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Depressive symptoms and somatic complaints among Zambian adolescents: Does a Western model of stress and coping translate?

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Angela L Neese
Abstract:
Based on the previously published research, the associations between perceived stress, coping strategies, depressive symptoms, and somatic complaints were examined in an exploratory study of 230 Zambian adolescents. Measures widely used with North American adolescent samples were used to assess most constructs including the Adolescent Perceived Events Scale, the COPE inventory, the Center for Epidemiologic Studies Depression Scale, and the Children's Somatization Inventory. In addition, the Collective Coping Scale, which was developed for use in non-American populations, was used to assess a specific coping strategy that may be utilized within collective cultures like Zambia. Although some subscales demonstrated inadequate internal consistencies, the majority were adequate and the overall psychometric properties of these measures seemed acceptable to explore the associations of interest in this Zambian sample. Zambian adolescents reported high levels of depressive symptoms and somatic complaints, indicating a need to gain further insight into factors influencing this population. As has been found in other populations, perceived stress due to negative life events was found to be positively associated with both depressive symptoms and somatic complaints. However, unlike some previous research, approach coping was found to be positively associated with depressive symptoms. In addition, approach coping moderated the relationship between stress and somatic complaints whereas as stress increased so did somatic complaints in adolescents who used low levels of approach coping, but not in those who used high levels of approach coping. Neither avoidant coping nor collective coping was associated with either of the internalizing symptoms examined. The possible cultural explanations for these findings as well as limitations of the study and future directions were discussed.

TABLE OF CONTENTS Page LIST OF TABLES .................................................................................................. viii LIST OF FIGURES .................................................................................................... x LIST OF APPENDICES ............................................................................................ xi Chapter 1. LITERATURE REVIEW ............................................................................ 1 Depression in Developing Countries .................................................... 2 Assessment of Theoretical Constructs Across Cultures ........................ 4 Zambian History and Culture ................................................................ 8 Spiritual Influences ....................................................................... 11 Adolescence in Zambia ................................................................. 13 Stressful Life Events ........................................................................... 16 Stressful Life Events and Depression ........................................... 17 Stressful Life Events in Adolescence ............................................ 19 Assessment of Stressful Life Events Among Zambian Adolescents ................................................................................... 21 Coping ........................................................................................... 23 Coping Models .............................................................................. 24 Coping and Depression ................................................................. 29 Coping as a Moderator .................................................................. 33

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Chapter Page Coping and Somatic Complaints ................................................... 34 Coping in Adolescence ................................................................. 35 Assessment of Coping Among Zambian Adolescents .................. 36 The Current Study ............................................................................... 39 2. METHOD .................................................................................................. 48 Participants .......................................................................................... 48 Procedure ............................................................................................. 50 Measures ............................................................................................. 52 Background Questionnaire ............................................................ 52 Stressful Life Events ..................................................................... 52 Coping Strategies .......................................................................... 55 Collective Coping ......................................................................... 59 Depressive Symptoms ................................................................... 61 Somatic Complaints ...................................................................... 62 3. RESULTS ................................................................................................. 65 Description of Sample ......................................................................... 65 Reliability and Validity of the Measures ............................................ 67 The COPE ..................................................................................... 67 Adolescent Perceived Events Scale (APES) ................................. 72 Children’s Somatization Index (CSI) ............................................ 76 Collective Coping Scale ................................................................ 78

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Chapter Page Description of Major Study Variables ................................................. 78 Control Variable Analyses .................................................................. 80 Correlation Analyses ........................................................................... 85 Coping and Symptom Measures ................................................... 85 Collective Coping ......................................................................... 86 Regression Analyses ........................................................................... 88 4. DISCUSSION ........................................................................................... 99 Assessment in Zambian Adolescents ................................................ 100 Reliability .................................................................................... 100 Validity ........................................................................................ 106 Exploratory Findings ......................................................................... 111 Age .............................................................................................. 112 Stress ........................................................................................... 112 Coping ......................................................................................... 113 Limitations ........................................................................................ 118 Future Directions ............................................................................... 120 REFERENCES ....................................................................................................... 127 APPENDICES ........................................................................................................ 148

