Abstract

Although changes have been observed in social relationships in the recent years, especially among younger generations, little evidence is available concerning factors associated with adolescents’ perceived social relationships. In this study we investigated the association between self-perceived social relationships, health-related behaviors, biological maturation, and mental health in adolescents. This is a cross-sectional study conducted with 1,336 adolescents (605 boys and 731 girls) aged between 10 to 17 years from public schools. Self-perceived social relationships (family, friends, and teachers), feelings of stress and sadness, academic performance, tobacco smoking, alcohol and fat consumption, physical activity, and screen time were evaluated by a questionnaire. Biological maturation was assessed by the peak height velocity. We observed that worse perceived social relationships were associated with tobacco smoking (family and teachers), alcohol drinking (teachers), higher consumption of fat (teachers), greater feelings of stress (family and teachers) and sadness (family and friends), and poor academic achievement (friends and teachers).

Key words:
Mental disorders; Social support; Healthy lifestyle; Academic performance

Resumo

Apesar das mudanças observadas nos relacionamentos sociais nos últimos anos, especialmente entre as gerações mais novas, pouca evidência está disponível sobre os fatores associados à percepção dos relacionamentos sociais. Neste estudo nós investigamos a associação entre a percepção das próprias relações sociais, comportamentos associados à saúde, maturação biológica e indicadores de saúde mental em adolescentes. Este é um estudo transversal conduzido com 1.336 adolescentes (605 meninos e 731 meninas) com idades entre 10 e 17 anos, alunos de escolas públicas. A percepção dos relacionamentos sociais (família, amigo e professores), frequência de sentimentos de estresse e tristeza, o desempenho acadêmico, consumo de álcool, tabaco e alimentos gordurosos, bem como o nível de atividade física e tempo de tela foram avaliados por questionário. A maturação biológica foi estimada a partir do pico de velocidade de crescimento. Observamos que as piores relações sociais percebidas estiveram relacionadas ao consumo de tabaco (família e professores), de álcool (professores), alto consumo de alimentos gordurosos (professores), sentimentos de estresse (família e professores) e de tristeza (família e amigos) mais frequentes, e pior percepção do desempenho acadêmico (amigos e professores).

Palavras-chave:
Transtornos mentais; Apoio social; Estilo de vida saudável; Desempenho acadêmico

Introduction

Humans tend to construct relationships with their peers, developing in this way, a desire to belong¹1 Baumeister RF, Leary MR. The need to belong - desire for interpersonal attachments as a fundamental human-motivation. Psychol Bull 1995; 117(3):497-529.. When positive and significant social relationships are established, subjects tend to present greater cognitive and mental health²2 Heinrich LA, Gullone E. The clinical significance of loneliness: A literature review. Clin Psychol Rev 2006; 26(6):695-718.. However, in situations where social relationships are violated or pass through turbulent moments, individuals can perceive feelings such as loneliness and social isolation, which are negative for mental health and well-being, causing various diseases and disturbances²2 Heinrich LA, Gullone E. The clinical significance of loneliness: A literature review. Clin Psychol Rev 2006; 26(6):695-718..

Since Durkheim³3 Durkheim E. Suicide. New York: Free Press; 1951 [1987]. found that suicide rates are greater among single subjects (when compared with married persons), several investigations have presented possible paths of influence of social relationships and health, such as a meta-analysis developed in 2010 that concluded that individuals with good social relationships had a 50% greater propensity for survival compared to people with poor social relationships⁴4 Holt-Lunstad J, Smith TB, Layton JB. Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 2010; 7(7):e1000316.. In this way, good social relationships seem to be protective factors for several negative health and psychological outcomes, such as depression and anxiety⁵5 Giletta M, Scholte RHJ, Prinstein MJ, Engels RCME, Rabaglietti E, Burk WJ. Friendship Context Matters: Examining the Domain Specificity of Alcohol and Depression Socialization Among Adolescents. J Abnorm Child Psychol 2012; 40(7):1027-1043.

