Observational Study Medicine ®

OPEN

Social support, resilience, and self-esteem protect

against common mental health problems in early
adolescence
A nonrecursive analysis from a two-year longitudinal study
∗
Qiaolan Liu, PhDa, Min Jiang, PhDb, Shiying Li, PhDc, Yang Yang, PhDa,

Abstract
The aim of this study is to examine the mutual effects of self-esteem and common mental health problems (CMHPs) as well as the
mutual effects of self-esteem and resilience in early adolescence. The recruited participants were 1015 adolescents aged 12.7 years
(SD = 0.5 years) from two junior high schools. Data were repeatedly collected at five time points at 6-month intervals over 2-year
years. The Social Support Rating Scale (SSRS), Block and Kremen’s Ego-Resiliency Scale (ER89), Rosenberg Self-esteem Scale
(RSES), and Mental Health Inventory of Middle School Students (MMHI-60) were used to measure social support, resilience, self-
esteem, and CMHPs, respectively. Nonrecursive structural equation modeling (SEM) was performed to analyze the data.
There were bivariate partial correlations among the five-time measurements for the SSRS, ER89, RSES, and MMHI-60 scores.
Self-esteem negatively predicted CMHPs with a standardized direct effect of 0.276 (95% CI: 0.425 to 0.097), and the opposite
effect was 0.227 (95% CI: 0.383 to 0.072). Self-esteem positively predicted resilience with the standardized direct effect of
0.279 (95% CI: 0.093–0.425), and the opposite effect was 0.221 (95% CI: 0.063–0.376). Social support was a protective factor for
mental health status.
The findings of mutual effects of self-esteem and CMHPs as well as self-esteem and resilience can provide researchers and
practitioners with a conceptual framework that can help them build effective intervention methods to promote adolescent mental
health status.
Abbreviations: AGFI = adjusted goodness of fit index, CFI = comparative fit index, CI = confidence interval, CMHPs = common
mental health problems, ER = ego-resiliency scale, GFI = goodness-of-fit index, MMHI = mental health inventory of middle school
students, NFI = normed fit index, RMSEA = root mean square error of approximation, RSES = Rosenberg self-esteem scale, SEM =
structural equation model, SSRS = social support rating scale.
Keywords: common mental health problems, nonrecursive Structural equation modeling, resilience, self-esteem, social support

1. Introduction personal attributes and qualities.[3] According to the sociometer

Adolescence is an important stage in life. With unbalanced theory of self-esteem, self-esteem reflects the emotional state of an
physiological and psychological development, adolescents often individual’s degree of integration into interpersonal relation-
face many common mental health problems (CMHPs), including ships. In other words, self-esteem is a subjective measure of the
depression and anxiety. Adolescent CMHPs are public health relationship between an individual and society and other
issues that have received much attention. Self-esteem is important people. Previous studies have found that high self-
fundamentally associated with CMHPs.[1,2] Self-esteem is the esteem is a protective factor for physical and mental health. High
evaluative and affective dimension of the self-concept, and it self-esteem can lead to better mental health, while poor self-
reflects the sum of an individual’s beliefs and knowledge about esteem is associated with a broad range of mental disorders.[3] In

Editor: Meixia Lu.

This study was supported by grants from the National Natural Science Foundation of China (NO: 81472994 and 30972546), Applied Psychology Research Center
Foundation of Sichuan Province, China (NO: CSXL-182004) and the Fundamental Research Fund for Chinese Central Universities (NO: 20826041C4234).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the present study are available from the corresponding author on reasonable request.
a
Department of Health-related Social and Behavioral Sciences, b Department of Epidemiology and Health Statistics, West China School of Public Health and West
China Fourth Hospital, Sichuan University, c Department of Sociology and Psychology, School of Public Administration, Sichuan University, Chengdu, China.
∗
Correspondence: Yang Yang, Department of Health-related Social and Behavioral Sciences, West China School of Public Health and West China Fourth Hospital,
Sichuan University, No.17, Section 3, South Renmin Road, Chengdu 610041, China (e-mail: yangyang@scu.edu.cn).
Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to
download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.
How to cite this article: Liu Q, Jiang M, Li S, Yang Y. Social support, resilience, and self-esteem protect against common mental health problems in early adolescence:
A nonrecursive analysis from a two-year longitudinal study. Medicine 2021;100:4(e24334).
Received: 30 May 2020 / Received in final form: 5 December 2020 / Accepted: 7 December 2020
http://dx.doi.org/10.1097/MD.0000000000024334

