Stress Factors in Adolescent Exposed to Violence During the COVID-19 Pandemic Based on the Ecological Model: A Secondary Data Analysis
Article information
Abstract
Purpose
This study identifies the factors affecting stress among adolescents exposed to violence during the COVID-19 pandemic, using an ecological model.
Methods
A cross-sectional design was employed to analyze secondary data from the Korea Youth Risk Behavior Web-based Survey conducted in 2020 and 2021. Descriptive statistics were utilized to examine the prevalence of general and health-related characteristics among participants, while a complex sample logistic regression analysis was performed to identify the factors associated with their stress levels.
Results
A total of 1,494 adolescents received hospital treatment for violence. Among them, 44.3% (n=662) reported experiencing little stress, while 55.7% (n=832) reported feeling a high level of stress. Stress was significantly associated with individual factors (lack of physical activity, skipping breakfast, dissatisfaction with sleep, and feelings of loneliness), family factors (living with family), and school factors (lower academic achievement).
Conclusion
The pandemic heightened stress levels among adolescents, underscoring the need for greater attention and support. This emphasizes the importance of a multifaceted youth mental health policy grounded in an ecological model, encouraging regular stress management and the maintenance of physical, mental, and social well-being. This equips them to cope effectively with unexpected challenges.
INTRODUCTION
Violence against adolescents exacerbates stress during their growth period. Globally, approximately one billion adolescents experience violence each year [1], of whom one-third, aged 15~19 years, experience violence from close acquaintances [2]. The situation is particularly concerning in South Korea; although the overall adolescent violence experience rate decreased from 26.9% in 2019 to 22.8% in 2020, the victimization rate increased from 19.0% to 19.7% [3]. This result indicates an increase in violence victimization among young people in South Korea during the Coronavirus disease (COVID-19) pandemic.
Adolescents who have experienced violence are subjected to high levels of stress and may develop various health problems. Their underdeveloped ability to cope with stress leaves them vulnerable to mental health problems, particularly psychological issues such as anxiety, depression, and sleep disorders [4]. As stress levels rise, adolescents tend to skip breakfast and neglect healthy behaviors, such as sleep and physical activity [5]. The psychological impact of experiencing violence can manifest as depression and anxiety [6], which can lead to sleep disorders such as decreased sleep satisfaction [7]. Furthermore, students who have experienced violence may turn to alcohol use owing to feelings of loneliness [8]. In the COVID-19 context, adolescents experienced stress factors, such as worrying about their health and that of their family and friends, or fear of isolation [9]. These pandemic conditions resulted in limited social interactions, which increased feelings of helplessness and aggression [10].
To understand the association between experiences of stress and violence on adolescent development, this study adopted the ecological model as its theoretical framework. The ecological model suggests that individual behavior and development results from complex interactions between different levels of environmental influences [11]. Such an approach is essential for understanding the stress of adolescents exposed to violence during the COVID-19 crisis.
The pandemic affected different aspects of adolescents’ lives —altered daily activities and health behaviors due to school closures (individual factor) [5], increased prolonged contact with family (family factor) [12], and learning environment (school factor) [4]. Individual factors such as smoking, gender, drinking, physical activity, eating breakfast [13], substance misuse [14], sleep satisfaction [15], and loneliness [16] increase stress levels in adolescents exposed to violence. Family factors, such as living with family [12] and general economic status [16], also increase stress levels in exposed youth, as do school factors, such as academic performance [15]. Effective management of stress in adolescents exposed to violence requires consideration of factors that influence their stress levels, such as individual, family, and school. However, research considering these interrelated networks in disaster situations such as COVID-19 is lacking. Therefore, this study examines stress and the factors that influence it at different levels.
This study identifies the factors associated with stress in adolescents exposed to violence based on the ecological model during the COVID-19 pandemic. The findings contribute to the development of integrated nursing interventions for adolescents who have experienced violence, and enhancing community health professionals’ understanding and ability to intervene appropriately.
