| |

Received: 22 April 2020    Revised: 25 September 2020    Accepted: 29 September 2020

DOI: 10.1002/brb3.1899

ORIGINAL RESEARCH

Effects of psychosocial and socio-environmental factors on

anxiety disorder among adolescents in Bangladesh

Md. Mostaured Ali Khan1,2  | Md. Nuruzzaman Khan3,4

1
Department of Population Science and
Human Resource Development, University Abstract
of Rajshahi, Rajshahi, 6205, Bangladesh Background: Anxiety is a common psychiatric disorder among adolescents in devel-
2
Practical Action, MEL and Research,
oping countries. This study aimed to examine the risk factors of anxiety disorder and
Dhanmondi, Dhaka, 1205, Bangladesh
3
Research Centre for Generational Health
the adverse consequences of anxiety disorder among adolescents in Bangladesh.
and Ageing, School of Public Health and Methods: A total of 2,989 adolescent data of the 2014 Global School-based Student
Medicine, Faculty of Health and Medicine,
The University of Newcastle, Callaghan,
Health Survey (GSHS), Bangladesh, was analyzed WHO. The prevalence of anxi-
NSW, Australia ety disorder across psychosocial and socio-environmental factors was calculated as
4
Department of Population Science, descriptive statistics, whereas their effects on occurring anxiety disorder were de-
Jatiya Kabi Kazi Nazrul Islam University,
Mymensingh, 2220, Bangladesh termined using the unadjusted and adjusted multivariable binary logistic regression
model. The consequences of anxiety disorder were also determined using the multi-
Correspondence
Md. Mostaured Ali Khan, Department of variable binary logistic regression model.
Population Science and Human Resource Results: The prevalence of anxiety disorder was 4.7%, which was found higher among
Development, University of Rajshahi,
Rajshahi-6205, Bangladesh. female than their male counterparts. The psychosocial factors were found associated
Email: mostaured.khan@gmail.com with the anxiety disorder are loneliness (AOR: 2.26, 95% CI: 1.08–4.72), being bullied
(AOR: 6.00, 95% CI: 3.14–11.47), and physical abuse (AOR: 2.12, 95% CI: 1.07–4.21).
Moreover, poor understandings with parents (AOR: 1.75, 95% CI: 1.02–3.01) and lack
of peer support (AOR: 2.23, 95% CI: 1.18–4.23) were the socio-environmental fac-
tors that found associated with the anxiety disorder. Subgroup analysis across gender
found these associations were consistent for adolescent male and female. Moreover,
the likelihood increased with the increasing number of the adverse psychosocial, or
socio-environmental factors.
Conclusions: Around 5% of school-going adolescents in Bangladesh reported anxiety
associated with the exposure of single or multiple adverse psychosocial and socio-
environmental factors including bullying and physical abuse. Early screening and in-
terventions are essential, targeted to adolescent at risk, which could reduce the rate
of anxiety disorder among adolescent in Bangladesh.

KEYWORDS

adolescents, adverse childhood experiences (ACE), anxiety disorder, Bangladesh

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. Brain and Behavior published by Wiley Periodicals LLC