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Liu et al. Medicine (2021) 100:4 Medicine

contrast, self-esteem is regarded as the core and the consequence Wenchuan earthquake, while the other was the school (school B)
of mental health. Self-esteem can be strengthened or eroded. with the slightest damaged from that earthquake. The first
Adolescents with high self-esteem can view themselves from a baseline survey included 1256 participants whose age was 12.7
positive perspective and are more likely to be confident and years (SD = 0.5 year; range = 10.9–15.4 years), and who were in
optimistic. Some studies have reported that CMHPs such as the first semester of grade 7 in the junior high schools in October
depression and anxiety lead to reduced self-esteem.[5–7] These 2010. Then, the follow-up survey was performed among the same
existing findings indicate that there might be a mutual participants every half a year until October 2012, when the
relationship between CMHPs and self-esteem in the adolescent participants were in the first semester of grade 9. In total, five-
population. time assessments were collected. In the present study, the 1015
Resilience can maintain well-being in the face of adversity. individuals who participated in all five surveys were included. All
Because of a current lack of consensus on the operational participants gave both oral and written consent before the survey.
definition, resilience has been accepted as a personality trait that The whole study process was supervised by the Quality Control
can help individuals adapt to negative stressors and maintain Group and Medical Ethical Committee from Sichuan University.
psychological function.[8,9] Internal protective factors of resil- The detailed study design has been reported elsewhere.[24]
ience, such as self-esteem, have been widely studied in adolescent
populations.[10,11] Moreover, some findings have shown that
2.2. Measures
resilience can play a crucial role in promoting self-esteem.
Resilience positively affects life satisfaction and psychological Data were collected from the students using self-reported
distress through the mediation effects of self-esteem.[12,13] High questionnaires that included demographics, CMHPs, social
self-esteem has been regarded as a protective factor for resilience, support, self-esteem, resilience, and other factors.
at the same time, resilience is seen as a promoting factor for self-
2.2.1. Mental Health Inventory of Middle School Students
esteem.[14] It indicates that there might be a mutual relationship
(MMHI). CMHPs were measured using the 60-item Mental
between resilience and self-esteem.
Social support as a protective factor for adolescent mental Health Inventory of Middle School Students (MMHI-60).[25]
health is highly valued. Social support includes visible physical This scale consisted of 60 items, and each item was scored from 1
support, such as material assistance and social networks, as well to 5. It included 10 subscales (each scale included 6 items)
as physical emotional support, such as the experience of being including depression, anxiety, study stress, maladjustment,
understood, accepted and respected. Social support has a hostility, psychological unbalance, interpersonal sensitivity and
generally beneficial effect on relieving individual psychological tension, emotional instability, obsessive–compulsive and para-
pressure, inhibiting negative emotions, providing positive noia. A higher score indicated poorer mental health. The total
emotional experience and promoting mental health.[15,16] As score for the 60 items was divided by 60 and classified into one of
an important coping resource, social support can improve four groups: <2 no mental health problem; 2 to 2.99, mild; 3 to
3.99, moderate; and ≥4, severe. In this study, Cronbach’s alpha
adolescents’ self-evaluation, help them form a good self-image,
and promote their self-esteem.[17,18] Social support can not only coefficient across the five surveys was 0.96 to 0.97.
directly protect mental health but can also indirectly affect mental 2.2.2. Rosenberg Self-esteem Scale (RSES). The Rosenberg
health by improving self-esteem.[19,20] Social support can also be Self-esteem Scale (RSES) was used to evaluate adolescents’ self-
considered one of the most important external resources to buffer esteem. The Chinese version of this scale has been widely used in
the negative effects of stressors, and some studies have indicated the Chinese population, including adolescents.[26,27] The greater
the positive effect of social support on resilience.[21–23] the score was, the higher the self-esteem. Cronbach’s alpha
Most previous studies have assessed responses at a single coefficient for the RSES across the five surveys in this study was
survey. However, social support and CMHPs often change with 0.81 to 0.85.
the age of adolescents, and resilience and self-esteem also vary
during adolescence. These relationships among social support, 2.2.3. Social support rating scale. The Social Support Rating
self-esteem, resilience and CMHPs may not be stable or maybe Scale (SSRS) developed by Shuiyuan Xiao was a 10-item
incomplete when based on only one measurement value. questionnaire for measuring social support, including objective
Moreover, in the same population, the mutual effects between social support (3 items), subjective social support (4 items), and
self-esteem and CMHPs as well as between self-esteem and utilization of social support (3 items). A higher score indicated
resilience are unclear. In the present study, we used five waves of more social support. The SSRS has been widely used and shows
repeated data that were obtained every 6 months over a 2-year acceptable reliability and validity in the Chinese adolescent
longitudinal study among junior high school students to test the population.[28–30] Cronbach’s alpha coefficient for the SSRS
following hypotheses: First, correlations will occur between all across five surveys in this study was 0.75 to 0.78.
five measurements of social support, self-esteem, resilience, and
2.2.4. Ego-Resiliency Scale (ER89). Psychological resilience
CMHPs. Second, there will be mutually influencing effects of self-
was measured using Block and Kremen’s Ego-Resiliency Scale
esteem and CMHPs as well as self-esteem and resilience.
created in 1989 (ER89). This scale consisted of 14 items and
measured the extent to which an individual was able to
2. Materials and methods successfully adapt to their surroundings despite significant
challenges or threats. All participants were asked to score each
2.1. Participants and procedures item on a 4-point scale ranging from 1 (does not apply) to 4
The adolescents were recruited in this study from two junior high (applies very strongly). A higher score indicated greater ego
schools by using stratified cluster sampling. One school (school resilience. This scale has been reported to be suitable for the
A) was the most seriously damaged and rebuilt after the 2008 Chinese adolescent population.[31,32] In our study, Cronbach’s

