Graphical abstract

Introduction

According to the World Health Organization (WHO), mental disorders account for 3 of the top 10 causes of disability in individuals aged 15 to 44 years and are often associated with other factors [1,2]. A meta-analysis examining the onset of common mental disorders (CMDs) throughout the lifetime found that approximately 50% of CMDs cases began by age 14 and 75% by age 18 [3]. The prevalence of CMDs among young people varies across studies. One review spanning multiple countries indicated that about 25% of children and adolescents were affected by CMDs [1]. Additionally, a WHO international survey involving college students from 8 countries reported that 31% of respondents had experienced CMDs [4].

One theoretical framework concerning mental health status suggests that a combination of inherent factors (gender and age), demographic factors (education, employment, socioeconomic status, and place of residence), health, and behavioral factors collectively determine an individual’s mental health status [5]. Previous studies have identified a range of behavior-related issues that can impact mental health, including sleep disturbances, poor dietary habits, smoking, and drinking [6,7], as well as early sexual activity and excessive screen time or internet use [8]. The mental health of adolescents is significantly influenced by social behavioral factors, such as peer interactions and community support [6]. Additionally, demographic characteristics [6,9] and area of residence—urban [10] or rural [11]—have been linked to the prevalence of mental health disorders, although the findings have been inconsistent.

Multiple studies have identified an elevated vulnerability to mental health issues in urban populations, as evidenced by research on mental illness and depression in Denmark, Canada, and Indonesia [12–14]. Conversely, some previous research has suggested a heightened risk of mental health problems in rural communities, as seen in a study conducted in West Java, Indonesia [15]. Research in Germany also reported that among residential settings, rural areas experienced the greatest increase in the prevalence of depression within adolescent and adult populations between 2009 and 2017 [16]. However, a study among university students in Bangladesh revealed no significant difference in the prevalence of depression or anxiety between urban and rural residents [17].

Previous research has explored the determinants of mental health in either rural [18,19] or urban settings [20]. However, these studies have typically focused on a single population and have not compared the determinants between urban and rural environments. Urban health hazards differ from those in rural areas. The rise in non-communicable diseases, including CMDs, is attributed to the unhealthy lifestyles prevalent in urban areas, which include physical inactivity, poor diet, tobacco use, and excessive alcohol consumption [21]. Conversely, in rural regions, challenges in managing mental health issues are generally due to lower mental health literacy, reduced access to care, and underutilization of mental health services [11]. Previous research employing a theoretical framework to assess mental health status, considering inherent, demographic, health, and behavioral factors [5], only accounted for health-related behaviors associated with the consumption of addictive substances, such as cigarettes and khat leaves, which are known for their stimulant and euphoric effects. This study omitted khat leaves from consideration, as they are not commonly used by Indonesian youth. Furthermore, it included indicators of vegetable, fruit, and alcohol consumption in the analysis of behavioral factors representing potential determinants of mental health issues.

CMDs affect health conditions and quality of life [18] and have emerged as a leading cause of disability [22]. This can lead to economic losses due to reduced productivity and increased medical expenses [23]. In low-resource communities, the prevalence of CMDs can present a challenge due to inadequate mental health services. As a result, individuals with CMDs may not be able to access or pursue the necessary treatment [24]. CMDs are also associated with a relatively high incidence of suicidal thoughts among adolescents with moderate to severe depressive symptoms [22]. Additionally, children with a depressed parent face an increased risk of developing depression themselves [25]. These impacts of CMDs underscore the urgency of addressing this issue. Understanding the different factors influencing youth CMDs in urban and rural areas is crucial for designing effective strategies to prevent mental health problems among young people. This study aimed to identify the differences in risk and determinants of CMD prevalence among youth in rural and urban areas of Indonesia.

Materials and Methods

Study Design

This study utilized data from the 2018 Indonesia National Health Survey (INHS), a cross-sectional survey conducted by the National Institute of Health Research and Development (NIHRD) under the auspices of Indonesia’s Ministry of Health [26].