Brain and Behavior. 2020;10:e01899.  wileyonlinelibrary.com/journal/brb3 |

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https://doi.org/10.1002/brb3.1899
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1 |  I NTRO D U C TI O N found associated with increased risk of the anxiety disorder (Hoge
et al., 2017), mainly due to lack of emotional regulation skills and
Understanding adolescent psychological problems are turning into social attachments (Hoge et al., 2017).
a growing need for the global health and safety concern, of which Around 7 million people, represents around 4.4% of the total
anxiety disorder is very crucial. It includes a set of mental sicknesses population in Bangladesh, faces different forms of the anxiety disor-
that characterized by excessive fear (that could be unrealistic), der (WHO, 2017b). The World Health Organization in 2017 reported
worry, obsessive thoughts, and sleep disturbance due to worry or this prevalence was 5% among adolescent, a group that represents
fear (Joyce-Beaulieu & Sulkowski,  2016; Parekh,  2019). The 2017 around 10.2% of the total Bangladeshi population (WHO,  2017a).
Global Burden of Disease Study found around 284 million (3.8%) However, the factors associated with such higher prevalence of
people is suffering from different types of anxiety disorder world- anxiety disorder among adolescent in Bangladesh are mostly un-
wide, with a 32.3% increase from 1990 to 2017 (James et al., 2018). known. There are relatively few studies on this aspect that have
Around 23% of these population with the anxiety disorder live in been conducted in Bangladesh identified some specific factors (e.g.,
South-East Asian countries (WHO, 2017a). This prevalence is even physical violence, poor partner relationship, etc.) of anxiety in the
higher among adolescent at around 6% prevalence worldwide which antepartum period (Nasreen et  al.,  2010, 2011). A few other stud-
further varies across regions (WHO, 2017a) and gender (prevalence ies identified factors associated with mental disorders and their
is higher among female than male adolescent) (James et  al.,  2018; associated comorbidities (Hossain et al., 2014). Moreover, a recent
WHO, 2017a). study found that around 11% of adults in Bangladesh were suffered
There are several forms of anxiety disorder reported worldwide. from anxiety disorder (Sadiq et  al.,  2019). Importantly, these stud-
These are generalized anxiety disorder (GAD), social anxiety disor- ies were also equivocal concerning the prevalence of the anxiety
der, panic disorder, obsessive-compulsive disorder (OCD), phobias, disorder and its associated factors. Moreover, global level studies
and post-traumatic stress disorder (PTSD). Their symptoms are dif- found a different set of factors associated with the anxiety disor-
ferent and could be ranged from mild to severe (WHO, 2017a), how- der (e.g., bullying, poor peer support, etc.) than the factors reported
ever, each form affects adolescent education and social and family in these Bangladeshi studies (Bandelow & Michaelis,  2015; James
lives substantially (Creswell et al., 2014). Consequently, it increases et  al.,  2018; Lee et  al.,  2007). Moreover, so far no study has been
the risks of lower self-esteem, depression, tobacco use, illicit drug conducted to assess the risk of anxiety disorder in case of multiple
dependence, and suicidal behavior (Essau et  al.,  2014; Lawrence adverse events, such as a person faces more than one adverse psy-
et al., 2017; Lee & Hankin, 2009). These are challenging for adoles- chosocial or socio-environmental risk factors at a time, though this
cent healthy life and development; extensive work and continued ef- scenario is common in Bangladesh.
forts are therefore important to identify the factors associated with This study is therefore conducted to identify the prevalence of
anxiety disorders. This could help the policymakers and planners to anxiety disorder among adolescent of Bangladesh and its associated
take evidence-based policies targeting to reduce anxiety disorder individual, psychosocial or socio-environmental risk factors. Effects
among adolescent. of anxiety disorder on different adverse consequences among ado-
A limited number of studies have been conducted to date lescents in Bangladesh are also determined.
aiming to identify the etiology and determinants of anxiety dis-
order; however, these were mainly for adulthood (aged 21  years
or more). They found a gender difference in the occurrence of 2 | DATA A N D M E TH O D O LO G Y
anxiety disorder, girls were more likely to reported anxiety disor-
der than boys (Essau et al., 2014). Other important determinants 2.1 | Sample design
of anxiety disorder identified were different intrinsic, familial,
and social environmental factors. These were lack of family sup- Data from the 2014 Bangladesh Global School-based Student Health
port, parental and school aversiveness, poor understanding with Survey (GSHS) were analyzed (2018). The World Health Organization
parents, interparental conflicts (Cardamone-Breen et  al.,  2017), (WHO) conducts this survey in 44 developing countries whereas the
parents with a mental disorder (Ghandour et  al.,  2019), low peer Centers for Disease Control (CDC), USA provided financial and tech-
relationship, lower number of a close friend, and relational vic- nical supports. The primary target group was adolescent. The survey
timization (Pickering et  al.,  2019; Siegel et  al.,  2009). Excessive used a two-stage stratified cluster sampling technique. Schools were
stress, loneliness (both social and emotional), and experience of selected at the first stage through probability proportional to enroll-
peer victimization or bullying (physical, verbal, or psychological) ment size, whereas classes in each selected school were selected in