LIST OF TABLES

Table Page 1. Demographic Frequencies ......................................................................... 66

2. Cronbach’s Alpha Reliability Coefficients for COPE Subscales Compared to American Samples ............................................................... 68

3. Factor Loadings for Exploratory Factor Analysis of COPE Subscales .... 70

4. Factor Loadings for Exploratory Factor Analysis of CES-D Items .......... 75

5. Psychometric Properties of the Major Study Variables ............................ 79

6. Means and Standard Deviations of Variables by Gender and English Spoken in Home ........................................................................................ 82

7. Means, Standard Deviations and Analysis of Variance for Coping and Symptom Measures by Location of Family Homes .................................. 83

8. Means, Standard Deviations, and Analyses of Variance for Coping and Symptom Measures by Culture ................................................................. 84

9. Pearson Correlations Between Variables .................................................. 86

10. Pearson Correlations Between COPE Subscales ...................................... 87

11. Zero-Order Correlations between COPE Factors and Subscales and Collective Coping ..................................................................................... 88

12. Hierarchical Regression Predicting Depressive Symptoms and Somatic Complaints by Age and Perceived Stress .................................................. 89

13. Hierarchical Regression Predicting Depressive Symptoms and Somatic Complaints by Coping Subscales ............................................................... 91

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Table Page 14. Multiple Regression Predicting Depressive Symptoms and Somatic Complaints by Coping and Stress ............................................................. 94

15. Multiple Regression Predicting Depressive Symptoms and Somatic Complaints by Collective Coping and Stress ............................................ 97

LIST OF FIGURES

Figure Page 1.Graph of APES x Coping Style Interaction .......................................................... 96

LIST OF APPENDICES

Appendix Page

A. CONSENT FORM ................................................................................. 148

B. ASSENT FORM ..................................................................................... 151

C. EXPERIMENTER SCRIPT .................................................................... 154

D. BACKGROUND QUESTIONNAIRE ................................................... 157

E. ADOLESCENT PERCEIVED EVENTS SCALE ................................. 159

F. COPE ...................................................................................................... 169

G. COLLECTIVE COPING SCALE .......................................................... 176

H. CENTER FOR EPIDEMIOLOGY SCALE – DEPRESSION ............... 178

I. CHILDREN’S SOMATIZATION INVENTORY ................................. 182

J. DEBRIEFING ......................................................................................... 184

K. FREQUENCY OF APES ITEM ENDORSEMENT .............................. 186

CHAPTER 1 LITERATURE REVIEW

Although extensively researched in North America and Western Europe, mental health issues are only recently beginning to gain attention in developing cultures. Worldwide, various studies indicate as many as 30-40% of all adults seeking medical treatment in developing countries have a psychological disorder that is often left undiagnosed and untreated (WHO, 2005). In the last decade, depression has been recognized as a significant problem in developing countries which likely has been, and continues to be, underreported (Patel, Abas, Broadhead, Todd, & Reeler, 2001; WHO, 2001). Community surveys in developing countries have shown incident rates of depression ranging from 15-50% depending on the population surveyed (Broadhead & Abas, 1998; Mumford, Saeed, Ahmad, Latif, & Mubbashar, 1997; Patel et al., 2001). The World Health Organization (2005) reported that rates of depression and suicide are increasing among adolescents in developing countries. In studies of North American adolescents the annual incidence of clinical depression increases from 3 – 18% between the ages of 15 and 18 years (Hankin et al., 1998) and 35-40% of adolescents in this age range exhibit depressive symptoms (Petersen et al., 1993). However, little epidemiological information is available with regard to child and adolescent mental disorders in developing countries (WHO, 2004). There is also