6 Sakyi KS, Surkan PJ, Fombonne E, Chollet A, Melchior M. Childhood friendships and psychological difficulties in young adulthood: an 18-year follow-up study. Eur Child Adolesc Psychiatry 2015; 24(7):815-826.^-77 McKercher C, Sanderson K, Schmidt MD, Otahal P, Patton GC, Dwyer T, Venn AJ. Physical activity patterns and risk of depression in young adulthood: a 20-year cohort study since childhood. Soc Psychiatry Psychiatr Epidemiol 2014; 49(11):1823-1834. and even all-cause mortality⁴4 Holt-Lunstad J, Smith TB, Layton JB. Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 2010; 7(7):e1000316.^,88 Lund R, Christensen U, Nilsson CJ, Kriegbaum M, Rod NH. Stressful social relations and mortality: a prospective cohort study. J Epidemiol Community Health 2014; 68(8):720-727.

9 JS, Landis KR, Umberson D. Social relationships and health. Science 1988; 241(4865):540-545.^-1010 Berkman LF, Syme SL. Social networks, host-resistance, and mortality - 9-year follow-up-study of alameda county residents. Am J Epidemiol 1979; 109(2):186-204.. Moreover, good social networks are related to greater healthy behaviors such as physical activity and low sedentary behavior¹¹11 Sawka KJ, McCormack GR, Nettel-Aguirre A, Hawe P, Doyle-Baker PK. Friendship networks and physical activity and sedentary behavior among youth: a systematized review. Int J Behav Nutr Phys Act 2013; 10:130., which in turn seem also to be related to psychological health¹²12 Kirkcaldy BD, Shephard RJ, Siefen RG. The relationship between physical activity and self-image and problem behaviour among adolescents. Soc Psychiatry Psychiatr Epidemiol 2002; 37(11):544-550.^,1313 Ussher MH, Owen CG, Cook DG, Whincup PH. The relationship between physical activity, sedentary behaviour and psychological wellbeing among adolescents. Soc Psychiatry Psychiatr Epidemiol 2007; 42(10):851-856..

Several pathways can connect poor perceived social relationships with negative health outcomes, given that a potential psychological mechanism may be through the adoption of healthier behaviors among persons inserted in good social relationships, which could lead to lower risk and greater well-being, when compared to their socially socially isolated individuals⁴4 Holt-Lunstad J, Smith TB, Layton JB. Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 2010; 7(7):e1000316.^,88 Lund R, Christensen U, Nilsson CJ, Kriegbaum M, Rod NH. Stressful social relations and mortality: a prospective cohort study. J Epidemiol Community Health 2014; 68(8):720-727.^,99 JS, Landis KR, Umberson D. Social relationships and health. Science 1988; 241(4865):540-545.. Another mediator could be through negative feelings caused by social isolation such as sadness, stress, and loneliness¹⁴14 Uchino BN. Social support and health: A review of physiological processes potentially underlying links to disease outcomes. J Behav Med 2006; 29(4):377-387.. Consequently, in both direct and indirect ways, bad social relationships are related to health risks⁴4 Holt-Lunstad J, Smith TB, Layton JB. Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 2010; 7(7):e1000316.^,88 Lund R, Christensen U, Nilsson CJ, Kriegbaum M, Rod NH. Stressful social relations and mortality: a prospective cohort study. J Epidemiol Community Health 2014; 68(8):720-727.. However, the correlates of social relationships from early ages in different cultural contexts are unclear. Herein, we investigated the association between self-perceived social relationships, health-related behaviors, biological maturation, and mental health adolescents.

Methods

This is a cross-sectional epidemiological school-based study in Brazilian adolescents aged between 10 and 17 years, enrolled in public schools of Londrina-PR. Londrina has 506,701 inhabitants, a medium human development index of 0.778, and a gross domestic product per capita of US$ 8,530.77 (both above the average of Brazilian cities)¹⁵15 Insituto Brasileiro de Geografia e Estatística (IBGE). Gross Domestic Product of Municipalities 2013 [Interent]. [cited 2018 May 18]. Available from: http://www.ibge.gov.br/cidadesat/xtras/perfil.php?codmun=411370&search=parana.
http://www.ibge.gov.br/cidadesat/xtras/p... . All the procedures used in the study were approved by the Research Ethics Committee of the Londrina State University, according to the Declaration of Helsinki.