were also found to be associated with the increased risk of de- the second stage through random sampling. Finally, students study-
veloping adolescent anxiety disorder (Acquah et  al.,  2016; Alisic ing in the selected classes (class 7–10, age 11–18) were selected and
et  al.,  2014; Swearer & Hymel,  2015). Abuse, both physical and interviewed using a conventional school-based questionnaire mod-
mental, was also found as a significant determinant of the anx- ule. Every student in the selected classes was eligible to participate
iety disorder (Rehan et  al.,  2017). Moreover, the excessive use in the survey, whereas they were completed a self-administered
of digital and social media, including Facebook, Twitter, etc., was questionnaire. Broad description regarding this survey and sampling
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procedure can be found in the WHO’s webpage (https://www.who. Asante et al., 2017; Khan et al., 2020; Pickering et al., 2019; Randall
int/ncds/surve​illan​ce/gshs/en/) (WHO, 2018). et al., 2014; Swearer & Hymel, 2015). The forward regression model
was then used to select the explanatory variables for this study. We
also checked the multicollinearity of the selected variables using
2.2 | Sample size variance inflation factor (VIF) and dropped the relevant variable if
evidence of multicollinearity was found (the VIF values were <2 in
A total of 2,978 adolescent responds to the question of anxiety dis- all variables included in this study). The complete list of explanatory
order was included in this study. This sample extracted from 2,989
adolescent interviewed in the survey. The interviewed adolescent was variables, their categories, and coding are presented in Table 1.
asked several questions related to dietary behaviors, mental health, Moreover, of the explanatory variables were selected finally for
physical activity, sexual behaviors, tobacco, alcohol, and drug use. this study, we have classified relevant variables in two broad cat-
egories: psychosocial factors and socio-environmental factors. We
then count the number of adverse responses under each category to
2.3 | Outcome variables calculate Multiple Adverse Experience (MAE) scores. For instance,
if a person had three adverse experiences then the MAE score was
Anxiety disorder among adolescent was our primary outcome of 3. We followed the Adverse Child Experience (ACE) score genera-
interest. During survey, each interviewed adolescent was asked, tion procedure to calculate MAE score. The ACE score generation
“During the past 12 months, how often have you been so worried or procedure was developed and designed by Kaiser Permanente in
panic about something, or you could not sleep at night due to tension collaboration with the Centers for Disease Control and Prevention,
or panic?”. Responses were recorded in 5 points Likert scale: never conducted from 1995 to 1997 (Felitti et al., 1998).
(1), rarely (2), sometimes (3), most of the time (4), and always (5). We
recoded these responses to create dichotomous anxiety disorder
variable: Yes [1] versus No [0]. Respondents responded either most 2.5 | Statistical analysis
of the time (4) and always (5) were recorded as “Yes” to anxiety dis-
order, and otherwise considered as “No” response to anxiety disor- Unadjusted and age-adjusted prevalence of anxiety disorder were
der. The classification was done based on previous research (Asante calculated across psychosocial and socio-environmental factors.
et al., 2017; Randall et al., 2014). Age-adjusted prevalence was calculated using the age-standardized
We have also selected five adverse outcome variables avail- weights derived from the national population and housing census
able in the dataset to see their associations with the anxiety dis- of Bangladesh 2011. The association between the anxiety disorder
order. These were suicide ideation (yes, no), suicide plan (yes, no), and different individual, psychosocial and socio-environmental fac-
suicide attempts (yes, no), alcohol use (yes, no), and drug use (yes, tors was determined using a multivariable binary logistic regression
no). Information on suicide plan, ideation, and attempt was collected model. Both unadjusted and adjusted model were considered. The
by asking the respondents “how many suicide plans, ideations, or at- anxiety disorder variable with a specific variable was considered in
tempts they had taken in past 12 months?”. Response options were the unadjusted model, whereas anxiety disorder variable was con-
never (1), rarely (2), sometimes (3), most of the time (4), and always sidered with all individual, psychosocial and socio-environmental
(5). Responses recorded were recoded positively to use in this study factors in the adjusted model. A set of five different multivariable
if respondents’ reported any suicide plan, ideation, or attempt, oth- binary logistic regression models was also used to the association
erwise recoded as negative response to the respective questions. between anxiety disorder with suicide ideation, suicide plan, suicide
Information on alcohol use was collected by asking the respondents attempt, alcohol use, and drug use adjusting with possible confound-
“how many times drank alcohol in past 30 days? At least one drink of ers. Complex survey design and sampling weights were considered
alcohol during this period was considered positive response to alco- in all analyses. We have done these analyses following imputation
hol use. Similarly, adolescents drug use information was collected by of the missing value (if any and not more than 5%) for explanatory
asking the respondents about how many times they had taken any variables using logistic regression model (Khan et al., 2020; Sterne
drugs (cannabis, amphetamine, etc.) in lifetime and recoded as “1” if et al., 2009). The STATA program version 13.0 SE (StataCorp. LP) was
they ever used, otherwise “0”. used for all analyses.