METHODS
1. Study Design
Secondary data analysis with a cross-sectional design was applied to nationally representative data from the 16th (2020) and 17th (2021) cycles of the Korea Youth Risk Behavior Web-based Survey (KYRBS) [17].
2. Data Source and Study Sample
According to the National Health Promotion Act, KYRBS has been conducted from 2005 to the present to understand the health behavior of middle- and high-school students in Korea. Participants in the 16th and 17th cycles of KYRBS were selected using nationwide stratified cluster sampling of middle- and high-school students as of August 2020 and 2021, respectively (https://www.kdca. go.kr/yhs/home.jsp).
The anonymous, self-administered online survey was conducted among 400 middle schools and 400 high schools. In the 16th and 17th cycles, 54,948 (94.9% response rate) and 54,848 (92.9% response rate) students participated, respectively. From these data, we identified respondents who experienced violence by considering their response to the following question: “In the past 12 months, have you ever been treated at a hospital for violence (physical violence, threats, bullying, etc.) perpetrated against you by friends, seniors, or adults?” The original seven-point response options (ranging from 0 to 6 or more times) were dichotomized into ‘no experience’ (0 times) and ‘experienced’( 1 or more times). We selected 1,494 participants who reported experiencing such incidents one or more times during the past 12 months (Figure 1).
Flowchart of the study sample.
3. Description of the Dependent Variable
The stress level among adolescents was assessed using the question: ‘How much stress do you usually feel?’ For the responses, ‘Feel very much’ and ‘Feel a lot’ were reclassified as ‘Feeling a lot of stress,’ while ‘Feel a little’, ‘Rarely feel’, and ‘Don’t feel at all’ were classified as ‘Feeling less stress.’
4. Descriptions of the Independent Variables
1) Individual factors
Gender refers to boys and girls. Smoking, drinking, and drug misuse were asked: 1) “Have you ever smoked, even one or two puffs of a regular cigarette?”; 2) “Have you ever had more than one sip of alcohol?”; 3) “Have you ever habitually or intentionally taken drugs, inhaled butane gas, or inhaled glue?” Participants could respond ‘yes’ or ‘no’ to each question.
Physical activity refers to the number of days in the past 7 days that participants engaged in any type of physical activity for at least 60 minutes that increased their heart rate or made them breathe harder than usual. Responses were categorized as ‘Less than once a week’, ‘1~2 days/week’, and ‘3 days/week or more’, and coded as 1, 2, and 0, respectively.
Eating breakfast indicates the number of days participants had breakfast in the past 7 days, excluding instances where they only had milk or juice. Responses were categorized as ‘Not eating’, ‘1~2 days/week’, ‘3~4 days/week’, and ‘5 days/week or more’, and coded as 1, 2, 3, and 0, respectively.
Sleep satisfaction refers to how refreshed participants felt after sleep during the past 7 days, regardless of sleep quantity. Responses were classified as ‘Not adequate’, ‘Moderate’, and ‘Adequate’ and coded as 1, 2, and 0, respectively.
Loneliness measures how often participants felt lonely in the past 12 months. Responses were categorized as ‘Often feel lonely’, ‘Sometimes feel lonely’, and ‘Never feel lonely’, and coded as 1, 2, and 0, respectively.
2) Family factors
Family factors included general economic status and living with family (yes or no). General economic status refers to the household’s condition, categorized as high, middle, or low, and coded as 1, 2, and 0, respectively.
‘Living with family’ indicates whether one resides with one’s family. Responses to the question “What is your current living arrangement?” were classified as ‘Yes’ if the answer was ‘Living with family’. All other responses (e.g., living with relatives, in a boarding house, alone, in a dormitory, or in a care facility) were classified as ‘No’. ‘Yes’ was represented as 0, and ‘No’ as 1.
