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Association between physical activity and mental health among high-school adolescents in Boushehr province: A population based study.

Objective Mental health is one of the evaluating factors of community indicators, and physical activity is considered an important tool for the importance of public health. Previous studies have demonstrated associations between physical activity and mental health, but these studies did not include those populations in which training children have some traditional and religious aspects. Methods Multiple logistic regression analyses were used to compare the prevalence of mental health among those who had inactive, minimally and HEPA activity in a representative sample of adolescents aged 15–19 in South of Iran using data from the Mental Health Survey (n=2584). The GHQ-28 and IPAQ-short forms were used to evaluate the mental health and physical activity, respectively. Results A total of 2584 adolescents (1401 male and 1178 female) participated in the study. The observed odds of psychological symptoms in boys compared to girls is 1.2 times (p=0.018). We observed that HEPA-activity decreases odds of somatic distress and social dysfunction compared with inactivity (p=0.031 and 0.001, respectively); minimally activity decreases odds of anxiety compared with inactivity (p=0.038); but physical activity rate was not affected on odds of adolescent's depression (p>0.05). Conclusion Physical activity decreases mental health subscales except for depression among adolescents in Boushehr, southern city of Iran.

depression in childhood and adolescence has increased (8,9). Although in previous decades it was believed that depression did not occur in adolescents, recent prevalence studies have suggested that 2% to 8% of young people experience their first episode of major depression by age 16 (10)(11)(12)1). Also, American surgeon general assembly report in 1999 showed that 74 percent of adolescents suffer from mental disorder (13). Despite the increasing burden of common mental disorders (anxiety and depression) in society, few data are available on the relation between physical activity and mental health (14)(15)(16)(17)(18)(19)(20). The aim of this paper is to examine the association between physical activity and mental health using a population-based study among adolescents in a city in south of Iran (Boushehr), with a religious community.

Mental Health Study
We used data from the Mental Health Study (MHS), a population based study of adolescents in Boushehr Province (South of Iran) in 2005. The MHS was conducted on 2697 high-school students aged 15-19 years. Multi-stage random sampling technique was used in the MHS, where number of students was determined by proportion sampling method based on male and female students in counties and schools, and also by student grade. Data were collected by a questionnaire with four sections. Section one included demographic characteristics (e.g. age, sex, educational level, students' field) and some of socio-economic factors (e.g. parent educations, family income, parent job, visit relatives, hours watching TV); section two included 28-item of General Health Questions (GHQ-28); section three included questions of International Physical Activity Questionnaire; and section four included food consumption pattern questionnaire (21). Mental health was measured using the 28-item General Health Questionnaire (GHQ-28) that is a screening instrument for psychiatric disorders (22,23). The Iranian version of the GHQ-28 (24) was also used to estimate mental health state. GHQ-28 (25) is a 28item self-rating questionnaire addressing a range of psychological symptoms, including anxiety, depression, somatic symptoms, and social dysfunction. The questionnaire determines whether respondents have experienced a particular symptom or behavior recently. The 28-items GHQ is scored on a four point Likert-type scale according to a 0-1-2-3 system (i.e., less than usual, no more than usual, rather more than usual, or much more than usual). Therefore, minimum and maximum score based on the Likert scale is zero and 84, respectively. In this study, the cut-point was 23 with reliability coefficient of 88 per cent (23). Before use, the GHQ-28 was translated into Persian based on Iranian culture by Tehran Psychiatric Institute. Multi-stage random sampling technique was used in MHS, and trained interviewers conducted faceto-face interviews using a questionnaire. Subjects were selected by proportional stratified sampling method in each stage based on number of students in counties, their sex and educational level. Questioners were educated in 2 three hour sessions. Questionnaires were supplemented by students. The MHS was conducted one month prior to the students' examinations or quizzes, and the 12th graders were excluded because of their final quizzes and examinations.

Assessment of Levels of Physical Activity
The short-form of the Iranian version of the International Physical Activity Questionnaire (IPAQ)(26) was used to estimate levels of physical activity. The IPAQ short form assesses physical activity about three specific types of activity (walking, moderate-intensity activities and vigorous-intensity activities performed for at least 10 minutes per session) undertaken in four domains including: a) leisure time physical activity; b) domestic and gardening activities; c) work related physical activity; d) transport related physical activity (2). Weekly minutes of walking, and moderate-intensity and vigorous intensity activities, were calculated separately by multiplying the number of days per week in which the activity took place by the duration of the activity in an average day. The three levels of physical activity used to classify populations were "inactive," "minimally active," and "HEPAactive". These categories were based on standard scoring, as follows. "Moderate active" is more than the minimum level of activity recommended for adults in current public health recommendations. "HEPAactive" can be computed for people who exceed the minimum public health physical activity recommendations, and are accumulating enough activity for a healthy lifestyle.