2.4 | Explanatory variables 3 | R E S U LT S

A set of socio-demographic, psychosocial, and socio-environmental 3.1 | Prevalence of anxiety disorder

factors were used as the explanatory variables, which were se-
lected in two stages. A list of explanatory variables was first gen- Table 2 represents the unadjusted and age-adjusted preva-
erated by reviewing the relevant literature (Arat & Wong,  2016; lence of anxiety disorder across individual, psychosocial, and
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TA B L E 1   The complete list of

Variables Category Variable type
independent variables
Age 11–17 years (coded Demographic
categorically) variables
Gender 1 = Male
2 = female
School grade 1 = Class VII
2 = Class VIII
3 = Class IX
4 = Class X
Food insecurity (useful proxy of 0, No = Never/rarely/
socioeconomic status)a  sometimes
1, Yes = Most of the time/
always
Lonelinessb  0, No = Never/rarely/ Psychosocial risk
sometimes factors
1, Yes = Most of the time/
always
Bullieda  0, No = Never
1, Yes = One or more days
No close friends 0, No = Have at least one
close friend
1, Yes = No close friends
Ever sexual intercourse 0, No
1, Yes
a
Smoke cigarette or other tobacco   0, No
(including marijuana) 1, Yes = One or more days
b
Physically abused   0, No
1, Yes = One or more times
a
Parents rarely check homework   0, No = Never/rarely/ Socio-environmental
Poor understanding with parentsa  sometimes factors
1, Yes = Most of the time/
Poor parental monitoringa  always
Lack of positive peer support a 
Truancya 
Parental tobacco or drug abuse 0, No
1, Yes
a
In past 30 days.
b
In the past 12 months.

socio-environmental factors. The unadjusted and age-adjusted prev- disorder with the increase of the number of adverse psychosocial,
alence of adolescent anxiety disorder were 4.7% and 5.0%, respec- and socio-environmental factors.
tively. The prevalence was higher among Grade 10 (14.6%) and male
(6.6%) students. Prevalence was also found higher among students
reported loneliness (17.8% vs. 3.4%), being bullied (13.8% vs. 2.0%), 3.2 | Risk factors of anxiety disorder
sexual experience (37.0% vs. 3.8%), and smoke cigarette or other to-
bacco (43.1% vs. 3.4%) than those adolescents who did not experi- The association of adolescent's anxiety disorder with adolescents’
ence such adverse factors. The age-adjusted prevalence of anxiety adverse experiences is presented in Table 3. We found a higher odds
disorder was found around double among the students whose par- of anxiety disorder among female adolescents (AOR: 2.06, 95% CI:
ents rarely check homework (7.3% vs. 3.4%), who lacked peer sup- 1.12–3.77) compared to male adolescent. Students reported loneli-
port (7.3% vs. 4.2%), and who reported their parents to use tobacco ness (aOR: 2.26; 95% CI: 1.08–4.72), being bullied (aOR: 6.00; 95%
and drugs (10.6% vs. 3.9%) than their counterpart. Moreover, we CI: 3.14–11.47), and physically abused (aOR: 2.12; 95% CI: 1.07–4.21)
found a cumulative increase of age-adjusted prevalence of anxiety reported higher odds of anxiety disorder than their counterparts.
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TA B L E 2   Prevalence of anxiety disorder according to different TA B L E 2   (Continued)

socio-demographic and adolescent's adverse experiences in
Prevalence of anxiety in adolescents (%,
Bangladesh: Global School-Based Health Survey (GSHS), 2014
95% CI)
(n = 2,978) Background
characteristics Unadjusted Age-adjusted
Prevalence of anxiety in adolescents (%,
95% CI) 1 2.8 (1.6–4.8) 1.6 (1.1–2.4)
Background
characteristics Unadjusted Age-adjusted 2 5.7 (3.5–8.9) 5.6 (1.4–9.7)
≥3 14.7 (10.3–20.8) 25.8 (7.7–44.0)
Prevalence of anxiety 4.7 (3.6–6.1) 5.0 (2.5–7.5)
disorder Socio-environmental factors

Age Parental rarely homework check

11–12 4.3 (1.3–13.3) 4.3 (0.8–9.3) No 4.2 (2.6–6.8) 3.4 (0.6–6.2)

13 5.2 (3.4–7.7) 5.1 (3.1–7.2) Yes 5.3 (4.1–6.8) 7.3 (3.2–11.4)

14 4.1 (2.7–6.1) 4.1 (2.4–5.7) Poor understanding with parents

15 4.4 (2.9–6.7) 4.4 (2.5–6.2) No 3.7 (2.3–5.9) 4.1 (1.0–7.4)

16–18 7.1 (2.2–20.8) 7.1 (1.7–15.2) Yes 5.6 (4.2–7.5) 5.9 (3.4–8.1)

School grade Poor parental monitoring

Class VII 4.9 (3.2–7.5) 3.2 (1.1–5.4) No 5.3 (3.5–8.1) 6.1 (2.4–9.8)