3) School factors
School factors included academic achievement, defined as performance over the past 12 months. Responses were categorized as high, middle, or low, with high coded as 0, low as 1, and middle as 2.
5. Statistical Analyses
Data for the KYRBS were collected using a complex sample design. The KYRBS uses sampling weights based on stratification and clustering variables, which helps ensure national representativeness and reduces potential bias in the estimation process [17]. This study followed the Korea Centers for Disease Control and Prevention guidelines for complex sample analysis, using stratification variables, cluster variables, weights, and finite population correction coefficients as appropriate. Percentages and other statistical values were calculated by complex sample analysis, and the number of samples per item for each variable reflected the actual number of samples of the raw data analysis. The data were analyzed using IBM SPSS 27.0 (Armonk, NY, USA).
The specific statistical analysis methods are as follows. First, the stress reported by youth exposed to violence was analyzed using descriptive statistics. Second, the participants’ individual, family, and school factors characteristics were related to stress using complex sample crosstabulation. Third, the factors affecting the stress reported by adolescents exposed to violence were analyzed using complex sample logistic regression analysis. The model included individual factors (gender, smoking, drinking, drug misuse, physical activity, eating breakfast, sleep satisfaction, loneliness), family factors (living with family, general economic status), and school factor (academic achievement) as independent variables. The model’s explanatory power was assessed using pseudo-R2 values, with Nagelkerke R2=.242 and Cox and Snell R2=.18. The strength of associations between variables was estimated using odds ratios (ORs) with 95% confidence intervals (CIs); variables were selected using backward stepwise selection with entry and removal criteria set at p<.05 and p>.10, respectively.
RESULTS
1. Prevalence of Violence Among Adolescents
The rate of violence experienced was higher for boys (62.8%) than for girls. The most common frequency of treatment for violence among adolescents was once (49.1%), followed by three to five times (18.9%), twice (17.6%), and six or more times (14.4%) (Table 1).
Stress Variations by Individual, Family, and School Factors (N=1,494)
2. Stress Variations by Individual, Family, and School Factors
All individual, family, and school factors showed significant statistical differences between feeling less stress and feeling a lot of stress groups (Table 1). Of the individual factors examined, it was found that a higher proportion of boys (56.6%) were in the group of people who reported feeling a lot of stress. In the high-stress group, the proportion of adolescents who smoked was 29.0%, significantly higher than the 23.5% observed in the low-stress group (x2=5.90, p=.022). Similarly, the rate of drinking was 52.9% in the high-stress group compared to 46.1% in the low-stress group (x2=6.96, p=.012), and drug misuse was reported by 8.7% versus 4.9% in the respective groups (x2=8.12, p=.009). A higher proportion of physical activity more than 3 days a week was reported in the feeling less stress group (47.5%) compared to the other group (39.1%; x2=14.81, p=.001). The proportion of eating breakfast more than 3 or 4 days a week (22.7%) and 5 days a week (40.6%) was higher in the feeling less stress group than in the feeling a lot of stress group (18.1%, 36.7%; x2=15.66, p=.002). A higher proportion of inadequate sleep satisfaction was reported in the feeling a lot of stress group (56.0%) compared to the feeling less stress group (32.5%; x2=83.93, p<.001).
Regarding family factors, the majority of adolescents in both the feeling less stress (97.0%) and feeling a lot of stress groups (96.4%) lived with family (x2=7.76, p=.009) during COVID-19. A higher proportion of low economic status was reported in the feeling a lot of stress group (15.6%) compared to the other group (9.4%; x2=8.35, p=.018).
Regarding school factors, a higher proportion of low academic achievement was reported in the feeling a lot of stress group (36.3%) compared to the feeling less stress group (30.1%; x2=30.76, p<.001).