Samples

A multistage systematic random sampling method was used for participant selection. The initial phase involved identifying census blocks (CBs) as the primary sampling units (PSUs). Within each PSU, CBs were chosen using a probability proportional to size approach, which was based on the master sampling framework of the Indonesia Central Bureau of Statistics. This selection process yielded 180,000 CBs from a total of 720,000. These CBs represented a mix of urban and rural areas across each sub-district at the district level. The INHS carried out the sampling procedure in partnership with the Indonesia Central Bureau of Statistics. Regions were classified as urban or rural according to definitions provided by the Indonesia Central Bureau of Statistics. Face-to-face interviews were conducted with all eligible household members who had lived there for at least 6 months and were part of the same food management unit. Our analysis was focused on individuals aged 15 to 24 years, of whom 123,201 took part in the survey. However, we excluded 1,087 participants from our analysis because they did not complete the 20-item Self-Report Questionnaire (SRQ-20). Consequently, our study included complete data from 122,114 individuals (Figure 1) [26].

Variables

The outcome variable in this study was the presence of CMDs, which was assessed using the SRQ-20. This instrument comprised 20 yes-or-no questions that inquired about the participants’ feelings over the past month. The cut-off point for this study was set at 6; participants who answered “yes” to 6 or more questions were considered to be experiencing a mental-emotional disorder [27].

The study incorporated a variety of independent variables, which included inherent factors (gender and age), demographic elements (education, marital status, employment, socioeconomic status, and place of residence), and behavioral aspects (fruit and vegetable consumption, smoking status, and alcohol intake). Data on gender, age, education level, employment status, socioeconomic status, place of residence, and marital status were gathered using a validated questionnaire and through interviews with the study participants. Gender was categorized as either male or female. Age was classified into 2 groups: 15 to 18 years, representing early young adulthood, and 19 to 24 years, representing young adulthood [28]. Education level was segmented into 5 categories: none, elementary school, junior high school, senior high school, and university. Marital status was divided into 3 groups: unmarried, married, and divorced. Place of residence was distinguished between urban and rural settings.

Employment status was categorized as employed, unemployed, or student. Socioeconomic status was determined using the classifications from the Indonesia Central Bureau of Statistics, which consider household assets, average income, and expenditure. These factors are then used to assign placement within a wealth index that is divided into 5 quintiles, with 1 representing the poorest and 5 constituting the richest [29].

Smoking status was categorized into 3 groups: non-smoker, occasional, and daily. Non-smokers were individuals who reported never having smoked. Occasional smokers were respondents who smoked from time to time, while daily smokers were those who smoked every day. Alcohol consumption was classified into 2 categories: “yes” for participants who consumed alcohol in the prior month and “no” for those who did not consume alcohol in the month preceding the interview.

Fruit consumption was categorized as “yes” for participants who consumed at least 7 portions of fruit per week and “no” for those who consumed fewer than 7 portions per week. Similarly, vegetable consumption was classified into 2 categories: “yes” for consuming at least 7 portions of vegetables per week and “no” for consuming less than this amount [30].

Data Analysis

The research variables were analyzed using descriptive, bivariate, and multivariate analyses. Descriptive statistics were utilized to characterize respondent demographics. In bivariate analysis, the chi-square test was used to explore the relationship between the independent and the dependent variables. Logistic regression analysis was conducted to determine the adjusted associations between CMDs and various independent variables. To ensure an accurate assessment of the risk difference associated with urban or rural residence in youth mental health, while accounting for other variables in comprehensive multivariate models, adjustments were made for demographic variables (education, marital status, employment, and socioeconomic status), inherent variables (gender and age), and behavioral variables (smoking status and consumption of alcohol, fruits, and vegetables). Statistical analyses were performed using IBM SPSS for Windows ver. 21.0 (IBM Corp.).

Ethics Statement

Ethical approval for this study was granted by the Ethical Committee of Health Research at the NIHRD, Ministry of Health, Republic of Indonesia, under the approval number LB.02.01/2/KE.267/2017.