Class VIII 5.0 (3.3–7.5) 4.3 (1.7–8.4) Yes 4.2 (3.1–5.8) 5.1 (3.5–9.8)

Class IX 3.8 (2.6–5.4) 2.1 (1.2–2.9) Lack of peer support

Class X 5.0 (2.1–11.6) 14.6 (4.4–33.6) No 3.8 (2.9–5.0) 4.2 (2.2–6.2)

Gender Yes 9.5 (5.4–16.4) 7.3 (3.1–14.2)

Male 4.5 (2.9–6.7) 4.9 (2.4–7.4) Parental tobacco or drug use

Female 5.2 (3.9–6.8) 6.6 (2.8–10.4) No 3.7 (2.7–5.3) 3.9 (1.9–6.8)

Food insecurity Yes 6.8 (4.4–10.3) 10.6 (3.6–17.7)

No 4.7 (3.6–6.0) 5.0 (2.8–7.3) Truancy

Yes 5.4 (2.6–10.9) 6.2 (3.4–13.2) No 4.1 (3.1–5.5) 3.6 (1.8–5.3)

Adverse experiences in adolescence Yes 6.1 (3.9–9.3) 9.4 (1.9–18.1)

Psychosocial risk factors No. of adverse socio-environmental factors

Loneliness 0 1.0 (0.3–2.6) 1.0 (0.7–2.3)

No 2.9 (2.1–3.9) 3.4 (1.2–5.6) 1 3.6 (1.9–6.8) 2.6 (0.9–4.5)

Yes 19.2 (12.9–27.6) 17.8 (7.2–28.3) 2 5.4 (3.9–7.5) 7.6 (1.3–14.0)

Bullied ≥3 6.1 (3.3–10.9) 8.9 (6.7–14.9)

No 3.0 (2.2–4.2) 2.0 (1.3–2.7) Note: All percentages are weighted. Percentages may not total 100.0
Yes 9.9 (6.8–14.3) 13.8 (7.0–20.4) because of rounding.

