The mental health of adolescent girls from a tribal region of Central Rural India during the COVID-19 pandemic – A cross-sectional study to determine the role of gender disadvantage

INTRODUCTION

The Lancet Commission on adolescent health and well-being emphasized the need to reduce inequities linked to gender and poverty, especially related to social and cultural factors for improving the mental health of adolescents.^[1] The World Health Organization identified gender-related risk factors as critical determinants of mental health, well-being, and resilience.^[2] Women’s mental health in India across the lifecycle is shown to be impacted by social determinants including gender disparities^[3,4] and the country ranks 140^th out of 156 in the Global Gender Gap 2021 Rankings.^[5] Poor nutrition and early marriage also add to this vulnerability.^[6] Girls between 14 and 19 years in rural and underserved India are especially vulnerable.^[7]

Women in the state of Chhattisgarh in Central India, where this study was conducted, have high rates of vulnerabilities – with 39.9% population being below poverty line, 79.9% of girls not completing higher secondary education, 23.5% being married before the age of 18 years, and 5% adolescent girls having teenage pregnancies.^[7-9]

Within this state is the district of Bastar, a district with a high tribal (65.9%) population.^[10]

This study was conducted as part of the Swabhimaan program and is a 5-year initiative launched by Deendayal Antyodaya Yojana – National Rural Livelihoods Mission to improve nutrition outcomes among adolescent girls and women through women collectives in five poorest resource blocks of three Indian States – Bihar, Chhattisgarh, and Odisha.^[11] As part of this program adolescent girls’, groups are mobilized into groups that conduct regular meetings, enhance access to health services, and provide loans to promote secondary education and prevent child marriage. Midline evaluation of the program in Bastar (where the present study was conducted) showed that 31% of the adolescent girls aged 15–19 years were not attending school. In addition, only 15% of girls reported having the autonomy to participate in activities outside their home, and while 60% could take decisions about going to school, only 18% thought they could take decisions regarding whom to marry.^[12] Addressing gender disadvantage and studying its association with mental health hence gained importance.^[13]

Public health emergencies have an impact on mental health and psychosocial well-being^[14-18] and the coronavirus disease 2019 (COVID-19) pandemic exacerbated effects of existing gender inequalities especially, gender-based violence among women and girls and food insecurity.^[19-25] Disruptions in health and education services, safety nets, and income sources led to insufficiency of resources and girls faced increased household responsibilities at the cost of their education.^[26,27] A country-wide surveys in India showed that 56% school children lack access to smartphones^[28] with gender differences in ownership and online means of learning.^[27] Early marriages of girls and early unplanned pregnancies further increased vulnerability.^[26] There is evidence that education of girls delays age of marriage.^[29] An assessment conducted with adolescents (10–19 years) in central and eastern states during the pandemic stated that 32% girls lacked adequate meal consumption as a result of income loss, thereby increasing their vulnerabilities.^[27]

The pandemic also had an impact on the mental health of adolescents and studies from India reported high rates of depression, anxiety, and self-harm.^[30-32] Due to all the gender-related factors mentioned above the mental health of girls, especially from rural and low resource areas have been adversely affected.^[31] However, evidence is lacking as data gathering during the pandemic was challenging (had to be done through phones), especially related to sensitive issues such as gender disadvantage and domestic violence.

This study, therefore, aimed to understand the association of gender disadvantage with psychological distress and resilience among adolescent girls in the tribal area of Bastar during the first wave of the COVID-19 pandemic, who were already part of the ongoing Swabhimaan program.

MATERIALS AND METHODS

RESULTS

The mean age of girls was 17.62 years (SD 1.64) with an age range of 14–20 years. The mean level of education was 10.65 years (SD 1.76). Of the 102 girls interviewed, 48 were currently in school and 54 were out-of-school with 70.8% of the girls in school continued their studies by self-reading or attending online classes (60.4%). Out of 102 girls, 56.3% aspired to get an undergraduate degree, 66.7% aspired for formal employment, majority of them preferring a career as teachers or health professionals. About 80% of out-of-school girls (n = 54) desired to continue their education. Most common reasons reported for discontinuation of education were as follows: No desire for further education, dropping out due to shutdown of school during the COVID-19 lockdown, and parents unwilling to continue education. Lack of money and poor academic performance were also cited as reasons for dropping out.

About 73% girls reported not receiving weekly iron and folic acid supplementation by school-teachers or Accredited Social Health Activists (ASHAs) in the 2 months before the interview. While 70% of girls were members of the adolescent girls’ groups mobilized in their villages, <15% girls reported the use of group platforms to discuss issues about their life and future. The desired mean age of marriage expressed by girls was 22 years (SD 8.46). Gender disadvantage as indicated by the five items most endorsed on the CAGED questionnaire was: lack of space or privacy within the household or neighborhood (39%), feelings of curtailed freedom and restrictions on pursuing interests (32%), their opinions not being considered because they were girls (31%), financial difficulties as hindrance to future opportunities as a gender-related barrier (28%), and emotional distress due to gender discrimination (26%). The least endorsed item was the experience of sexual abuse (5.9%) [Table 1]. The mean score on the BRS was 2.82 (SD 0.64), with 51% of the girls scoring below 2.99 [Table 1]. Scores on the Kessler psychological distress scale (K-10) scores indicated that 19.6% girls had severe distress, 7.8% had moderate distress, and 18.6% girls had mild distress [Table 1]. Mean score on the K-10 was 19.68 (SD 9.23).