Sample recruitment was performed in two stages. First, all public schools of the city were separated into regions (north, south, east, west, and center) and two schools were randomly selected from each location. Subsequently, classes of these schools were randomly selected and all students within the classes (except those using prescription medicine or undergoing treatment for an illness) were invited to participate in the study. Students who failed to return a consent form signed by parents were ineligible. Recruitment peaked at 1,395 adolescents but 59 failed to provide all required data for the analysis of this study and were excluded. Thus, the final sample was composed of 1,336 adolescents (605 boys and 731 girls).

Perception of social relationships

Self-perception about relationships with friends, families, and teachers was assessed through a questionnaire. Specifically, the questionnaire contained questions with a Likert type scale (from 1 to 4; “very unsatisfied” to “very satisfied”) and asked: “Regarding your relationship with your classmates and friends, are you?”; “Regarding your relationship with your family, are you?”; and “Regarding your relationship with your teachers, are you?”. The reproducibility of the measures was tested through repeated application (7-day interval) of the questions in 74 adolescents, which were not included in the current sample. The intraclass correlation coefficient (ICC) was calculated. For perception of social relationships, the ICCs of the questions were 0.50 (friends), 0.53 (family), and 0.69 (teachers). We classified as poor social relationships those who answered “unsatisfied and very unsatisfied” in each domain.

Sadness and stress

Sadness was also collected through a Likert type scale question: “How often you feel sad or depressed?”, options ranged from “very frequently” to “rarely” (four possibilities) with an ICC of 0.62. Likewise, stress was evaluated through a scale type question: “How often you feel stressed?”, options ranged from “very frequently” to “rarely” with an ICC of 0.80. We considered as stressed and sad, those who answered “very frequently” and “frequently” for each question.

Academic performance

To access academic performance, the participants were asked: “How do you classify your academic performance?”. Answer options ranged from “Bad” to “Great” (four possibilities) with an ICC of 0.81. We considered as low academic performance those who answered “Bad”.

Alcohol and tobacco consumption

Information on alcohol consumption and tobacco smoking was obtained in a dichotomous manner through indication of use during the previous 30 days. The ICCs for alcohol consumption and tobacco smoking were 0.74 and 0.78 respectively.

Fat consumption

The consumption of fatty food was evaluated by means of one question (ICC=0.76) concerning the frequency of consumption (no consumption, one to three days, four to six days, and seven days) during the previous week. The cutoff used for inadequate dietary pattern was the consumption of these foods on four or more days per week.

Physical activity and screen time

The Baecke questionnaire¹⁶16 Baecke JAH, Burema J, Frijters JER. A short questionnaire for the measurement of habitual physical-activity in epidemiological-studies. Am J Clin Nutr 1982; 36(5):936-942. was applied and the score proposed by the authors adopted as an indicator of physical activity (ICC=0.73). The Baecke questionnaire was not designed to propose prevalence, thus, the sample was divided into quartiles and adolescents in the highest quartile of the sample distribution were considered “active”. The screen time (ICC=0.77) in minutes per week and at the weekend was adopted as an indicator of sedentary behavior. Similar to physical activity, adolescents in the lowest quartile of screen time were considered as not sedentary.

Socio-economic status

Socio-economic status was estimated through the ABEP questionnaire¹⁷17 Associação Brasileira de Empresas de Pesquisa (ABEP). Dados com base no Levantamento Socioeconômico. São Paulo: ABEP; 2000., which considers the education of the household leader and certain possessions, providing a score based on this information. From the information reported by the parents, it was possible to categorize the participants into classes (A1, A2, B1, B2, C, D, and E). Classification in classes C, D, and E was considered as low socioeconomic status.