No close friends
No 4.6 (3.4–6.1) 5.2 (2.5–7.9)
Moreover, poor understandings with parents and lack of peer sup-
Yes 6.2 (2.8–12.9) 3.6 (0.8–6.2)
port appeared to had 1.75 times (95% CI: 1.02–3.01) and 2.23 times
Ever sexual intercourse
(95% CI: 1.18–4.23) higher likelihoods of anxiety disorder, respec-
No 4.6 (3.4–6.1) 3.8 (2.0–5.7)
tively, than their counterparts. Effects of these risk factors are com-
Yes 5.5 (2.8–10.7) 37.0 (35.6–38.5)
paratively higher for female adolescents on accelerating the anxiety
Smoke cigarettes or other tobacco
disorder (Table S1).
No 4.2 (3.1–5.5) 3.4 (2.0–4.7)
Yes 9.9 (5.2–17.8) 43.1 (37.5–48.6)
Physical abused 3.3 | Effect of multiple adverse experiences (MAE)
No 2.2 (1.3–3.8) 3.2 (1.8–8.7)
Yes 6.1 (4.5–8.2) 4.8 (2.2–7.4) Table 4 presents the odds of the association of adolescents’ anxiety
No. of psychosocial factors disorder with psychosocial and socio-environmental factors. Both
0 2.1 (1.0–4.0) 2.5 (0.8–5.5) the unadjusted and adjusted odds ratios (AOR) were calculated. We
found adolescents who experienced at least 2 and ≥3 adverse psy-
(Continues) chosocial factors had 3.19 times (95% CI: 1.47–6.95), and 9.71 times
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(95% CI: 4.09–23.06) higher likelihoods of having anxiety disorder, the previous studies that reported increased odds of psychopatho-
respectively, compared to who did not experience any adverse psy- logical disorders, including anxiety and depressive symptoms among
chosocial factors. Moreover, relative to those who did not experi- lonelier people (Lasgaard et  al.,  2011; Stickley et  al.,  2016). The
ence any forms of adverse socio-environmental factors, those who causes are many, however, the major causes are loneliness affects
experienced at least 2, and ≥3 adverse socio-environmental factors health behaviors, sleeping quality (Stickley et al., 2016), reduces in-
had increased likelihood of anxiety disorder by 4.41 times (95% CI: dividuals coping up ability (Drake et al., 2015), and increases adoles-
1.63–11.88), and 5.61 times (95 CI: 1.66–18.96), respectively. There cents peer victimization behaviors (harassment or bullying) (Acquah
is no difference is observed in case of multiple psychosocial risk et al., 2016). These are the factors that have been found as indepen-
factors but multiple socio-environmental risk factors are affecting dent risk factors of anxiety disorder: Another important psychoso-
more in females compared to male adolescents (Table S2). cial factor, being bullied, has proven to be a statistically significant
risk factor for anxiety disorder among adolescent. Bullying is a sig-
nificant life stressor (Swearer & Hymel,  2015), has negative con-
3.4 | Consequences of anxiety disorder sequences on adolescent's mental health, low self-esteem, major
depression, etc. and that can extend into adulthood (Juvonen &
Effects of adolescent anxiety disorder on selected adverse conse- Graham, 2014). Moreover, Klomek et al. (2015) have demonstrated
quences are presented in Table 5. We found a gradual increase in the that childhood bullying victimization can affect three of the most
likelihoods of adverse consequences with the increasing frequency burdensome areas in adulthood: psychopathology, criminality, and
of the anxiety disorder. Higher likelihoods of suicidal ideation (aOR, suicidality. These study findings also uncovered that adolescent
4.23, 95% CI, 2.21–8.11), suicidal plan (aOR: 3.93, 95% CI: 2.17–7.09), who was physically abused, more likely to be suffered from an anx-
suicidal attempt (aOR: 6.52, 95% CI: 3.72–11.41), and drug use (aOR: iety disorder, which does coincide exactly with existing literature
3.41, 95% CI: 1.32–8.78) were found among the adolescent who re- (Rehan et al., 2017). These psychosocial factors are vital role players
ported that they feel anxiety most of the times compared to those in reducing anxiety disorder in adolescence.
who never feel anxiety. Similarly, the likelihood of suicidal idea- Socio-environmental factors also develop anxiety disorder
tion, plan, attempt, alcohol and drug use was 12.71 times (95% CI: among adolescent in different pathways. As found in this study,
4.41–36.60), 5.93 times (95% CI: 2.18–11.22), 8.09 times (95% CI: adolescent having a poor understanding with parents reported
2.97–21.98), 25.43 times (95% CI: 7.83–42.58) and 12.69 times (95% higher likelihood anxiety disorder, a finding that was also reported
CI: 3.74–23.06) higher among the adolescent who reported that they in a study conducted in the USA (Platt et  al.,  2016). The causes
always feel anxiety relative to those who never feel anxiety. are a lack of family support and parental aversiveness, factors
that Cardamone-Breen et al. (2017) found significantly associated
with the anxiety disorder. Moreover, lack of parental support also
4 |  D I S CU S S I O N minimizes the chance of developing adolescent coping up skills
(Burstein et al., 2010) and capability of handling adversities (Platt
The current study analyzed a nationally representative dataset com- et  al.,  2016). These increase the risk of developing anxiety dis-
prising of 2,978 adolescents to assess the risk factors of anxiety dis- order among adolescent. Consistent with the available literature,
order and the adverse effects of anxiety disorder among adolescent peer supports also found as important predictors of developing
in Bangladesh. We found that the prevalence of anxiety disorders anxiety disorder among adolescent (Stapinski et  al.,  2014). The
among Bangladeshi adolescents was 4.7%; 4.5% among male adoles- reason is low peer supports increase adolescent loneliness which
cent and 5.2% among female adolescent. Several adverse psychoso- contributes to developing anxiety disorder (Pickard et  al.,  2018).
cial factors including feel lonely, being bullied and physically abused Moreover, peer victimization, which the previous studies found
were found significant to the increased risk of anxiety disorder. increases the risk of generic and gender-based risk factors such
Poor understanding with parents and lack of peer support were also as, poor life satisfaction, loneliness, etc. also makes adolescent
found associated with the increased risk of anxiety disorder. The risk highly vulnerable to develop psychiatric disorders (McLaughlin
of anxiety disorder further increased with increasing the number of et al., 2009; Pickering et al., 2019).
adverse factors. We also found the adolescent experience of anxiety In this study, we found a dose-response relationship between
disorder increase their tendency to suicidal ideation, plans, and at- MAE and the likelihood of developing anxiety disorders during
tempts as well as increase alcohol and drug use. These findings were adolescence. For example, adolescent experience to increase the
robust with analyzing nationally representative data and would be number of adverse psychosocial or socio-environmental factors
helpful for the policymakers to make evidence-based policy target- was found associated with the cumulative increase in developing
ing to reduce anxiety among adolescents. the risk of anxiety disorder. These findings are in line with previ-
This study has revealed that several adverse psychosocial factors ous studies (Bielas et al., 2016; van der Feltz-Cornelis et al., 2019;
are significant in developing anxiety disorder among adolescent. For Hunt et al., 2017). In addition to the reasons mentioned above, the
instance, a higher likelihood of anxiety disorder was found among multiple adverse experiences, either psychosocial or socio-envi-
lonelier adolescents. Our finding is consistent with the findings of ronmental, have a broad negative impact on a child's development
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TA B L E 3   Association between adolescents’ anxiety disorder and TA B L E 2   (Continued)