Results

Table 1 displays the characteristics of the study sample. Among the 122,114 participants, the prevalence of CMDs was higher in urban environments (10.4%) compared to rural areas (8.9%). The distribution of male and female participants was approximately equal in both settings. In urban areas, more participants were aged 19 to 24 years (52.6%) than 15 to 18 years (47.4%). Conversely, in rural areas, participants aged 15 to 18 constituted a higher percentage (51.4%) than those aged 19 to 24 (48.6%). Regarding education level, a substantial proportion of urban youth achieved higher education, most frequently senior high school (42.4%) but in some cases university (6.0%). In rural areas, the largest proportion of participants had completed up to junior high school (39.6%), while the smallest had attained a university-level education (2.8%). A greater proportion of youth in rural areas were married (21.9%) relative to urban areas (13.3%). In terms of employment status, students represented the largest group of participants in both rural (36.6%) and urban (41.5%) areas. The greatest number of respondents in urban areas fell into the wealthiest socioeconomic quintile (31.4%), nearly 3 times the proportion found in rural areas (11.7%). The largest socioeconomic category in rural areas was the poorest quintile (23.5%). Most participants consumed fewer than 7 portions of fruits and vegetables per week in both urban (fruits, 86.3%; vegetables, 51.1%) and rural (fruits, 91.9%; vegetables, 50.6%) areas. Fruit consumption of 7 or more portions per week was more common in urban areas (13.7%), while higher vegetable consumption (≥7 portions per week) was more frequent in rural areas (49.4%). Most participants in both urban (73.4%) and rural (72.6%) areas were non-smokers. Similarly, a high percentage of participants did not consume alcoholic beverages in both urban (95.0%) and rural (94.2%) settings.

The results presented in Table 2 delineate the risk factors associated with CMDs in urban and rural settings. No significant association was observed between age and CMDs in either urban or rural populations (p>0.05). In terms of the adjusted odds ratio, in urban areas, female respondents were 2.993 times more likely than male participants to have CMDs (95% confidence interval [CI], 2.664–3.363). Individuals with only an elementary school education had a 2.093 times higher risk of CMDs than those with a university education (95% CI, 1.639–2.674). Regarding economic status, individuals in the fourth quintile (“rich”) and those in the second quintile (“poor”) had a lower likelihood of experiencing CMDs, by 0.868 times (95% CI, 0.760–0.991) and 0.869 (95% CI, 0.756–0.998) times respectively, compared to those in the fifth quintile (“richest”).

Regarding fruit consumption, respondents who consumed fewer than 7 portions per week were 1.168 times more likely to have CMDs than those who consumed 7 or more portions per week (95% CI, 1.022–1.335). In terms of weekly vegetable intake, individuals consuming fewer than 7 portions per week were 1.346 times more likely to have CMDs compared to those eating 7 or more portions per week (95% CI, 1.231–1.472).

The findings revealed that urban residents who smoked, either occasionally or daily, were at a 2.119-fold (95% CI, 1.812–2.478) or 2.020-fold (95% CI, 1.734–2.354) increased risk of developing CMDs, respectively, compared to non-smokers. Urban respondents who consumed alcohol were found to be 2.283 times more likely to experience CMDs than those who abstained (95% CI, 1.916–2.721). In urban settings, neither marital status nor employment status was significantly linked to the likelihood of CMDs (p>0.05). Similarly, no significant association was found between CMDs incidence and being in the middle or poorest economic quintile (p>0.05).

In rural areas, female participants were 2.889 times more likely to experience CMDs than male respondents (95% CI, 2.557–3.267). Respondents with no education were 1.906 times more likely to experience CMDs compared to those with a university-level education (95% CI, 1.415–2.567). Divorced respondents exhibited a 1.772 times higher risk of experiencing CMDs than those who were unmarried (95% CI, 1.245–2.381). In turn, being married appeared to represent a protective factor against CMDs in rural areas, with married respondents having a 0.842 times lower risk of CMDs than their unmarried counterparts (95% CI, 0.751–0.945).

Unemployed respondents were 1.265 times more likely to experience CMDs than their employed counterparts (95% CI, 1.139–1.404). Those who consumed fewer than 7 portions of vegetables per week were at a 1.179 times greater risk of CMDs compared to individuals who consumed 7 or more portions per week (95% CI, 1.088–1.278). However, weekly fruit consumption, socioeconomic status, and possession of a senior high school education did not significantly influence the incidence of CMDs in rural areas (p>0.05).