Biological maturation

Biological maturation was estimated through somatic maturation derived from estimated age at peak height velocity using the algorithm proposed by Mirwald et al.¹⁸18 Mirwald RL, Baxter-Jones AD, Bailey DA, Beunen GP. An assessment of maturity from anthropometric measurements. Med Sci Sports Exerc 2002; 34(4):689-694.. This method estimates distance in years from peak height velocity through anthropometric variables (stature, sitting height, leg length, and body mass). The prediction of age at peak height velocity is determined by subtracting the maturity-offset from chronological age.

Statistical procedures

Values of means and standard deviations, as well as frequencies and confidence intervals are used to characterize the sample. The Mann-Whitney’s test was used to compare general characteristics between sexes. The chi-square and chi-square for trend were used to test associations between social relationships and potential correlates. For the main analyses, binary and multinomial logistic regressions with odds ratio and 95% confidence interval were used. All analyzes were performed in software SPSS 23.0.

Results

In total, 1,395 adolescents were evaluated. However, due to missing data, 59 adolescents were excluded from the initial sample. Thus, the final sample was composed by 1,336 adolescents. Table 1 presents the general characteristics of the sample.

Table 2 presents the correlates of poor social relationships (with family, friends, and teachers). While girls were less satisfied with their relationships with friends, older adolescents showed poorer relationships with family and teachers. Early maturers presented more positive perceptions of relationships with friends and teachers. In the adjusted models (p<0.05), a lower prevalence of satisfaction with friends was observed among those who reported less screen time. Smokers and alcohol drinkers showed a poorer perception of relationships with family and teachers. In addition, poor perception of social relationships was associated with inadequate fat consumption (teachers), bad school performance (friends and teachers), and a high prevalence of feelings of sadness (family and friends) and stress (family and teachers).

The association between exposures and clusters of bad social relationships are presented in Figure 1. After the adjustment for all variables of the model, we found that while the highest fat consumers (OR (CI95%)=1.56 (1.19 to 2.03)) and those delayed in maturation (OR (CI95%)=1.98 (1.21 to 3.25)) were more likely to report dissatisfaction with at least one social relationship, adolescents with the worst academic performance (OR (CI95%)=3.82 (2.51 to 5.82)), tobacco smokers (OR (CI95%)=3.45 (1.74 to 6.84)), the saddest (OR (CI95%)=2.53 (1.64 to 3.90)), and the most stressed (OR (CI95%)=2.37 (1.52 to 3.70)) were more likely to report dissatisfaction with more than one social relationship.

Discussion

Our aim was to verify the association between self-perceived social relationships and health-related behaviors, biological maturation, and mental health in adolescents. We found that adolescents who presented bad perceptions of social relationships demonstrated a greater prevalence of unhealthy habits (tobacco smoking, alcohol drinking, and higher fat consumption), worse perceived academic performance, and greater feelings of sadness and stress. Being inserted in good social relationships seems to protect against several negative health outcomes. Studies have shown associations between social inclusion/support and all-cause mortality¹⁰10 Berkman LF, Syme SL. Social networks, host-resistance, and mortality - 9-year follow-up-study of alameda county residents. Am J Epidemiol 1979; 109(2):186-204.^,1919 Barger SD. Social Integration, Social Support and Mortality in the US National Health Interview Survey. Psychosom Med 2013; 75(5):510-517.^,2020 Becofsky KM, Shook RP, Sui X, Wilcox S, Lavie CJ, Blair SN. Influence of the Source of Social Support and Size of Social Network on All-Cause Mortality. Mayo Clin Proc 2015; 90(7):895-902.. Thus, our finding shows potential behavioral, biological, and physiological pathways that could link social relationships and negative outcomes among adolescents.