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little research regarding how precipitating and protective factors affect depression in these adolescents. The WHO (2005) study suggested possible precipitating factors of adolescent depression including the substantial stressors of stringent academic pressures, high prevalence of sexual abuse, and extreme poverty found in developing countries. Magaya, Asner-Self, and Schreiber (2005) found Zimbabwean adolescents to be experiencing a high degree of stress. Many of these stressors were similar to those experienced by adolescents in Western studies, such as the pressure for academic success, but others were more specific to adolescents in Africa, such as experiencing the death of a family member to HIV/AIDS . A study of what factors are linked to depression in African adolescents seems appropriate, if not overdue. Thus, the current study examined stressful life events, coping, depressive symptoms and somatic complaints in adolescents residing in the sub-Saharan, African country of Zambia.

Depression in Developing Countries

Developing countries have many stressors that may contribute to depression, such as poverty, homelessness, limited health services, and gender inequality (e.g., Mufune, 2002; Patel et al., 2001). Poverty plays an important role in the prevalence of depression in these countries, as the relationship is circular (Patel et al., 2001; WHO, 2005). Factors associated with poverty are linked to depression, whereas depression also leads to behaviors that would limit productivity and the ability to earn money. For example, research in developing countries indicates that individuals

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with depression were ill (i.e., spent the day in bed) or were unable to carry out daily activities more than twice as often as individuals without depression (WHO, 2005). Similarly, Patel et al. (2001) found depressed individuals scored significantly higher on measures of social, psychological, and functional disability, which impaired their ability to work, necessitated more health care, and otherwise contributed to an increased likelihood for poverty. This cycle of poverty, disability, and depression has been found in several developing countries including Zimbabwe and Peru (e.g., Broadhead & Abas, 1998; Mumford, Saeed, Shmad, Latif, & Mubbashar, 1997; WHO, 2010a). In addition, heath-related concerns are prominent in developing counties and add stressors that likely contribute to depressive symptoms in the Zambian population. High infant mortality rates as well as short life expectancies compound the prevalence of disease and increase the likelihood of individuals experiencing loss of loved ones (WHO, 2010a). Colson (2006) reported that an increased preoccupation with the threat of death for the Zambian population has emerged within the past 15 years, due to the prevalence of HIV/AIDS-related deaths. Although no prevalence rates for adolescent depression in Zambia are available, specific depressive symptoms have been assessed. Three specific indicators of internalizing problems were investigated in a World Health Organization (2004) study conducted with seventh- through tenth-grade students in Zambia (N = 3,021). The assessment indicated that 24.1% of participants felt lonely the majority of the time during the past year, 26.4% felt worried most of the time,

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and 31.9% of participants had considered attempting suicide during the previous year. The prevalence of these symptoms suggests that the adolescent rate of depression in Zambia is likely similar to the rates of adult depression reported in developing countries by the WHO (2005). Adolescents in Zambia are growing up in a time of fear of illness, losses due to AIDS, and the impoverished conditions of a developing country, making depression a salient construct for this population.

Assessment of Theoretical Constructs Across Cultures

Given this study’s focus on adolescents from Zambia, several things need to be considered, including the impact of the cultural context and the operationalization and measurement of theoretical constructs (Wong, Wong, & Scott, 2006). Two main approaches aid understanding constructs in an understudied population. An emic approach identifies important constructs within a culture, typically building from the input of members of that population, themselves (i.e., qualitative interviews or observational approaches). An etic approach applies constructs researched in other cultures and thought to be more culturally universal in nature, to determine their applicability to the culture under examination (Alegria et al., 2009; Guerra & Jager, 1998; Phinney & Landen, 1998). The current study is etic in nature, as it examines a Zambian sample utilizing constructs that have been well established in a variety of other cultures. However, as suggested by Phinney & Landen (1998), the examination of constructs within a population allows for a better understanding of how these