Individuals who smoked, whether occasionally or daily, were found to have a 2.250-fold (95% CI, 1.917–2.642) or 2.117-fold (95% CI, 1.818–2.466) increased risk of CMDs, respectively, compared to non-smokers. Similarly, those who consumed alcoholic beverages were 2.420 times more likely to experience CMDs than those who abstained from alcohol (95% CI, 2.077–2.821).

Discussion

The results indicated that the prevalence of CMDs among youth was higher in urban than in rural areas. Similar findings were reported in a study conducted in Bangladesh and in a meta-analysis [20,31]. Various factors contribute to the incidence of mental disorders in urban settings, including the social environment, neighborhood characteristics, population density, and personal space [32]. The increased prevalence of CMDs in urban areas may be attributed to the stress associated with urban living and the diminished social support experienced by individuals who have migrated from rural areas [33]. Several demographic factors were found to be associated with elevated risk of CMDs, with differences observed between rural and urban youth. Being male and possessing a college education appear to reduce the risk of CMDs for both demographics. However, the impact of socioeconomic status, marital status, and employment varied between urban and rural populations.

This study revealed a significant relationship between CMDs and education level among both rural and urban youth. The risk of CMDs varied across educational attainment levels, with less educated individuals being more susceptible to CMDs than those with the highest attainment in both urban and rural contexts. Education is widely recognized as a strong determinant of mental health, improving mental health outcomes by increasing an individual’s literacy and ability to manage psychological stressors [34]. Additionally, advanced education contributes to economic stability, expanded social networks, and improved employment prospects, all of which support better mental health outcomes [35]. These findings are consistent with previous research conducted in Finland, Denmark, Poland, and Spain, which demonstrated a positive association between lower educational attainment and the prevalence of mental disorders [36,37].

The present research determined that age did not significantly impact CMDs in either urban or rural settings. We divided age into 2 categories: 15 to 18 years (early young adulthood) and 19 to 24 years (young adulthood) [28]. Consequently, the lack of significant age-related influence may stem from similarities in these developmental stages. These periods signify the transition from childhood to adulthood, marked by a shift from reliance on family to autonomy and a progression toward independent living [38].

Female participants exhibited a higher likelihood of experiencing CMDs than male respondents, regardless of their residence in urban or rural areas. These findings align with previous research conducted in Indonesia and Australia [39,40]. The underlying causes are likely a combination of social and biological factors. From a biological perspective, the differing sex chromosomes of men and women have been implicated as a contributing factor to the higher prevalence of mental disorders among women [41]. Additionally, during puberty, female adolescents are particularly susceptible to the effects of sex hormones. Fluctuations in hormones during puberty and other hormone-related transitional periods have been associated with an increased risk of mental illness in girls and women [42]. Social factors also play a significant role. Female individuals often face unique life experiences, including continuous exposure to social and cultural expectations and constraints that can adversely affect their mental health. For example, girls and young women may place a high value on physical attractiveness, largely because societal norms encourage this focus. Indonesian culture, in particular, expects women to marry by the age of 25. Those who do not meet this expectation may be stigmatized as “leftover” or undesirable [43]. Women may strive to embody these societal ideals to gain acceptance or respect, but this can lead to chronic stress and contribute to mental health problems [44].

This study determined that the association between marital status and CMDs was significant exclusively in rural regions. Divorced young people in these areas were more likely to experience CMDs compared to their unmarried counterparts. Conversely, marriage appeared to act as a protective factor against CMDs in rural settings. These findings align with previous research conducted in the United States, which found that individuals who married between the ages of 22 and 26 years reported greater life satisfaction than those who remained single or were in non-marriage relationships [45]. The substantial contribution of social support, including that provided by a spouse, was identified as a key factor in the protective influence of marriage against depression [46].

In contrast, the results of the present study indicated that marital status was not significantly associated with CMDs in urban areas. Several factors may account for this finding. Urban residents often prioritize personal choices, such as deciding when to marry. Conversely, in rural communities, family and community members frequently play a key role in shaping individual life choices and may exert social pressure [47]. Additionally, urban environments might exhibit less stigma toward unmarried, divorced, or widowed individuals, contributing to a culture of acceptance and support regardless of marital status. Being divorced or widowed in rural areas can be particularly difficult due to the associated stigma. In tight-knit communities where collective norms are strong, people often are deeply involved in one another’s personal affairs. Widowed individuals, particularly women, may face social marginalization and sexual objectification, which can intensify their stress and sense of vulnerability [48]. Similarly, divorced individuals face an increased risk of mental health problems, stemming from reduced social support and feelings of loneliness [49].