Statistical Analysis
Statistical significance was set at 0.05, and the unit of analysis was students. All tests were two-sided. Frequency distributions, percents, confidence intervals and odds ratios were determinate to describe the data. Multiple logistic regression analyses were used to determine the association between physical activity and mental health subscales, adjusting for sex, subjects' educational level, parent education, and family income.

Results
A total of 2584 adolescents (1401 male and 1178 female) participated in the study. The study showed that the prevalence of psychological symptoms among girls was significantly higher than boys. In other words, the odds of psychological symptoms in girls compared to boys is 1.2 times (p=0.018; Table 1   In the population studied, we observed that high physical activity (HEPA-activity) decreases odds of somatic distress and social dysfunction compared with inactivity (p=0.031 and 0.001, respectively; Table3); minimally activity decreases odds of anxiety compared with inactivity (p0.038; Table3). Iranian J Psychiatry 6:3, Summer 2011

Table2. Distribution of sex ratio in different levels of physical activity and mental health subscales among southern adolescent of Iran
In this study, inactivity was reported more often by females (p=0.003; Table2). However, proportion of boys was more than girls in the other levels of physical activity (p<0.001; Table2). The results showed that adolescent boys only in one of the mental health subscales, social dysfunction, had more problem than girls (p=0.003; Table2). Somatic distress and anxiety prevalence in girls were larger than boys (p<0.001; Table2). Depression prevalence in girls and boys was not different (p=0.728; Table2).

Discussion
The results of this study on young people 15 to 19 years was conducted in the city of Boushehr in south of Iran. The fact that they were brought up in religious families, indicate that the proportion of the adolescents with a high GHQ-28 score was high (40.7%), although we applied a highly conservative cut-off point, suggesting the existence of really serious mental problems. Although the percentage of psychological symptoms obtained in this study is less compared with some other studies (12,27,28), still it is larger than many studies (29). One of the reasons for the high prevalence of psychological symptoms among young people in this study compared with other studies may be that the subjects completed the questionnaire by themselves. Another reason for these high GHQ-28 scores could be the particular age group of the study sample. Adolescence is a stressful period of life. This period imposes many challenges to adolescents such as finding personality and values, and respect for self and others (29). In addition, the impact of the pressure of university entrance exam should also be considered. Adolescents in Iran are placed under the additional pressure of preparing themselves for the national university entrance exam. According to the results, young girls are more prone to mental health problems than young boys (OR=1.217, p=0.018; Table1). We observed that distribution of mental health subscales among boys and girls are not the same except for symptoms of depression. The higher risk of mental health problems among girls has been found in many investigations (29 -30). One of the reasons for the gender difference may be varying between societies with different cultures (31). In Iran, more limitations are exerted by society and families on girls compared with boys. As expected, boys reported higher physical activity than girls in the study. Sex ratios were not similar at different levels of physical activity (Table2), so most adolescent girls had low physical activity level (e.g. walking) in Boushehr. A number of studies have demonstrated similar gender differences in physical activity (32,33). Female exercising is very important as in menopause age, women could experience osteoporosis and many other diseases; so, it may lead to increased incidence of chronic diseases (e.g. mental disorders, cardiovascular disease, diabetes and Etc.) in the following years.
In this study, we observed that high physical activity (HEPA-activity) only decreases odds of somatic distress and social dysfunction compared with inactivity (p<0.05); and also, minimally activity decreases odds of only anxiety subscale compared with inactivity (p>0.05; Table3). In this study, such as Sadeghian's study (34), it was observed that increased levels of education will cause GHQ-28 score to increase.

Conclusions
This study shows that mental health problems are very serious in adolescents in the religious and traditional southern community/ city of Iran (Boushehr province). This study also indicates that physical activity decreases mental health subscales rates, except for depression. Furthermore, this study reveals that sport programs could help adolescents to improve their problem-solving skills and enhance their coping strategies with mental health problems, and even to prevent the onset of psychological symptoms.