.

Results
Sample and psychological distress characteristics among adolescents in Bolivia.The sample consisted of 7931 Bolivian adolescents.After missing data of the outcome variable were removed, the sample included 7377, with approximately 22.3% showing psychological distress.Adolescent females had a higher percentage of psychological distress, accounting for 26.2%, whereas adolescent males accounted for approximately 18.1%.The number of adolescents experiencing psychological distress was found to increase with age after 15 (Table 1).
In four dimensions of protective factors related to the relationship with parents, the percentage of adolescents experiencing psychological distresses was found to be a lower percentage than one-third in three dimensions for both genders.These dimensions were: parents check homework (18.5%), parents understood problems and worries (16.2%), and parents know what you were doing with your free time (19.6%).When these dimensions were analysed separately by gender, it was found that these three dimensions of parental involvement were associated with a lower percentage (less than 23%) of adolescents experiencing psychological distress (Table 1).
On the other hand, among both gender of Bolivian adolescents, in the cases of adolescents experiencing physically attacked in the past 12 months, were found a higher number experienced psychological distress approximately 40%, and physical fighting was around 35%.There were victimized adolescents of bullying who suffered from psychological distress approximately one-third.Being cyberbullied in the past 12 months (34.1%), was the majority of victimization of bullying experiencing psychological distress.Followed by being bullied outside school (32.2%) and being bullied at school (31.2%).The percentage of adolescents experiencing psychological distress was found to decrease with the number of close friends (Table 1).

Associations with psychological distress among adolescents in Bolivia.
The crude and adjusted odds ratios with a 95% confidence interval are presented in Table 2, showing the association between sociodemographic factors, protective factors, psycho-social factors, and psychological factors with psychological distress by gender.
Among Bolivian adolescent males, physical fighting and being cyberbullied were found to be the most significant predictors of psychological distress, with crude odds ratios of 2.37 and 2.05.Adolescent males aged 17 and over were found to be particularly vulnerable to psychological distress compared to other age groups.Contrary to the previously mentioned risk factors, parental involvement and having close friends were found to be protective against psychological distress in this study, with crude odds ratios of less than 1 (Fig. 1).
Cyberbullied, bullied outside school, and bullied at school were found to be significant predictors of psychological distress among Bolivian adolescent females, with crude odds ratios of 2.38, 2.37, and 2.09, respectively.The physical attack was also discovered to be a predictor of psychological distress in adolescent females.Adolescent females aged 16 and older were also identified as being at higher risk of psychological distress compared to other www.nature.com/scientificreports/age groups.In contrast, similar to adolescent males, parental involvement and having close friends were found to be protective against psychological distress, with crude odds ratios of less than 1 (Fig. 2).