We observed that adolescents who smoked tobacco and related using alcohol were more likely to report bad perceptions of social relationships with family and teachers. Instead, adolescents who are inserted in good social relationships tend not to present these negative habits. It was demonstrated that adolescents who present unhealthy and alternative behaviors tend to be discriminated against and could develop poor social perception²¹21 Seo D-C, Huang Y. Systematic Review of Social Network Analysis in Adolescent Cigarette Smoking Behavior. J Sch Health 2012; 82(1):21-27.^,2222 Roberts ME, Nargiso JE, Gaitonde LB, Stanton CA, Colby SM. Adolescent Social Networks: General and Smoking-Specific Characteristics Associated With Smoking. J Stud Alcohol Drugs 2015; 76(2):247-255.. This is probably related to the specific laws in each country. In Brazil, for example, alcohol consumption and tobacco smoking are prohibited for individuals under 18 years-old, which might explain the dissatisfaction with social actors who flout this. In this sense, given that adolescents tend to create relationships with subjects with similar lifestyles and habits²³23 Fisher LA, Bauman KE. Influence and selection in the friend-adolescent relationship - findings from studies of adolescent smoking and drinking. J Appl Soc Psychol 1988; 18(4):289-314., no association with these unhealthy behaviors and perceived relationships with friends was observed.

We also found that adolescents who reported higher fat consumption were more likely to present at least one poor social relationship, especially with teachers. A previous study reported that adolescents with high consumption of fast-foods presented a lower perception of general quality of life²⁴24 Walther J, Aldrian U, Stuger HP, Kiefer I, Ekmekcioglu C. Nutrition, lifestyle factors, and mental health in adolescents and young adults living in Austria. Int J Adolesc Med Health 2014; 26(3):377-386., and food practices are related to social relationships²⁵25 Neely E, Walton M, Stephens C. Young people's food practices and social relationships. A thematic synthesis. Appetite 2014; 82:50-60.. On the one hand meals with family tend to be healthier and could explain an association with satisfaction with family; however, the relation between fat consumption and satisfaction with teachers is curious and unclear. It is probably this relates to the link between health behaviors and academic performance, however further studies are needed.

Another interesting finding concerned screen time. Even though sedentary behavior is positively associated with cardiovascular risk factors²⁶26 Martinez-Gomez D, Eisenmann JC, Gomez-Martinez S, Veses A, Marcos A, Veiga OL. Sedentary Behavior, Adiposity and Cardiovascular Risk Factors in Adolescents. The AFINOS Study. Rev Esp Cardiol 2010; 63(3):277-285., we found that adolescents with higher screen time were less likely to present a bad perception of relationships with friends. A possible explanation for this finding is the association between some types of screen time (e.g., videogames and online games) and socialization among adolescents¹¹11 Sawka KJ, McCormack GR, Nettel-Aguirre A, Hawe P, Doyle-Baker PK. Friendship networks and physical activity and sedentary behavior among youth: a systematized review. Int J Behav Nutr Phys Act 2013; 10:130.^,2727 Granic I, Lobel A, Engels RCME. The Benefits of Playing Video Games. Am Psychol 2014; 69(1):66-78..

Considering a biological correlate, we found that early maturing adolescents were more satisfied with their friends and teachers. This bio-social relationship has been poorly studied, but it is supposed that adolescents who are advanced in the biological process (e.g., height, body mass, muscular strength)²⁸28 Malina RM, Bouchard C, Bar-Or O. Growth, Maturation, and Physical Activity. 2nd ed. Champaign: Human Kinetics; 2004. have greater social acceptability and social networks²⁹29 Cumming SP, Sherar LB, Gammon C, Standage M, Malina RM. Physical Activity and Physical Self-Concept in Adolescence: A Comparison of Girls at the Extremes of the Biological Maturation Continuum. J Res Adolesc 2012; 22(4):746-757.. The early development of secondary sexual characteristics could also be related with greater success among peers³⁰30 Reynolds BM, Juvonen J. The Role of Early Maturation, Perceived Popularity, and Rumors in the Emergence of Internalizing Symptoms Among Adolescent Girls. J Youth Adolesc 2011; 40(11):1407-1422.^,3131 McCabe MP, Ricciardelli LA. A longitudinal study of pubertal timing and extreme body change behaviors among adolescent boys and girls. Adolescence 2004; 39(153):145-166..