3. Factors Associated with Stress among Adolescents with Experiences of Violence
To identify factors influencing stress in adolescents who experienced violence, a complex sample logistic regression analysis was conducted by inputting variables significant in the univariate analysis (Table 2). The dependent variable was stress, with Cox and Snell R2 and Nagelkerke R2 values of .18 and .24, respectively, and a classification accuracy of 95%.
Factors Associated with Stress among Adolescents Exposed to Violence (N=1,494)
Among individual factors, physical activity, eating breakfast, sleep satisfaction, and loneliness showed significant results. Adolescents who did not engage in physical activity for a week were 1.47 times more likely to experience stress than those who exercised three or more days a week (95% CI=1.10~1.99). Similarly, adolescents who skipped breakfast had a 1.51 times higher probability of experiencing stress than those who had breakfast on five or more days per week (95% CI=1.09~2.07). In addition, adolescents dissatisfied with their sleep had a 1.95 times higher probability of having more stress than those who felt they got enough sleep (95% CI=1.38~2.74). Adolescents who sometimes or often felt loneliness had 1.95 (95% CI=1.46~2.60) and 5.31 times (95% CI=3.92~7.20) higher probability of experiencing stress, respectively, than adolescents who did not.
For family factors, living with family showed significant results. Adolescents who lived with family were 1.92 times more likely to experience stress than those who did not live with family, lived in a relative’s house, a dormitory, a care or boarding home, or were alone (95% CI=1.28~2.86).
Regarding school factors, academic achievement showed significant results. Adolescents with “low” academic achievement were 1.69 times more likely to experience stress compared to those with “high” academic achievement (95% CI=1.26~2.27).
DISCUSSION
This study identified factors influencing stress in adolescents who experienced violence during the COVID-19 pandemic, using the ecological model as a framework. Among individual factors, physical activity, eating breakfast, sleep satisfaction, and loneliness were found to affect stress levels. Family factors, particularly living with family, also impacted stress, as did school factors, with academic achievement influencing stress levels.
In this study, 55.7% of adolescents who had experienced violence reported high levels of stress. Before the pandemic, the proportion of adolescents in general who experienced significant stress was 12.7~16.0% [18], and 15.9% of adolescents who experienced violence during the COVID -19 pandemic showed deteriorated mental health, such as high stress levels [19]. This may have been due to the prolonged quarantine period, increased fear of infection, and increased stress, confusion, and emotional distress exacerbated by the lack of information in the sudden disaster situation of the COVID-19 pandemic [9].
Among individual factors, lack of physical activity, skipping breakfast, poor sleep, and loneliness were found to affect stress levels. In particular, exposure to violence during adolescence, an important period of identity formation, may increase the risk of depression and anxiety [8]. Depression and anxiety in adolescents often manifest as loss of appetite, reduced activity due to lethargy, and insomnia [20]. Reduced physical activity, skipping meals, and sleep problems may have worsened during the COVID -19 pandemic. Therefore, systematic online health behavior promotion programs that ensure regular meals, exercise, and adequate sleep may be beneficial for adolescents who have experienced violence, even in disaster situations such as COVID-19. In addition, it would be helpful to establish and provide a systematic health behavior management system that promotes emotional control, stress management, repeated psychological education, relaxation therapy, regular meals, exercise, and sleep to effectively manage the stress of youth exposed to violence in the event of a disaster [21].
In addition, loneliness among adolescents during the COVID-19 pandemic was associated with stress levels two to five times higher than those in pre-pandemic periods, with experiences of violence being a major contributing factor [14]. The isolation caused by COVID-19 measures, such as social distancing, further increased loneliness [10]. Moreover, according to previous research, adolescents who experienced violence showed 1.4~4.5 times higher levels of loneliness compared to those who did not [22]. Therefore, there is a need to provide opportunities and ways for adolescents to communicate with friends and family during quarantine, which can be isolating. Furthermore, as loneliness can be experienced throughout life, youth mental health policies need to be put in place to ensure that young people know how to recognize and manage their own emotions during adolescence.