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constructs may function uniquely, without leading to a deficit approach which can occur when comparing constructs developed in other countries to a new population. An important aspect of cultural context is the prioritization of personal versus group goals, which is typically referred to as the individualistic vs. collective nature of the culture (Kâğitçibai, 1997). While no culture can be defined as purely collective or individualistic (Schwartz, 1990), in general Zambian culture is collective in nature (Arnett, 2007; Colson, 2006) and may affect assessment in several ways. First, use of self-report measures requires that participants feel comfortable answering questions openly and honestly. In collective cultures, individuals rarely feel comfortable sharing personal information with outsiders (Arnett, 2007; Fukuyama, 1996). Additionally, withstanding stressors silently without burdening others is often considered a strength in collective cultures (Hobfoll, 1998), which may lead to a hesitance to report negative events or feelings. Finally, African collective cultures do not value forthright communication, especially if they feel it may cause discomfort for another person (Hobfoll). It is possible that because of a desire to make the researcher comfortable, a participant might hesitate to share potentially embarrassing topics. The employment of a self-report survey format, as compared to an interview format, may help participants avoid feelings of impropriety that may arise in direct communication, and thereby provide a more comfortable way of sharing experiences. Nsamenang and Dawes (1998) assert that research with African cultures should be a process in which the community is allowed to become familiar with

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individuals conducting research, and that care is taken to ensure the community does not feel coerced. Historically, anthropological and psychological research has been exploitive of African cultures and still impacts current attitudes and beliefs (Nsamenang & Dawes). These concerns can affect almost all aspects of data collection. For example, in research with children or adolescents, the presentation of a parental consent form may enhance, rather than alleviate, discomfort. Many collective cultures do not have the same proprietary feelings toward their children and generally rely on other adults in the community to help care for them (Clark, Colson, Lee, & Scudder, 1995). Combined with long histories of exploitations by Western countries, it is common for Africans to assume that anything requiring a signature must have serious implications (Maranz, 2001). Thus the concept of a written agreement allowing a child to participate in research may cause parents discomfort. Awareness of these considerations is important when conducting research in this culture. Additionally, collective values may influence the interpretation of some psychological constructs. For example, the appraisal of a life event or approaches to coping with stress may vary greatly between collective cultures and North American or other Western cultures. For example, self-efficacy, internal locus of control, and optimism are constructs thought to impact the perception of stressful events. These may be highly influenced by Western democratic views that value individual rights and freedoms (Wong et al., 2006). The influence of collective cultures would be likely to change the ways in which these constructs affect the experience of

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psychological distress. Coping strategies or beliefs found to be adaptive in Western cultures may not have the same adaptive effect in a more collective culture. Other constructs which may be targets of assessment, such as stress and depression, are, by definition, likely to be universally experienced as negative. However, cultural influence may lead to vastly different manifestations of these constructs. Patel et al. (2001) found depressive symptoms reported in Zimbabwe to be perceived as significantly distressing by participants, with somatic complaints being the most common manifestation of clinical depression. Somatic complaints are not specific to any individual culture and have been found to be related to depressive symptoms across a variety of cultures (Kirmayer, 2001). However, cultural value systems are thought to influence the regulation and expression of emotions and many parts of the world do not view emotional difficulties as social or moral problems for which seeking medical care is appropriate (Kirmayer, 2001). These influences may help foster a somatic expression of the emotional distress (Tomlinson, Swartz, Kruger, & Gureje, 2007). The high rate of depression found in individuals seeking medical attention in developing countries suggests that somatization may be a more culturally relevant expression of depressed mood in collective cultures (i.e., Chipimo & Fylkesnes, 2009; Fenta, Hyman, Rourke, Moon, & Noh, 2010; Kirmayer, 2001). Overall, the presentation of somatization as a primary concern has been shown to be higher in collective cultures than in Western, more individualistic cultures (e.g. Kirmayer, 2001; Kleinman, 1977; Patel et al., 2001). Therefore, when assessing

