Study design and setting
This was an institutional-based cross-sectional study. The study was conducted in 22 CCHs of five districts of Nepal—Kathmandu, Lalitpur, Kaski, Chitwan, and Bhaktpur. The CCHs in these districts are operated by government and nongovernmental organizations. These districts were selected because they had a large number of CCHs and OVAs [16] that included adolescents from highly populated and diverse population areas from all over the country. In this way, adolescents representing various cultures, ethnicities, and economic statuses of the country would be included in the study.
Study population
The study participants were 13–17-year-olds residing in CCHs; these adolescents were defined as OVAs in this study. OVAs include those who lost one or both parents or whose parents were in prison, those who ran away from home or were found living in public places and were very poor, those who had no proper rearing and care from their parents due to the physical and/or mental disability of parents, adolescents with HIV, and those staying in CCHs for any other reason [16]. According to the Children’s Act 2018, “children” refers to persons who have not reached 18 years of age. In this study, children aged 13 to 17 years were recruited. Persons of this age group are also referred to as adolescents.
Sample size calculation and sampling technique
By the sample size calculation formula for a cross-sectional [24], at Zα/2 = 1.96, α = 0.05, p = 0.52 [25], and considering a 20.0% nonresponse rate, then at least 459 samples were required for the analysis. The five study districts were selected purposively, and the CCHs in the selected districts were selected by a simple random method. Adolescents aged 13–17 years who lived in the selected CCHs were eligible for the study. Overall, 22 CCHs were selected from a total of 454 centers in five selected districts.
Research instruments
A validated questionnaire and the BDI-II [26] were used to collect information from the participants. The questionnaire consisted of five parts. In part one, six questions collected general information of the participants, e.g., sex, age, education, and ethnicity. In part two, four questions collected the parents’ status such as their life status, history of parental visits, presence of other family members or relatives, and information of the parents. In part three, two major questions related to alcohol and smoking use and behavior. In part four, three questions collected health information such as information related to health problems (congenital disorders, asthma, COPD (Chronic obstructive pulmonary disease), HIV) and the weight and height of the participants. In part five, four questions collected information related to abuse and social support.
The validity of the questionnaire was assessed by Item Objective Congruence (IOC) carried out by three external experts: a psychiatrist, an epidemiologist, and a public health specialist. Questions that scored less than 0.5 were deleted from the questionnaire, whereas those that scored 0.5–0.7 were revised as per the comments from the IOC committee before being included in the questionnaire. Questions that scored greater than 0.7 were included in the questionnaire without revision. Translation and back-translation methods was used to validate the questionnaire. In the current study, a pilot test was conducted among 30 participants from two CCHs (Jyoti Ko Ghar Nepal and Nepali Griha) to assesses feasibility, comprehension, and order of the questions. The Cronbach’s α was found at 0.79.
Beck depression inventory-II (BDI-II)
The BDI-II was used to measure the level of depression and consists of 21 self-reported questions. It is one of the most widely used instruments for measuring the severity of depression. Each question has 4 possible choices that are a given score from 0 to 3. The total score is used to interpret the severity of depression: 0–13 indicates minimal depression, 14–19 indicates mild depression, 20–28 indicates moderate depression, and 29–63 indicates severe depression [26]. In this tool, the total highest possible score is 63, and the lowest possible score is zero. This tool is applicable to people between the ages of 13 and 80 [27]. The sensitivity, specificity, and reliability of the Nepali version of the BDI-II are 85.0, 86.0, and 8.0%, respectively [28].
In the current study, those with BDI-II scores indicating mild to severe depression were defined as having clinically relevant depressive symptoms while those with a BDI-II score indicating minimal depression were defined as not having clinically relevant depressive symptoms.
Data collection procedures
Ethical approval to conduct the study was obtained from all relevant ethical committees (three committees). After this, all of the heads of the selected CCHs were contacted and briefly informed about the objective of the study, and an appointment was made to visit the CCHs. Essential information relating to the proceedings of the study was given to the person assisting with the data collection and to the eligible participants. Written consent was obtained from the caregivers of the centers and from the participating adolescents. The data were then collected via the self-administered questionnaire. Before collecting the data, all questions were explained to the participants; any confusion or questions that arose while the participants were filling out the questionnaire were addressed. At the same time, the weight and height of the participants were measured. To reduce instances of missing data, all completed questionnaires were double-checked before leaving the CCH.
Statistical analysis
All gathered data was checked, compiled, coded, and entered into MS Excel and then transferred into IBM SPSS version 20 (SPSS, Chicago, IL) for the analysis. In the descriptive analysis, categorical variables were analyzed by frequency and percentage, while the continuous variables were described as the mean and standard deviation (SD) to present the general characteristics of the participants. Logistic regression was used to determine the factors associated with clinically relevant depressive symptoms, and the significance at α = 0.05 was ascertained in the univariate and multivariate analyses. When selecting the independent variables for the model, the “ENTER” mode was used. Before model interpretation (including the final model), the Cox-Snell pseudo R2, the Nagelkerke R2, and the Hosmer-Lemshow chi-square values were used to determine the fit of the model.