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alpha coefficient for the ER89 across five surveys was 0.85 to 3.3. Partial correlation coefficients of the five
0.87. measurements and common method biases analysis
The five measurements (mean ± standard deviation) of self-
2.3. Statistical analysis esteem, social support, resilience, and CMHPs did not follow a
In the total sample, percentages, means and standard deviations linear or quadratic linear curve, while they presented an irregular
(SD) were calculated for the descriptive data analysis. The partial fluctuation state. All the partial correlation coefficients adjusted
correlations adjusted for covariates were analyzed among the for age, gender, and having a relative hurt or die in the
five-time measurements of self-esteem, resilience, social support earthquake had statistical significance. The partial correlation
and CMHPs. The data were obtained from the same adolescent coefficients between CMHPs and resilience were the lowest
participants using the same questionnaire, although the order of among them (Table 2).
some items in the questionnaire was changed in different surveys. The results of confirmatory factor analysis showed that when
Because artificial covariation, which is a kind of systematic error, we built the single factor with the MMHI-60, SSRS, RSES, and
could have occurred, confirmatory factor analysis was used for ER89 scores, the indices of the model were x2 =df = 28.946,
common method bias analysis.[33] GFI = 0.5903 NFI = 0.548, IFI = 0.556, CFI = 0.555 and RMSEA
Moreover, we conducted a nonrecursive structural equation = 0.166. The model fitted very poorly. There were no common
model (SEM), as shown in Figures 1 and 2. All the parameters in method biases among these variables, and the data could be
the nonrecursive SEM were freely estimated. The five-time further analyzed using nonrecursive SEM.
measurements of the MMHI-60 built latent variable CMHPs.
The other three latent variables, self-esteem, social support, and
resilience, were created using the five-time measurements of 3.4. Nonrecursive analyzing
RSES, SSRS, and ER89, respectively. SEM explicitly examined Figure 1 and Table 3 show the relationships of four latent
the direct effects and mediating effects among social support, self- variables built from the five-time repeated measurements of the
esteem, resilience, and CMHPs and improved the quality of MMHI-60, SSRS, RSES, and ER89. After adding statistically
regression relationships based on controlling measurement significant correlations of measurement errors, there were
errors. Nonrecursive SEM verified the mutual effects of these negative mutual effects of CMHPs and self-esteem. Self-esteem
latent variables. We used six fitting indices to assess the and social support negatively predicted CMHPs. Social support
nonrecursive SEM model: root mean square error of approxi- also negatively indirectly predicted MMHI-60 only through self-
mation (RMSEA), goodness-of-fit index (GFI), comparative fit esteem (CMHPs←self-esteem←social support) and both self-
index (CFI), normed fit index (NFI), adjusted goodness of fit esteem and resilience (CMHPs←self-esteem ← resilience ←social