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depressive symptoms in collective cultures it is important to consider somatic symptoms as additional indicators of internalizing distress. Collectively, these concerns about measuring constructs across cultures suggest the need to evaluate the psychometric properties of measures developed with American samples, including those used to assess depressive symptoms and somatic complaints, to determine if they are appropriate to use with Zambian adolescents. Guerra and Jager (1998) suggested that the examination of a measure’s internal consistency and factor structure are important first steps to determine whether it can appropriately be used in a new population. The internal consistency of a measure indicates whether it is reliable within the new population while the factor structure suggests whether the construct measured matches what is theoretically expected. Both of these suggest whether the measure is representing the construct in expected ways or whether there may be differences compared to the measure’s use in other populations (Guerra & Jager, 1998).

Zambian History and Culture

To understand further the cultural influences on the development of depression and somatization among adolescents in Zambia, some information about the history and government of the country is needed. Zambia is a sub-Saharan, land- locked, African country with nine provinces. Previously known as Northern Rhodesia, Zambia was a British colony until 1964 when the country gained its independence. Two of the country’s nine provinces are predominately urban, and the

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remaining provinces are rural with an agricultural economy. The provinces typically encompass one or two communities, or tribal groups, with relatively little conflict between communities (e.g., Colson, 2006; Irvine, 1969), and many Zambian children have parents from two different communities or lineages (Arnett, 2007). At various times, Zambia has adopted both single- and multiple-party political systems, and in the present decade has become a model of multi-party democracy for sub-Saharan Africa (Bratton & Mattes, 2000). Zambia is currently a country where freedoms are more prevalent than many neighboring countries such as Zimbabwe (S. Clark et al., 1995). Zambia’s official national language is English, but a wide variety of languages and dialects exist within the country, and seven additional official Zambian languages are used for the purposes of circulating information (Arnett, 2007). In 2008, the Central Statistical Office (CSO) of Zambia reported the population to be 12.6 million, with approximately 46% of the population under the age of 15 (WHO, 2010c). Like most African countries, Zambia is impacted by a high rate of HIV/AIDS. The World Health Organization (2010c) estimated that 1,077,000 individuals over the age of 15 (i.e., 15.2% of the total population) are living with HIV/AIDS in Zambia. The level of HIV/AIDS in Zambia leads to high rates of mortality, orphaned children, and child-headed households as well as additional individual economic, social, and emotional stressors (Foster & Williamson, 2000). Twenty percent of Zambian children under the age of 19 have lost both parents, largely due to HIV/AIDS (Arnett, 2007). The country is also impacted greatly by a

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vast degree of poverty and limited or unreliable access to resources (e.g., Sahn & Stifel, 2000; van Donge, 1985). In 2006, the average family income was less than 20 US dollars a month (CSO, 2002). The collective nature of Zambian society emphasizes taking responsibility for others over oneself (Arnett, 2007; Hofer, 2003). Although no culture can be described as exclusively collective or individualistic, African cultures tend to be more collective in nature. Resources are shared within a community, and social norms dictate this practice even within extremely impoverished groups (Ngulube, 1989). Family life is highly valued in Zambian culture, and both sexes live with family members until they are married, which tends to occur in late adolescence or early adulthood (Arnett; Taylor, 2006). Extended family plays a large role in Zambian adolescents’ lives. In Zambia, no distinction is made between a mother and a maternal aunt or between a father and a paternal uncle. Children have access to all of these family members, and all are expected to take on parental roles for all children in the family. However, in urban areas, large extended family groups rarely live together, decreasing the amount of additional outside support available to adolescents. This separation from extended family also allows less traditional, outside cultural factors to have a greater influence on children and adolescents than adults (Arnett). Recent Western influence seems to be contributing to a rise in individualistic approaches to the concepts of resources (Arnett, 2007). For example, many younger Zambians are seeking education and striving for upward mobility (Hofer &

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Chasiotis , 2004). Additionally, wireless phone technology and satellite communications have enabled access to a much broader influence of media, which was not previously available. This technological growth was the result of the Connect Africa Zambia (CAZ) initiative specifically designed to allow marginalized rural areas to become more connected with other Zambian communities (Mulenga, 2009). This change has contributed to a complex mix of indigenous traditions and beliefs and Western influences. Rapid westernization of the African society has increased potential stressors on all age groups, but is likely to have an even greater impact on adolescents developing their identity as adults.