adolescent's adverse experiences in Bangladesh: Global School-
Anxiety disorder in adolescents
Based Health Survey (GSHS), 2014
Risk Factors uOR 95% CI aORa  95% CI
Anxiety disorder in adolescents
Truancy
Risk Factors uOR 95% CI aORa  95% CI
No(RC) 1.00 1.00
Gender
Yes 0.84 (0.58–1.21) 1.36 (0.73–2.54)
Male(RC) 1.00 1.00
Note: Values with superscript asterisks * and ** indicate p < .05, and
Female 1.61* (1.11–2.34) 2.06* (1.12–3.77) p < .01, respectively.
Adverse experiences in adolescence Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; RC,
Psychosocial risk factors Reference category; uOR, unadjusted odds ratio.
a
Model was adjusted for individuals’ age, school grade, food insecurity
Loneliness
and all the predictors included in this table.
No(RC) 1.00 1.00
Yes 3.54** (2.50–5.01) 2.26* (1.08–4.72)
Bullied
et al., 2009). Moreover, multiple adverse psychosocial experiences
No(RC) 1.00 1.00
(e.g., loneliness, bullying, etc) together could act as a robust stressor
Yes 8.59** (5.96–12.37) 6.00** (3.14–11.47)
that enhances the susceptibility of developing lower self-esteem,
No close friends
reduce coping up ability. These are important factors develop-
No(RC) 1.00 1.00
ing anxiety disorder found in several studies (Bielas et  al.,  2016;
Yes 1.30 (0.75–2.27) 0.91 (0.38–2.18)
Drake et al., 2015; Forbes et al., 2019; Lee & Hankin, 2009). Similar
Ever sexual intercourse consequences can also occur for multiple socio-environmental
No(RC) 1.00 1.00 experiences.
Yes 1.04 (0.57–1.91) 0.87 (0.36–2.11) We found increased likelihoods of suicidal ideation, plan, and
Smoke cigarettes or other tobacco attempts, as well as alcohol and drug use among adolescent who
No(RC) 1.00 1.00 reported anxiety disorder than their counterpart. These findings
Yes 1.56 (0.91–2.69) 1.67 (0.61–4.49) are in line with the previous studies conducted in Bangladesh and

Physically abused other developing countries (Asante et al., 2017; Conway et al., 2016;

Khan et  al.,  2020; Randall et  al.,  2014). Furthermore, there is a
No(RC) 1.00 1.00
straight connection with anxiety and impulsivity: anxious individ-
Yes 3.89** (2.49–6.08) 2.12* (1.07–4.21)
uals are more likely to have impulsive decision-making tendencies
Socio-environmental factors
(Xia et  al.,  2017). Impulsivity accelerates adolescents’ engagement
Parental rarely homework check
in violent and risk-taking behaviors, such as substance use (Charles
No(RC) 1.00 1.00
et  al.,  2016), and suicidal behaviors (McHugh et  al.,  2019), etc.
Yes 1.48* (1.05–2.09) 1.29 (0.71–2.36) Researcher highly suggests an evidence-based primary treatment of
Poor understanding with parents mental disorders like anxiety, depression, etc. is essential targeted
No(RC) 1.00 1.00 to youths at risk to prevent suicidal behaviors and substance abuse
Yes 1.56* (1.03–2.06) 1.75* (1.02–3.01) (Conway et al., 2016; Hegerl, 2016).
Poor parental monitoring There are some strengths and limitations of this study. Firstly,
No (RC)
1.00 1.00 we analyzed GSHS data which is nationally representative and
Yes 1.10 (0.78–1.56) 0.55 (0.33–1.01) globally recognized. Secondly, we consider complex survey design