index (AGFI), and x2 =df (chi-square statistic divided by degrees support). The proportion of the mediating effect in total effects
of freedom). If GFI, CFI, NFI, and AGFI were 0.90 or above, from social support to CMHPs was 27.9% ( 0.137/ 0.490). Of
x2 =df was <5, and RMSEA was <0.08, we considered the model the total mediating effect from social support to CMHPs, the
appropriate. The 2000 iterations of the model by the bootstrap proportion of the mediating effect through both self-esteem and
method were used to estimate the 95% confidence intervals (CIs) resilience was 40.4% ( 0.055/ 0.137).
of the direct effects and indirect effects in all the models. We Figure 2 and Table 4 show that there were positive mutual
further compared the Nonrecursive effects in different genders effects of resilience and self-esteem. Self-esteem and social
and schools by using multigroup SEM. These analyses were support positively predicted resilience. Social support also
conducted using SPSS21.0 (IBM; Armonk, New York, NY) and indirectly predicted resilience only through self-esteem (resil-
AMOS 21.0 (IBM; Armonk, New York, NY). The significance ience←self-esteem←social support) and both self-esteem and
level was P  .05 based on two-sided tests. CMHPs (resilience←self-esteem←CMHPs←social support). The
proportion of the mediating effect of the total effects of social
3. Results support to resilience was 30% (0.138/0.460). Of the total
mediating effect from social support to resilience, the proportion
3.1. Study subjects of the mediating effect through only self-esteem was 43.7%
Of the 1015 participants included in this study with a mean age of (0.060/0.138).
12.7 years (SD = 0.5 years), 49.3% were boys. The rates of We further analyze all the relationships above between
moderate-to-severe CMHPs were 8.4%, 12.0%, 18.6%, 18.8%, different genders and schools, we did not find the different
and 15.5% in the first through the fifth survey respectively. The relationships though the values of effects were some different.
male ratio of missing data of five-time was 45.3%, 48.6%, (The results were not shown.) It showed that the models as
51.1%, 49.2%, and 52.5%, respectively. There was no statistical Figure 1 and Figure 2 were suitable for different genders
significance compared with the data used in the present study. It and schools, and gender and school were not moderating
indicated that missing data were random missing. factors.
As shown in Figure 1 and Figure 2, we adjusted for the
correlation of measurement errors between e6 and e7, e9 and e10,
3.2. Comparison of MMHI-60, RSES, SSRS, and ER89 in
e11 and e12, and e14 and e15. We also found relationships
different genders and schools between e1 and e16, e2 and e17, e3 and e18, e4 and e19, and e5
The participants in school A had higher resilience, social support, and e20 (lines not shown in the figures because of too many lines)
self-esteem, and lower CMHPs compared with school B. We just based on the modification indices in nonrecursive SEM. The six
found boys had higher resilience compared with girls. There was fitting indices for the two models were good because RMSEA =
no statistical significance of CMHPs, social support and self- 0.067, GFI = 0.915, NFI = 0.921, IFI = 0.934, CFI = 0.934, and
esteem in different genders (Table 1). x2 =df = 5.548.