For family factors, adolescents living with their families reported higher stress levels than those who did not during the COVID-19 pandemic. Previous studies have shown that adolescents separated from their families experience more stress due to a lack of emotional support [23]. However, during the COVID-19 pandemic, adolescents spent long periods in isolation with their families, which ap-pears to have exacerbated existing unresolved issues and increased adolescent stress [24]. In a survey of 900 adolescents in 2020, approximately 32.0% reported frequent conflicts with their parents and were stressed, and about 62.6% reported no change in their relationship with their parents despite spending a lot of time with them at home [25]. In particular, adolescents who have experienced violence may have high levels of depression [6], and unresolved issues and negative family communication patterns may exacerbate adolescent depression and increase family conflict [12]. Systematic online family counseling programs that resolve conflicts and improve communication between parents and adolescents can increase parents’ awareness of adolescent stress [5]. In addition, dialoguecentered counseling programs that respect adolescents’ opinions [26] may be effective strategies for improving adolescent-parent communication and resolving conflicts. In addition, peer support networks and alternative community spaces can help adolescents cope more effectively with family-related stress [16].
For the school factor, adolescents who experienced violence, those with high academic achievement were 1.7 times more likely to experience less stress compared to those with low academic achievement. Adolescents exposed to violence may face impaired problem-solving skills and self-regulation, leading to difficulties in cognitive development [27]. These challenges can affect their ability to concentrate in class and complete assignments, ultimately hindering their academic success. School-based Social-Emotional Learning (SEL) programs serve as protective factors that enhance emotional regulation and resilience among adolescents exposed to violence [28]. Therefore, comprehensive tailored programs should be developed that integrate these SEL approaches with mental health screenings, academic mentoring, and community support activities to not only improve academic achievement but also reduce anxiety and maladaptive behaviors in adolescents who have experienced violence.
Limitations
First, this study employed a cross-sectional design; thus, causal relationships between variables could not be established. A longitudinal study would better track how stress evolves over time among adolescents who have experienced violence. Second, data collection through selfreported surveys introduces potential social desirability bias and recall bias, which is particularly problematic when addressing sensitive topics such as violence experiences and mental health. Third, by defining violence experience as “cases requiring medical treatment,” adolescents who experienced violence but did not seek medical care may have been excluded. This definition potentially biased our sample and may not represent the full spectrum of adolescents who experienced violence. Finally, as this study used secondary data, it was not possible to control for various factors that may have influenced the stress experienced by adolescents exposed to violence. These factors include peer relationships, interpersonal conflict, family communication patterns, job instability, working from home and increased alcohol consumption at home. Despite the limitations described above, this study provides valuable insights into the stressors associated with adolescent exposure to violence based on an ecological model and highlights the importance of developing comprehensive intervention strategies that address individual, school and family factors.
CONCLUSION
This study identified factors associated with stress in adolescents who experienced violence during the COVID-19 pandemic using the ecological model. Factors increasing stress included lack of physical activity, skipping breakfast, sleep dissatisfaction, loneliness, living with family, and low academic achievement. To effectively manage stress in adolescents exposed to violence during disasters, a comprehensive stress management program addressing individual, family, school, and community is required. Programs that help resolve conflicts and enhance communication between parents and adolescents, along with counseling and psychological support services, can be effective strategies. Developing systematic health behavior management programs to ensure regular meals, exercise, and adequate sleep is essential for this population.
Notes
Goun Kim has been a member of the editorial board since January 2024, but had no role in the decision to publish this article. Except for that, no potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTIONS
Conceptualization or/and Methodology: Kim, G & Hong, J
Data curation or/and Analysis: Kim, G & Hong, J
Investigation: Hong, H
Project administration or/and Supervision: Kim, G
Resources or/and Software: Kim, G & Hong, J
Validation: Kim, G & Hong, J
Visualization: Hong, J
Writing: original draft: Hong, H
Writing: review & editing: Kim, G