The relationship between CMDs and socioeconomic status was not significant in rural youth; however, a significant association was observed among urban respondents. Research conducted in rural Canada indicates that depression rates are lower in rural regions compared to urban settings, perhaps due to a stronger sense of community belonging and social support. The incidence of depression does not decrease in correlation with socioeconomic advantage. Instead, the reduced risk of depression in rural areas is strongly linked to the level of community attachment and the availability of social support [13].

Compared to those in the highest (“richest”) economic quintile, urban residents in the second (“poor”) and fourth (“rich”) quintiles were less likely to experience CMDs. This disparity may be attributed to the greater expectations placed on the wealthiest by their families and social circles. The pressure to attain the highest level of education at prestigious schools and to secure employment could increase the vulnerability of the wealthiest individuals to CMDs, with the most severe symptoms often observed in students from higher socioeconomic backgrounds [50]. The findings of this study align with research conducted in Mozambique, which indicates that, compared to those in the highest wealth quintile, individuals in the lowest quintile exhibited a lower prevalence of depressive symptoms [24]. However, these results contrast with other studies that have identified a strong link between poverty and CMDs [51], suggesting that wealthier people are less prone to mental health issues [52].

The present study identified a significant link between unemployment among young people and CMD in rural, but not urban, areas. A systematic review in a Nordic country found that unemployed young individuals are more prone to mental health issues than their employed counterparts, which can be attributed to financial hardship and a lack of social support [53]. In India, research suggests that unemployed young people are at a greater risk of mental health problems compared to those who are employed. They are more likely to experience anxiety, depression, and challenges in regulating their emotions and behaviors. Unlike their employed peers, unemployed young people often report dissatisfaction with their lives, which contributes to reduced psychological well-being [54]. Additionally, a Swedish study indicated that unemployment is associated with an increased risk of mental health disorders among young people [55].

In terms of healthy diet, this study revealed an association between a lack of vegetable intake (fewer than 7 portions per week) and youth CMDs in both urban and rural settings. Previous research has demonstrated that individuals with mental health issues often consume greater amounts of high-fat and high-sugar foods and lower quantities of nutrient-dense options [56]. Additionally, research indicates that obesity may influence depression symptoms [57]. A study conducted in the Philippines reported that social-environmental and socioeconomic factors, along with proper nutrition education and accessibility, are key determinants of vegetable consumption in both urban and rural communities [58]. Research from Scotland indicated that rural youths tend to have healthier eating habits than their urban counterparts [59]. The cost and consumption of food also appear to be influenced by geographic location, with traditional foods being more prevalent in rural areas, while Western foods are more common in urban settings [60].

In turn, a lack of fruit consumption, defined as fewer than 7 portions per week, was associated with youth CMDs exclusively in urban areas. Research conducted in urban regions of India has also indicated an increasing trend in the inadequate consumption of fruits, as well as heightened intake of fast food, sweets, and snacks [61]. A meta-analysis examining dietary patterns and depression revealed that a higher intake of fruits and vegetables was associated with a lower incidence of mood disorders [62]. The provision of unsaturated fatty acids and antioxidant vitamins—found in abundance in fruits—along with zinc and selenium, and the concurrent restriction of saturated and trans fatty acids, appear to exert a synergistic effect in diminishing the inflammation linked to depression [57].

Smoking status and alcohol consumption were significantly associated with CMDs among youth in both urban and rural areas, although the prevalence rates varied slightly. Young people who smoked, whether occasionally or daily, were at a higher risk of CMDs compared to their non-smoking counterparts. Similarly, youths who consumed alcoholic beverages were more likely to face CMDs than those who abstained from alcohol. In Indonesia, alcohol consumption and smoking have been identified as risk factors for depression [25]. Multiple studies have highlighted the adverse effects of alcohol consumption on adult mental health [7,63]. A Brazilian investigation found associations between mental disorders in adolescents and smoking, alcohol use, and exposure to cigarette smoke [7]. In a study of several developing countries, 44.4% of young people who drank alcohol reported experiencing depression, while 82.1% described experiencing anxiety-related sleeplessness [63].