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Table 1
The difference of the five measurements from the scales of common mental health problems, self-esteem, resilience, and social support
between genders and schools.
Measure1 Measure 2 Measure 3 Measure 4 Measure 5
∗
Variables N (Oct. 2010) (Apr. 2011) (Oct.2011) (Apr. 2012) (Oct. 2012) F†/P
MMHI-60
School A 427 2.16 ± 0.62 2.25 ± 0.64 2.38 ± 0.68 2.38 ± 0.65 2.37 ± 0.64 3.83/.051
School B 588 2.05 ± 0.58 2.12 ± 0.67 2.23 ± 0.75 2.34 ± 0.76 2.25 ± 0.67
t/P 2.89/.004 3.18/.001 3.25/.001 0.94/.346 2.87/.004
Boys 500 2.12 ± 0.63 2.17 ± 0.68 2.30 ± 0.74 2.35 ± 0.72 2.31 ± 0.64 0.06/.815
Girls 515 2.07 ± 0.58 2.18 ± 0.65 2.28 ± 0.71 2.37 ± 0.71 2.30 ± 0.68
t/P 1.52/.129 0.20/.839 0.30/.762 0.24/.808 0.16/.877
RSES
School A 427 30.53 ± 4.28 30.57 ± 4.45 30.04 ± 4.39 30.10 ± 4.71 30.61 ± 4.52 12.74/<.001
School B 588 32.04 ± 4.41 32.36 ± 4.71 31.32 ± 4.98 30.85 ± 5.10 31.45 ± 4.62
t/P 5.47/<.001 6.12/<.001 4.25/<.001 2.41/.016 1.86/.063
Boys 500 31.18 ± 4.49 31.41 ± 4.81 30.87 ± 4.83 30.73 ± 4.89 31.08 ± 4.65 0.06/.804
Girls 515 31.62 ± 4.34 31.81 ± 4.56 30.69 ± 4.74 30.34 ± 5.00 30.76 ± 4.52
t/P 1.60/.109 1.37/.172 0.62/.533 1.25/.212 1.28/.261
ER89
School A 427 40.63 ± 6.18 41.51 ± 6.05 40.62 ± 6.08 40.46 ± 6.12 40.82 ± 5.78 34.67/<.001
School B 588 43.33 ± 6.24 44.19 ± 6.91 44.29 ± 7.04 43.07 ± 7.07 42.70 ± 6.44
t/P 6.838/<.001 6.432/<.001 8.689/<.001 6.148/<.001 4.808/<.001
Boys 500 42.49 ± 6.21 43.63 ± 6.82 43.18 ± 7.20 42.53 ± 7.15 42.53 ± 6.52 11.92/<.001
Girls 515 41.91 ± 6.48 42.51 ± 6.51 42.32 ± 6.56 41.43 ± 6.40 41.31 ± 5.90
t/P 1.44/.151 2.66/.008 1.97/.049 2.58/.010 3.13/.002
SSRS
School A 427 37.99 ± 5.54 39.25 ± 6.08 39.13 ± 6.34 38.70 ± 6.19 38.11 ± 6.01 12.22/<.001
School B 588 37.35 ± 5.84 38.41 ± 5.93 38.54 ± 6.43 37.50 ± 6.31 36.66 ± 5.99
t/P 1.76/.078 2.19/.029 1.92/.055 3.01/.003 3.82/<.001
Boys 500 37.16 ± 5.79 38.74 ± 6.03 38.59 ± 6.41 38.13 ± 6.28 37.34 ± 6.15 0.15/.701
Girls 515 38.06 ± 5.62 38.79 ± 5.99 38.78 ± 6.40 37.88 ± 6.28 37.20 ± 5.93
t/P 2.54/.011 0.13/.898 0.48/.635 0.63/.529 0.31/.697
∗
MMHI-60 refers to the 60-item Mental Health Inventory of Middle School Students; RSES refers to Rosenberg Self-esteem Scale; ER89 refers to Ego-Resiliency Scale, and SSRS refers to Social Support Rating
Scale.
†
Repeated Variance Analysis adjusted for age and having relative hurt or death in the 2008 Wenchuan earthquake at baseline survey.