Spiritual Influences

The traditional spiritual fabric of Zambian culture has changed more slowly. Spirituality in Zambian has been influenced for decades by Christian missionaries who provided educational and medical services complementary to those provided by the government (Colson, 2006). The majority of Zambians identify themselves as Christian (Arnett, 2007; Colson). However, other faiths, such as Islam, Buddhism, Baha’i, and Hinduism, are also practiced, and all religious beliefs are influenced by traditional indigenous beliefs (Arnett). Traditional tribal beliefs emphasize the role of ancestral spirits as mediators with God (Mbiti, 1990) as well as the constructs of witches and evil spirits enacting curses placed on individuals (Colson). In Zambia, adolescents are typically very active in churches. Church participation is often shared with family and community members; however,

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adolescents often play a leadership role in the church and participate in singing groups (Arnett, 2007). Singing is a significant means of storytelling and passing along historical information in Zambian culture (Taylor, 2006). Members of these singing groups often socialize outside of church and support each other (Colson, 2006). Alternately, adolescents are often influenced by “cults of affliction” or “communities of affliction,” which are separate from communities based on family lineage or geographical neighborhood (Colson). These groups interpret adversity and hardship as being inflicted by a spirit and advocate joining the group in order to remove or repel the spirit (Arnett). In addition to providing a group identity, both church singing groups and “cults of affliction” provide some form of an explanation for life’s hardships and a promise of eventual relief from misfortune. Zambians, like members of many African cultures, often ascribe their illness to witchcraft, curses, or evil spirits (WHO, 2005). Despite the influence of various religious faiths, these beliefs are ingrained in Zambian culture and often blend with Christianity or other religions, resulting in a uniquely African faith (Colson, 2006). When experiencing physical or emotional distress, Africans first seek help from a religious figure or a traditional healer, known in Zambia as a “witch finder” (Colson 2006; Tomlinson et al., 2007). In addition to these cultural reasons, medical health care is not readily accessible to many Zambians and most health care providers are limited in their ability to handle many problems, especially those related to mental health (WHO, 2005). The World Health Organization recommends that Zambian health care providers respect the role of spiritual healers and attempt to fit into the

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cultural model, especially in rural Zambian communities where the spiritual healers may discourage, or even forbid, patients to seek medical treatment (Colson, 2006; WHO, 2005). In Zambia religion influences all aspects of daily life. Any attempt to study or explain stressors and reactions in their lives must also address the religious beliefs of the culture.

Adolescence in Zambia

The transition from childhood to adulthood places many inherent stressors on individuals in all cultures. Zambian culture, like American culture, recognizes a period of adolescence, generally thought to coincide with the onset of puberty (Arnett, 2007; Mwanalushi, 1979; Ngulube, 1989). In a study of 2,638 Zambian school children Katzarski, Rao, and Brady (1980) found two indicators of the onset of puberty, the appearance of pubic hair and axillary hair both occurred in the group of 9-year-old girls and 10-year-old boys. These findings are similar to more recent research on similar sub-Saharan developing countries where the onset of puberty in girls is comparable to the 1980 data reported by Katzarski (Thomas, Renaud, Benefice, DeMeeus, & Guegan, 2001) as well as patterns found in the United States, where girls reach puberty before boys (Lee, Guo, & Kulin, 2001). Within the Tonga culture of Zambia, boys living in rural villages have been found to have higher levels of malnutrition and later ages of puberty onset than urban youth (Campbell, Gillette- Netting, & Meloy, 2004). It is likely that girls demonstrate a similar pattern. In some areas of the country, adolescence is more logically defined by a child’s degree of