Discussion
This recent study aimed to examine the associations between protective and psychosocial factors and psychological distress among Bolivian adolescents.We found a high prevalence of psychological distress (22.3%), similar to in Morocco (23.3%) 9 and in Liberia (24.5%) 8 , and higher than in Tonga (18.9%) 12 , in Caribbean nations (18.6%) 7 ,  www.nature.com/scientificreports/and in Indonesia (7.3-8.0%) in Indonesia 10,11 , calling for strategies to prevent and control psychological distress among adolescents in Bolivia.
In this study interpersonal violence (physically attacked, and physical fighting) and being bullied (being bullied online, at and outside schools) are the main predictors of contributing to psychological distress (loneliness and worry-induced sleep disturbance) among Bolivian adolescents.These current findings are consistent with those of previous studies, including a study in schools in countries of the Western Pacific islands 37 , a study of adolescents in four Caribbean countries 38 , and a study of Indonesian female adolescents 10 , which all found that violence was associated with loneliness.There is a study indicating the circumstances relation between violence and loneliness.It is indicated that factors such as the classroom environment and experiences of victimization can contribute to feelings of loneliness, which in turn can increase the likelihood of engaging in overt and relational violence 39 .Furthermore, some research indicated that violence and being bullied can have the power of stimulating sleep problems, which is one of the branches of psychological distress 40,41 .Violence can have a significant impact on sleep patterns and overall sleep quality.Exposure to violence, whether as a witness or a victim, can lead to sleep disturbances such as difficulty falling asleep, difficulty staying asleep, and frequent nightmares 42 .This is likely because violence can cause feelings of anxiety, stress, and fear, which can interfere with the ability to relax and fall asleep.Furthermore, violence can disrupt normal sleep patterns and routines, leading to difficulty sleeping.It is important for adolescents who have experienced violence to seek support and seek help if they are experiencing sleep problems as a result.In some cases, therapy or medication may be helpful in managing sleep difficulties related to violence 43 .Furthermore, psychological interventions, namely mindfulness meditation, also indicated positive results in improving sleep quality 44,45 .
According to the logistic regression analysis of the present study, parental involvement can indicate that it may serve as a protective element to minimize psychological distress (such as loneliness, worrying, and poor sleep quality).Strong and positive relationships among family members can provide a sense of support and security.It can also be an important protective factor against violence and bullying 46 .On the other hand, unhealthy relationships within a family can contribute to an environment where violence and bullying are more likely to occur.There are many ways that families can work to promote healthy relationships and reduce violence and bullying.Some strategies might include: (1) setting clear boundaries and expectations for behavior 47 ; ( 2) encouraging open communication and listening to one another 48 ; (3) resolving conflicts peacefully and with respect 49 ; (4) seeking support from a therapist or counselor if needed 50 ; (5) educating family members about the impact of violence and bullying 51 ; and (6) the importance of being kind and respectful to one another 52 .It is important to note that addressing violence and bullying within a family can be challenging, and it may be necessary to seek outside help in order to create lasting change.Seeking support from therapists, psychologists, or community organizations specialized in these issues can help identify family-related stressors and perceptions of violence 53 .
Having close friends was also found to be a protective factor in this current study in both sexes.Previous evidence suggests that social relationships are able to prevent loneliness and sleep disturbance.In other words, feeling satisfied with one's social interactions is strongly correlated with reduced loneliness in all age groups 54 .Furthermore, perceived support from peers is associated with improved sleep quality.There is evidence to suggest that perceived social support, including support from peers, can be associated with improved sleep quality 55 .For example, a study found that adolescents who reported higher levels of social support from their peers had better sleep quality and were less likely to experience sleep problems 56 .The way to address loneliness was suggested to educate people on how to build and maintain positive relationships, such as friendships, and provide the necessary support for these relationships to thrive 57 .
The findings of this research suggest that violence and bullying victimization (inside and outside schools) have a negative and notable influence on the mental health and well-being of adolescents.It is important to understand the root causes and relevant context of these issues in order to effectively address them and promote the well-being of adolescents.Adolescents are particularly vulnerable to the effects of violence and are bullied due to their developmental stage and the central role that social relationships play in their lives.These experiences can have long-term consequences on mental health, including an increased risk of anxiety, depression, and suicidality.Given the serious and lasting effects of violence and bullying on the mental health of adolescents, it is essential to implement strategies to prevent these issues and to provide support and intervention for those who have experienced traumatic experiences.It is well established that addressing violence and bullying is necessary for promoting the overall well-being of adolescents.Effective prevention and intervention strategies may include educating adolescents about healthy relationships and communication, providing resources and support for those who have experienced violence or are bullied, and promoting a culture of respect for others and inclusion within schools and communities.By addressing these issues, we can work towards creating a safer and more supportive environment for adolescents to thrive.
In addition, protective factors, specifically, parental involvement can be an important factor in minimizing psychological distress, including loneliness, worrying, and sleep problems, in children and adolescents.Research has shown that children and adolescents who have supportive and involved parents tend to have better mental health outcomes 58,59 , and are less likely to experience psychological distress.Parental involvement can take many forms, including participating in activities with children, providing emotional support and encouragement, setting clear expectations and boundaries, and being available to talk and listen to children.By providing a supportive and nurturing environment, parents can help reduce the likelihood that children experience psychological distress and can also help mitigate the negative impact of stressors when they occur.

Study limitations
The GSHS measure is based on self-reports and only assessed from adolescents attending school.Therefore, there could be recall bias and the prevalence of psychological distress may be different in adolescents not attending school.Furthermore, cross-sectional survey data do not infer causality between psychosocial factors, protective factors, and psychological distress.In this study psychological distress was only assessed with a 2-item screener, and future research may want to include full psychological distress scales.

Conclusions
More than one in five school-going adolescents in Bolivia had psychological distress.Psychosocial factors, including physical attacks, physical fighting, and bullying victimisation (including in and outside schools and cyberbullied) are one of the key factors that influence psychological distress, especially worry-induced sleep disturbance and loneliness.On the other hand, a healthy relationship with parents and having close friends was protective against psychological distress.According to the evidence presented above, it is the responsibility of all those (parents, teachers, school staff, and so on) who are looking after children and adolescents to understand the factors that can cause their psychological problems, and also know how to support and care for them.Children and adolescents' caregivers may be able to have better aspects of a supportive and nurturing environment to address the problem and may assist in the positive development of children and adolescents in terms of health, well-being, and a good shape of developmental stages by understanding the root causes of psychological distress, such as loneliness, worry, and sleep difficulties.

Figure 1 .
Figure 1.The crude odd ratio for protective and psychosocial factors in adolescent males.

Figure 2 .
Figure 2. The crude odd ratio for protective and psychosocial factors in adolescent females.

Table 1 .
Sample and psychological distress characteristics among school adolescents in Bolivia, 2018 (% are weighted).