Table 2
Bivariate partial correlations between the five-time measuring scores of scales from common mental health problems, self-esteem, social
∗
support and resilience .
Variables† x ± sd RSES1 RSES2 RSES3 RSES4 RSES5 SSRS1 SSRS2 SSRS3 SSRS4 SSRS5 MMHI1 MMHI2 MMHI3 MMHI4 MMHI5 ER1 ER2 ER3 ER4 ER5
RSES1 31.41 ± 4.42 1 0.568 0.506 0.454 0.453 0.344 0.244 0.207 0.185 0.183 0.346 0.256 0.236 0.213 0.197 0.467 0.312 0.277 0.239 0.239
RSES2 31.61 ± 4.69 1 0.606 0.544 0.516 0.304 0.367 0.263 0.235 0.258 0.366 0.388 0.315 0.275 0.219 0.347 0.468 0.324 0.328 0.285
RSES3 30.78 ± 4.78 1 0.632 0.579 0.311 0.292 0.355 0.285 0.299 0.320 0.321 0.410 0.308 0.266 0.275 0.334 0.438 0.322 0.297
RSES4 30.54 ± 4.95 1 0.652 0.270 0.262 0.298 0.393 0.305 0.330 0.316 0.402 0.434 0.337 0.291 0.337 0.329 0.453 0.358
RSES5 30.92 ± 4.58 1 0.280 0.288 0.312 0.331 0.350 0.300 0.313 0.378 0.365 0.379 0.282 0.321 0.302 0.344 0.429
SSRS1 37.62 ± 5.72 1 0.615 0.526 0.525 0.500 0.358 0.2627 0.219 0.233 0.170 0.358 0.260 0.234 0.236 0.214
SSRS2 38.76 ± 6.01 1 0.633 0.580 0.614 0.287 0.348 0.286 0.233 0.201 0.246 0.340 0.215 0.252 0.260
SSRS3 38.68 ± 6.40 1 0.675 0.645 0.261 0.292 0.369 0.295 0.242 0.203 0.220 0.315 0.284 0.287
SSRS4 38.00 ± 6.28 1 0.696 0.244 0.283 0.301 0.357 0.250 0.202 0.222 0.253 0.360 0.292
SSRS5 37.27 ± 6.04 1 0.231 0.285 0.293 0.293 0.282 0.210 0.216 0.223 0.302 0.339
MMHI1 2.09 ± 0.60 1 0.589 0.497 0.493 0.462 0.196 0.132 0.116 0.153 0.168
MMHI2 2.18 ± 0.66 1 0.573 0.523 0.486 0.168 0.188 0.173 0.170 0.180
MMHI3 2.29 ± 0.72 1 0.613 0.567 0.150 0.151 0.203 0.201 0.220
MMHI4 2.36 ± 0.71 1 0.593 0.155 0.116 0.127 0.170 0.179
MMHI5 2.30 ± 0.66 1 0.129 0.095 0.142 0.180 0.173
ER1 42.19 ± 6.35 1 0.547 0.440 0.443 0.399
ER2 43.06 ± 6.69 1 0.541 0.529 0.461
ER3 42.74 ± 6.89 1 0.552 0.491
ER4 41.97 ± 6.80 1 0.537
ER5 41.91 ± 6.24 1
∗
The correlation analysis was adjusted for age, gender and having relative hurt or death in the 2008 Wenchuan earthquake.
†
MMHI1–MMHI5 were the five-time measuring scores of 60-item Mental Health Inventory of Middle School Students. SSRS1–SSRS5 were the five-time measuring scores of Social Support Rating Scale; RSES1–
RSES5 were the five-time measuring scores of the Rosenberg Self-esteem Scale, and ER1–ER5 were the five-time measuring scores of Ego-Resiliency Scale.