This study carries substantial implications. Its findings highlight the urgent need for comprehensive mental health policies tailored to the needs of Indonesian youth. It illuminates the prevalence of CMDs in this demographic, revealing that the determinants of CMDs vary between urban and rural settings. By identifying factors such as gender, education level, diet, smoking, alcohol consumption, employment status, and marital status as being associated with CMDs, the research offers vital information for policymakers. These insights can guide the development of targeted interventions and public health programs. The study underscores the necessity of recognizing the diverse determinants of mental health status among youth from different demographic backgrounds, establishing distinctions between urban and rural areas. Looking ahead, it is essential to explore how the determinants of mental health issues differ across various demographic characteristics, including socioeconomic status, parental education level, cultural background, and geographic location of residence. Such understanding is crucial for supporting mental health policies and interventions for youth on a global scale. The insights gained from this study should inform worldwide efforts aimed at addressing mental health issues among young people, informing the creation of more effective strategies and interventions across the globe.

Conclusion

A higher prevalence of CMDs was observed among urban than rural youth in Indonesia. Furthermore, the factors influencing CMDs in young people varied between urban and rural settings. For both populations, being male, holding a college degree, consuming at least 7 portions of vegetables per week, abstaining from smoking, and not drinking alcohol were associated with a reduced risk of CMDs. In rural areas, being married and employed were additional protective factors, whereas being divorced was linked to an increased risk of CMDs. In urban settings, consuming at least 7 portions of fruit per week and not being in the highest socioeconomic bracket were associated with lower risk. The findings underscore the importance of designing interventions that address specific risk factors tailored to regional differences to effectively reduce CMDs among Indonesian youth. Policymakers, healthcare providers, and community leaders should collaborate to promote healthy lifestyles and target vulnerable segments of the population to decrease the prevalence of CMDs within this demographic.

Strengths and Limitations

This study has contributed to our understanding of the determinants of CMDs among youth in Indonesia. It utilized secondary data from the 2018 INHS, a nationwide survey that offers a substantial dataset representative of the Indonesian population. The research encompassed a broad range of variables, including demographic and socioeconomic factors, as well as several health behavior indicators pertinent to the youth demographic. Nonetheless, the study is not without its limitations regarding the data variables. Notably, the analysis was confined to the variables made available by the INHS. Consequently, certain potential determinants of youth CMDs were not included in the analysis, such as sleep disturbances, early sexual activity, excessive screen time or internet use, peer interactions, community support, and neurological disorders [5,6,8].

HIGHLIGHTS

• The prevalence of common mental disorders (CMDs) was higher among urban than rural youth in Indonesia, with determinants also varying.

• Being male, possessing a college degree, consuming at least 7 portions of vegetables per week, not smoking, and not consuming alcohol were associated with lower CMDs risk in urban and rural youth.

• Among rural youth, marriage and employment were linked to lower CMDs risk, whereas divorced participants experienced higher risk.

• Among urban youth, consuming at least 7 portions of fruit weekly and having a socioeconomic status in neither the first nor the fifth quintile were associated with reduced CMDs risk.

Article information

Ethics Approval

Ethical approval for this study was granted by the Ethical Committee of Health Research at the National Institute of Health Research and Development (NIHRD), Ministry of Health, Republic of Indonesia, under the approval number LB.02.01/2/KE.267/2017.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Funding

None.

Availability of Data

All data generated or analyzed during this study are included in this published article. The data can be obtained by submitting a written request to the Data Management Laboratory of the National Institute of Health Research and Development (NIHRD) at datin.bkpk@kemkes.go.id.

Authors’ Contributions

Conceptualization: MK, LL; Data curation: all authors; Formal analysis: YF, SH, HDK; Investigation: all authors; Methodology: DY, DEE; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Acknowledgements

The authors wish to express gratitude to the Ministry of Health of Indonesia for their efforts in processing the 2018 Indonesian Basic Health Research.

Figure 1.

Flowchart of data selection, modified from the Indonesia National Health Survey 2018 report [26].

CBs, census blocks; SRQ-20, 20-item Self-Report Questionnaire.

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