Lack of peer support

and sample weights along with appropriate statistical methods
(RC) that make this study's results are more precise and reasonable for
No 1.00 1.00
policymaking. Moreover, we adjusted anxiety disorder with several
Yes 1.83** (1.20–2.78) 2.23** (1.18–4.23)
psychosocial and socio-environmental factors which is another
Parental tobacco or drug use
important strength of this study. However, in the GSHS, no data
No(RC) 1.00 1.00
was collected on specific types and levels of anxiety disorders. The
Yes 1.61** (1.12–2.29) 1.64 (0.86–3.12)
survey was cross-sectional, so the association reported were cor-
(Continues) relational only, not casual. Moreover, we did not consider many
important confounding variables (e.g., region, place of residence,
by exhibiting subsequentially changes in adolescents’ emotion and alcohol use, parental conflict, other psychological problem histo-
behavior, via disruptions to stress response systems, and also medi- ries, etc.) in the model which was another important limitation of
ate the development of internalizing psychopathology (McLaughlin this study.
8 of 10       | KHAN and KHAN

TA B L E 4   Influence of multiple adverse

Anxiety disorder in adolescents
experiences (MAE) on adolescents’
Multiple adverse experiences uOR 95% CI aORa  95% CI anxiety disorder

No. of psychosocial risk factors

0 (RC) 1.00 1.00
1 1.35 (0.49–3.69) 1.51 (0.55–4.09)
2 2.88** (1.29–6.41) 3.19** (1.47–6.95)
≥3 8.31** (3.71–18.56) 9.71** (4.09–23.06)
No. of adverse socio-environmental factors
0 (RC) 1.00 1.00
1 3.62** (1.42–9.21) 3.58 (0.88–8.62)
2 5.49** (1.99–15.14) 4.41* (1.63–11.88)
≥3 6.27** (1.85–21.19) 5.61** (1.66–18.96)

Note: Values with superscript asterisks * and ** indicate p < .05, and p < .01, respectively.
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; RC, Reference category; uOR,
unadjusted odds ratio.
a
Models were adjusted for age, gender, school grade, and food insecurity variable.

TA B L E 5   Effects of adolescent's anxiety disorder on selected adverse consequences: Global School-Based Health Survey (GSHS), 2014

Adjusted odds ratio (aOR) (95% CI)

Suicide ideationa  Suicide plana  Suicide attemptsa  Alcohol useb  Drug usec 

Feeling anxiety
Never (RC) 1.00 1.00 1.00 1.00 1.00
Rarely 0.35 (0.16–0.75) * 0.37 (0.18–0.74) * 0.65 (0.36–1.17) 1.20 (0.50–2.85) 1.18 (0.57–2.44)
Sometimes 1.25 (0.82–1.89) 1.43 (0.98–2.03) 1.32 (0.89–1.96) 0.98 (0.45–2.12) 0.60 (0.29–1.24)
Most of the time 4.23 (2.21–8.11) ** 3.93 (2.17–7.09) ** 6.52 (3.72–11.41) ** 2.28 (0.64–8.11) 3.41 (1.32–8.78) **
Always 12.71 (4.41–36.60) ** 5.93 (2.18–11.22) ** 8.09 (2.97–21.98) ** 25.43 (7.83–42.58) 12.69 (3.74–23.06)
** **

Note: Each of the models were adjusted for individuals’ age, school grade, gender, food insecurity. Values with superscript asterisks * and ** indicate
p < .05, and p < .01, respectively.
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; RC, Reference category.
a
Measured in past 12 months.
b
Measured in last 30 days.
c
Measured in lifetime.

5 |  CO N C LU S I O N S etiology of anxiety disorder among the adolescent and identify
the policies and preventive interventions to reduce the burden
The current study reported around 4.7% of anxiety disorder effectively.
among adolescent in Bangladesh and it significantly increasing the
tendencies of adolescent suicidal ideation, plans, and attempts AC K N OW L E D G M E N T S
and alcohol and drug abuse tendencies. This endeavor has con- This paper uses data from the Global School-Based Student Health
tributed to an understanding of the risk factors of developing anx- Survey (GSHS). The authors are grateful to the Department of
iety among these populations. Several single and multiple adverse Chronic Diseases and Health Promotion, World Health Organization,
psychosocial and socio-environmental experiences are accelerat- and the United State Centers for Disease Control and Prevention.
ing the risk. Social and environmental factors need to enhance We acknowledge the support of the Ministry of Health and Family
positively to support adolescents in reducing anxiety disorder. Welfare and Ministry Education, Bangladesh, for their support in
The study findings emphasize the essentiality of early screening conducting the survey in Bangladesh.
and interventions targeted to youths at risk, which might reduce
the rate of anxiety disorder in this age cluster. In-depth and com- C O N FL I C T O F I N T E R E S T
prehensive research is urgent to extend the understanding of the The authors have no competing interest to declare.
KHAN and KHAN |
      9 of 10

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