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Figure 1. Mutual effects analysis between self-esteem and common mental health problems in early adolescence (n = 1015) in a nonrecursive structural equation
model. MH1–MH5 refer to the five-time measurement scores of 60-item Mental Health Inventory of Middle School Students. SSRS1–SSRS5 refer to the five-time
measurement scores of Social Support Rating Scale; RSES1–RSES5 refer to the five-time measurement scores of the Rosenberg Self-esteem Scale, and ER1–
ER5 refer to the five-time measurement scores of Ego-Resiliency Scale.

Table 3
The mutual effects of self-esteem and common mental health problems and the direct and indirect relationships of resilience and social
support.
∗
Mutual and direct relationship Direct effect (standard error) Standardized direct effect (95%CI) Standardized total effect (95%CI) P
CMHPs←self-esteem 0.039 (0.012) 0.276 ( 0.425 to 0.097) <.001
Self esteem←CMHPs 1.600 (0.518) 0.227 ( 0.383 to 0.072) .002
CMHPs←social support 0.029 (0.005) 0.353 ( 0.467 to 0.257) 0.490 ( 0.547 to 0.425) <.001
Self-esteem←social support 0.110 (0.027) 0.187 (0.091∼0.284) 0.496 (0.433∼0.558) <.001
Self-esteem←resilience 0.279 (0.026) 0.430 (0.356∼0.491) <.001
Resilence←social support 0.416 (0.035) 0.460 (0.392∼0.524) <.001

Indirect relationship Total mediating effect (95%CI) Standardized total mediating effect (95%CI)
CMHPs←self-esteem←social support 0.011 ( 0.018 to 0.004) 0.137 ( 0.216 to 0.050) .005
CMHPs←self-esteem←resilience←social support
Self-esteem←CMHPs←social support 0.181 (0.130–0.238) 0.309 (0.226–0.395) .001
Self-esteem←resilience←social support
∗
All arrows are independent variables at the sending end and dependent variables at the pointing end, and CMHPs refers to common mental health problems.

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Figure 2. Mutual effects analysis between self-esteem and resilience in early adolescence (n = 1015) in a nonrecursive structural equation model. MH1–MH5 refer
to the five-time measurement scores of 60-item Mental Health Inventory of Middle School Students. SSRS1–SSRS5 refer to the five-time measurement scores of
Social Support Rating Scale; RSES1–RSES5 refer to the five-time measurement scores of the Rosenberg Self-esteem Scale, and ER1–ER5 refer to the five-time
measurement scores of Ego-Resiliency Scale.

Table 4
The mutual effects of self-esteem and resilience and the direct and indirect relationships of common mental health problems and social
support.
∗
Mutual and direct relationship Direct effect (standard error) Standardized direct effect (95%CI) Standardized total effect (95%CI) P
Self-esteem←resilience 0.143 (0.040–0.251) 0.221 (0.063–0.376) .004
Resilience←self-esteem 0.291 (0.145–0.681) 0.279 (0.093–0.425) .006
Self-esteem←social support 0.104 (0.053–0.161) 0.178 (0.092–0.273) 0.496 (0.433–0.558) <.001
Resilience←social support 0.291 (0.197–0.403) 0.322 (0.217–0.441) 0.460 (0.392–0.524) <.001
Self-esteem←CMHPs 3.117 ( 3.748 to 2.572) 0.442 ( 0.504 to 0.370) <.001
CMHPs←social support 0.041 ( 0.048 to 0.034) 0.490 ( 0.547 to 0.425) <.001

Indirect relationship Total mediating effect (95%CI) Standardized total mediating effect (95%CI)
Resilience←self-esteem←Social support 0.125 (0.045–0.204) 0.138 (0.049 to 0.219) .006
Resilience←self-esteem←CMHPs←social support
Self-esteem←CMHPs←social support 0.186 (0.141–0.242) 0.318 (0.246–0.394) .001
Self-esteem←resilience←social support
∗
All arrows are independent variables at the sending end and dependent variables at the pointing end, and CMHPs refers to common mental health problems.

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4. Discussion individuals have higher self-esteem, and a sense of higher social