A significant relationship was observed between K-10 scores and the three gender disadvantage domains of CAGED: Gender-related barriers (P < 0.001), gender discrimination (P < 0.001), and violence and sexual harassment (P < 0.001). A higher total score on the CAGED and in the three above-mentioned domains was associated with higher levels of psychological distress [Table 2]. Psychosocial outcome measures were compared between those who were school-going and out-of-school showed significant differences [Table 3]. More out-of-school girls faced gender discrimination (61.1%, P = 0.017) and suffered from moderate-to-severe distress (13–24.1%).

Significant negative correlations were observed between three CAGED domains and resilience: Gender-related barriers (−0.21, P = 0.018), violence and sexual harassment (−0.23, P = 0.016), and emotional distress (−0.24, P = 0.016). Girls with more perceived gender disadvantage had lower resilience scores. Higher distress was significantly associated with a lower resilience score.

DISCUSSION

This study which assessed psychological distress and its relationship with resilience and gender disadvantage among adolescent girls between 15 and 20 years from a tribal population during the COVID-19 pandemic found that nearly 27.5% of the girls had high levels of psychological distress. Severity of psychological distress was associated with higher perceived gender disadvantage and low scores on self-reported resilience. These rates of distress are similar to a study among tribal adolescents in West Bengal (both girls and boys) which revealed a high prevalence (66.8%) of mental health problems and distress.^[37] However, rates were higher than those reported among urban young women in Gujarat and Bangalore.^[33,38] All these studies were, however, done before the COVID-19 pandemic. The pandemic had different impacts on adolescent mental health by gender. Recent analysis from six countries in the Asian Pacific region showed that adolescent girls were more likely to feel isolated or stressed, be concerned about education and household income.^[39]

High levels of psychological distress have been reported during the COVID-19 pandemic among adolescents in different parts of India.^{[17,31,32,40-42]} A study among adolescent girls from six states reported concerns related to self-isolation, worries about academics, physical health and safety, as well as global and societal concerns.^[43] Our study, in addition, highlighted specific gender-related concerns especially among girls who were out of school.^[44]

The mental health of young girls is an important determinant of their educational and employment aspirations.^[45] Interventions to improve mental health of adolescent girls must address realities of gender disadvantage to be effective as demonstrated by a randomized controlled trial of a large-scale resilience-based school program in the state of Bihar which showed significant improvement in emotional resilience, self-efficacy, social-emotional assets, psychological well-being, and social well-being among girls who received the intervention.^[46]

Based on our findings and available literature, we recommend for a more nuanced understanding of mental health, especially for young women in underserved areas such as tribal regions. Theoretical models such as the pathways toward adolescent girls’ psychosocial and broader well-being,^[4] the five domains of adolescent well-being that underpin the adolescent well-being framework,^[47] and socioecological impact of gender on mental health^[48] emphasize the need to focus on the following domains – health and nutrition, agency, resilience, supportive environment, strong social networks, education, and skills. We recommend that interventions for the mental health of adolescent girls related to the impact of the pandemic should focus on enhancing agency, improving life skills, be participatory, involve the adolescents in codesign, and involve peer support.^[49,50] Risk factors such as income and food insecurity, being out of school, and early marriage increase gender disadvantage and reduce resilience also leading to poorer mental health outcomes. These should be addressed through self-help groups, financial support, and ensuring continuity of education. Interventions should also be gender transformative and include fathers and brothers who need to promote gender equity in families.^[49,50]

The assessment of different domains of gender disadvantage is a distinct strength of the study. In addition, we included in our study, girls who were out of school increasing the generalizability of the study as most studies among adolescent girls are done among those attending school or college.

The limitations of the study include the following – firstly, tools such as CAGED, BRS, and K-10 were used for the first time with adolescent girls in a tribal setting in India. While rigorous translation methods were used, and piloting was done, before, the main study, it is possible that responses on a structured questionnaire did not capture the cultural and social context of the respondent’s experience. While these tools have been used in Indian adolescent girls, these have predominantly in urban settings. There is a need to validate these tools in rural and tribal settings with low levels of literacy.

Second, interviews were not done face to face due to the pandemic. Telephonic interviews require investment in rapport building and ensuring privacy and may not be able to capture data as effectively as an in-person assessment. To capture data and information that reflects the context, the researcher must also understand the context and interpret the information accurately.^[51] Finally, many of the girls we interviewed had been part of the collectives and this may also have influenced the rates of distress. Girls who are not part of such collectives may report even higher rates of distress.

CONCLUSION

The study identifies the need for integrating concepts of gender disadvantage and mental health into collectives for young women. Gender inequality, poverty, and low educational attainment are linked to poor mental health. It has been shown that interventions addressing agency and gender attitudes delivered by community-based peers among highly disadvantaged young women can lead to sustained improvements in anxiety and depression and attitudes to gender equality, improving mental health.^[52]

While adolescent girls’ groups can provide social support, to mitigate challenges and build resilience,^[19] there is a strong need to work with fathers, brothers, and mothers using gender transformative interventions to change existing gender attitudes and enhancing the sense of self-worth and participation among young women.^[53]