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responsibility rather than age. These children or adolescents often contribute to family income, help gather resources such as water and firewood, or take charge of their younger siblings (Arnett). This combination of adult and juvenile roles is thought to be an added stressor on these adolescents (Ngulube). Educationally, approximately 30% of Zambian adolescents attend school, but only 10% complete secondary education and pursue higher education (Arnett, 2007). Secondary schools have limited availability, and students must first pass national examinations in order to move from primary to secondary school and then pass another test to graduate from secondary school (Arnett). Throughout sub-Saharan Africa, higher percentages of children are attending school, and more children are remaining in school longer than in the past (Blum, 2007). However, no alternative forms of occupational education are provided for students who are not able to attend secondary school in Zambia (Arnett). The distinct differences in opportunities available to the students with versus those without secondary education lead to a high level of pressure on students from teachers, parents, and themselves (Magaya et al., 2005). Additional stressors are placed on Zambian adolescents at earlier ages than many other cultures, including other collective cultures. They are often given adult responsibilities at a younger age (Nsamenang & Dawes, 1998). The legal age of adulthood in Zambia is 18, but adulthood is more frequently defined by responsibility and social role than age (Arnett, 2007). For example, Zambian adolescents who become married are automatically considered adults (Ngulube,

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1989). Many Zambian communities participate in rites of passage into adulthood, which often involve joining groups of adult dancers and honoring ancestors in some way (Arnett). Girls in the majority of Zambian communities undergo a rite of passage when they reach menarche (Arnett). These rites are often religious in nature and involve the honoring of ancestors who are believed to protect the young women and make them fertile (Colson, 2006). Although the legal age for marriage is 16 for both males and females (Organization for Economic Co-Operation and Development, 2006), some adolescents marry earlier than 16. Lately, however, it is not uncommon for adolescents enrolled in school to wait until they are in their twenties to marry, especially if they continue to postsecondary education (United Nations, 2004). As part of this developmental period, Zambian adolescents openly engage in sexual practices (Pillai & Gupta, 2000). The majority of adolescents report being sexually active by their mid-teen years, with some younger female adolescents being pressed into prostitution to help support their families (Arnett, 2007). The experience of dating and engaging in consensual sexual behavior is similar in many ways to that of American adolescents, and is likely to lead to similar stressors. However, developing sexually in a country with an HIV/AIDS epidemic is likely to contribute to stress levels among Zambian adolescents as compared with American adolescents. The additional stressors of poverty and significant health concerns compound the prevailing stressors of adolescence (i.e., identity development, academics, and sexual maturation) to make Zambian adolescents a unique group to study.

Full document contains 207 pages
Abstract: Based on the previously published research, the associations between perceived stress, coping strategies, depressive symptoms, and somatic complaints were examined in an exploratory study of 230 Zambian adolescents. Measures widely used with North American adolescent samples were used to assess most constructs including the Adolescent Perceived Events Scale, the COPE inventory, the Center for Epidemiologic Studies Depression Scale, and the Children's Somatization Inventory. In addition, the Collective Coping Scale, which was developed for use in non-American populations, was used to assess a specific coping strategy that may be utilized within collective cultures like Zambia. Although some subscales demonstrated inadequate internal consistencies, the majority were adequate and the overall psychometric properties of these measures seemed acceptable to explore the associations of interest in this Zambian sample. Zambian adolescents reported high levels of depressive symptoms and somatic complaints, indicating a need to gain further insight into factors influencing this population. As has been found in other populations, perceived stress due to negative life events was found to be positively associated with both depressive symptoms and somatic complaints. However, unlike some previous research, approach coping was found to be positively associated with depressive symptoms. In addition, approach coping moderated the relationship between stress and somatic complaints whereas as stress increased so did somatic complaints in adolescents who used low levels of approach coping, but not in those who used high levels of approach coping. Neither avoidant coping nor collective coping was associated with either of the internalizing symptoms examined. The possible cultural explanations for these findings as well as limitations of the study and future directions were discussed.