Based on five repeated measurements over 2 years of longitudinal value.[46] Among adolescents, the sources of vertical social
data, the results of nonrecursive SEM analysis in the same support are parents, teachers and more senior others, and the
adolescent population showed that self-esteem and CMHPs had sources of horizontal social support are friends and classmates.
negative mutual effects on each other. Additionally, self-esteem Low social support from friends, family and other resources in
and resilience had positive mutual effects on each other. The adolescents has been associated with depressive symptoms.[47] In
results of this study also identified that social support was a contrast, when adolescents received active social support,
promoting factor for self-esteem and resilience, and it was a including emotional support, instrumental support and informa-
buffering factor against CMHPs. Self-esteem played a mediating tional support from their surroundings, they felt secure, confident
role in the relationships between social support and CMHPs and and companionable in their lives. Objective social support and
a mediating role in the relationships between resilience and subjective social support could both protect against negative
CMHPs. stressors and CMHPs, and thus, adolescents who perceived their
The results of the present study demonstrated that self-esteem, social relations as supportive were very likely to experience good
resilience, social support and CMHPs all fluctuated in early results that promote self-esteem, resilience and well-being.[8,48–50]
adolescence. In grade 7, mental health status including self- The noticeable strength of our study is the 2-year longitudinal
esteem and resilience in adolescents was the best, while in grade 8, design, in which we conducted repeated measurements of the
it became the worst. These results were consistent with previous RSES, SSRS, ER89, and MMHI-60 at five-time points. The
studies in Chinese early adolescents.[34] associations of these variables were stable because the latent
Self-esteem is thought to be an individual’s feeling of their own variables built using five measurements. Moreover, the mutual
positive attitude in social practice. It reflects whether an effects of self-esteem and CMHPs, as well as self-esteem and
individual has good interpersonal relationships and thus has resilience, were verified by a nonrecursive SEM.
positive emotional experiences. It is the result of interactions The limitations of our study should be mentioned.
between subjective and objective aspects and is fully reflected 1. The questionnaire in each survey was self-reported, which
through self-acceptance and self-value. Good self-esteem is a could have led to bias. Some confounding factors such as
protective factor for mental health and psychological function- academic achievement and family economic status were not
ing.[35] Individuals with an adequate level of self-esteem can see included in the nonrecursive SEM, the mutual effects of self-
themselves from a positive perspective, which is manifested as esteem and CMHPs as well as self-esteem and resilience might
more self-confidence, self-improvement, and an ability to change be unstable and needed more correction.
the situation and better cope with various problems and 2. The participants recruited in this study were from the 2008
stressors.[35–37] Our results were consistent with previous Wenchuan earthquake areas. Although the baseline survey
prospective studies showing that lower self-esteem can lead to was conducted 2 years after the earthquake and the last survey
worse mental health status.[3,4] Our results were not in was conducted 4 years after the earthquake, mutual effects of
accordance with a few previous studies in which it was found self-esteem and CMHPs as well as self-esteem and resilience
that depression did not decrease self-esteem in adults based on could have been affected by the earthquake
longitudinal data.[38,39] However, a meta-analysis covering 77
studies on depression and 18 studies on anxiety evaluated Therefore, further studies in other adolescent populations are
vulnerability and scar models of low self-esteem and depression required.
and low self-esteem and anxiety. After controlling for prior levels
of the predicted variables and age, gender, or time lag between 5. Conclusion
assessments, the findings showed that low self-esteem predicted
Self-esteem and CMHPs affect each other negatively, while self-
depression and anxiety. The latter also caused low self-esteem.
esteem and resilience interact positively. Social support is a
Self-esteem could be considered as an important indicator of
protective factor for all health indicators. The findings can
mental health status, not just a protective factor for mental health
provide practitioners with a good conceptual framework in
status.[40] Our results supported these findings.
which the mutual effects and the core factors that can be easily
Resilience and self-esteem are attributes of positive psychology
changed should be considered to promote adolescent mental
and are important indicators of positive mental health. Resilience
health.
enables individuals to cope with adverse situations and pressures,
while self-esteem promotes self-acceptance, self-responsibility
and self-maintenance. Our findings suggested that these two Acknowledgments
indicators promoted each other, which is of great significance for
future psychological interventions and public health interven- The authors thank all the participants for participating in this
tions in the adolescent population.[14,41] Self-esteem is relatively study.
stable and it is difficult to improve it in practice. Resilience is
affected by widely internal and external factors and it is relatively
Author contributions
easy to improve. So practitioners can improve self-esteem by
enhancing resilience. Self-esteem acts as a mediating factor, as has Conceptualization: qiaolan liu, Yang Yang.
been proven in many previous studies, especially because it has a Data curation: Shiying Li.
mediating effect on the relationships of social support promoting Methodology: qiaolan liu, Min Jiang.
subjective well-being and buffering CMHPs.[42–45] Writing – original draft: qiaolan liu.
Our results were consistent with previous studies in which Writing – review & editing: qiaolan liu, Min Jiang, Shiying Li,
social support was verified as a positive factor to make Yang Yang.

7
Liu et al. Medicine (2021) 100:4 Medicine

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