Perceived social relationships were also related to mental health indicators. Adolescents who reported a greater frequency of feelings of sadness were more likely to be dissatisfied with their relationships with family and friends. Moreover, those with higher stress were less satisfied with their relationships with family and teachers. The explanation for these findings could be two-fold although we cannot confirm this in a cross-sectional designed study. People might develop a worse mental health condition since they are not satisfied with their social cycle or, in another path, people with poor mental health tend to perceive or create worse social relationships. This situation could be more drastic in adolescence, considering this is a period with great changes in school, romantic relationships, biological maturation, and responsibilities, among others³²32 Calvete E, Cardeñoso O. Gender differences in cognitive vulnerability to depression and behavior problems in adolescents. J Abnorm Child Psychol 2005; 33(2):179-192.^,3333 Hankin BL, Mermelstein R, Roesch L. Sex differences in adolescent depression: stress exposure and reactivity models. Child Dev 2007; 78(1):279-295.. Thus, given the high prevalence of mental disorders and their relationship with perceived social relationships, surveillance and promotion of social support during this phase should be mandatory³⁴34 Prado CV, Lima AV, Fermino RC, Añez CR, Reis RS. Social support and physical activity in adolescents from public schools: the importance of family and friends. Cad Saude Publica 2014; 30(4):827-838..

Based on our findings, adding that unhealthy habits are correlated, multi-behavioral strategies aiming to decrease alcohol consumption, tobacco smoking, fat consumption, and other negative behaviors should be adopted. Previous studies showed that simple counseling could provide positive results for reducing alcohol consumption and unhealthy dietary patterns³⁵35 Steinka-Fry KT, Tanner-Smith EE, Hennessy EA. Effects of Brief Alcohol Interventions on Drinking and Driving among Youth: A Systematic Review and Meta-analysis. J Addict Prev 2015; 3(1):11.^,3636 Werch CE, Bian H, Carlson JM, Moore MJ, DiClemente CC, Huang IC, Ames SC, Thombs D, Weiler RM, Pokorny SB. Brief integrative multiple behavior intervention effects and mediators for adolescents. J Behav Med 2011; 34(1):3-12.. However, broader and multilevel interventions need to be conducted in school-based environments³⁷37 Busch V, de Leeuw JRJ, de Harder A, Schrijvers AJP. Changing Multiple Adolescent Health Behaviors Through School-Based Interventions: A Review of the Literature. J Sch Health 2013; 83(7):514-523..

This study has limitations that should be pointed out. Firstly, since the Likert scale questions were used for perceived social relationships, adolescents with poor mental health and/or who were unsatisfied with just one social relationship, may have tended to report worse perceptions of other social relationships (instrument effect). In addition, a cross-sectional design could lead to possible reverse causality relationships between exposures and outcomes. In this sense, it is not clear if unhealthy behaviors and poor mental health could lead the subject to poor perceived social relationships or vice-versa. Therefore, we cannot point causality. On the other hand, we tested and showed the reproducibility indicators of the questionnaire used. Given that perceived social relationships reflect the actual perceptual moment of the adolescent, we observed acceptable values for teachers (0.69), but relatively moderate to low values for family (0.53) and friends (0.49). Similarly, the reproducibility of self-perception of stress (0.80) and sadness (0.62), as well as fat consumption (0.74), tobacco smoking (0.78), alcohol consumption (0.89), and screen time (0.79) were acceptable. In addition, we used an objective and valid indicator of somatic maturation³⁸38 Mirwald RL, Baxter-Jones ADG, Bailey DA, Beunen GP. An assessment of maturity from anthropometric measurements. Med Sci Sports Exerc 2002; 34(4):689-694., which allowed a rare analysis of social-biological interaction. Thus, given the context of the study and sample size, the current findings contribute to the understanding of the association between social, behavioral and biological variables among adolescents, especially in the context of low-to-middle income countries.

Finally, we conclude that self-perceived social relationships are related to health risk behaviors, mental health, and academic performance in adolescents. Adolescents who smoked tobacco, had a higher consumption of alcohol and fat, greater screen time, delayed maturation, with greater feelings of stress and sadness, and poor academic achievement were more likely to be dissatisfied with their social relationships.

References

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