Adolescent girls’ explanations of high rates of low mood and anxiety in their population: A co-produced qualitative study

doi:10.21203/rs.3.rs-3780794/v1

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Adolescent girls’ explanations of high rates of low mood and anxiety in their population: A co-produced qualitative study

https://doi.org/10.21203/rs.3.rs-3780794/v1

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Background: From early adolescence, girls face greater risk of experiencing low mood and anxiety, with recent evidence that this may be worsening. There is a paucity of mental health research that meaningfully progresses understanding of such disparities, including that engages adolescent girls’ own perspectives, limiting our ability to direct further research and enhance intervention approaches.

Aims: We examined low mood and anxiety from the perspective of adolescent girls, rather than relyingon researcher hypotheses, asking: What do adolescent girls perceive to be causing their population’s high rates of low mood and anxiety?

Methods: We adopted a co-produced qualitative design, guided by ecological systems theory, conducting focus groups in 2022 with 32 adolescent girls aged 16 to 18 years in England, and analysing with reflexive thematic analysis.

Analysis: Participants framed low mood and anxiety among adolescent girls as ‘normal’, and discussed potential explanations including persistent reiteration and expectation of gendered norms, intense educational pressures in ways that can be gendered, difficulties within peer relationships, and comparison and insecurity in social media contexts. Throughout, participants highlighted complexities including individual differences, sociodemographic contexts, and societal contexts.

Conclusions: The study offers a critically important contribution to evidence on gendered inequalities in low mood and anxiety, drawing attention to the interwoven and complex nature of girls’ lives, and holds policy and practical relevance to enhance systems to meet girls’ needs.

gender

adolescent girls

mental health

low mood

anxiety

qualitative

co-production

From early adolescence, girls experience greater risk of low mood and anxiety relative to boys, and from mid-adolescence onwards are twice as likely to report depression [1–3]. In recent years, evidence suggests that these rates have increased among adolescent girls [4–7], and the COVID-19 pandemic appeared to exacerbate this [8, 9]. Such evidence constitutes a growing public health concern warranting investigation [10, 11], particularly given a longstanding paucity of research meaningfully unpacking the gender mental health gap [12]. We note comparisons among girls/women and boys/men partially because established evidence lacks recognition of transgender and nonbinary adolescents, though evidence suggests that they also experience poorer mental health [13]. We use ‘girls and women’ inclusively, but acknowledge that the literature drawn upon often uses sex-based language and sampling.

Research and policy highlights uniqueness in the drivers and patterns of mental health among girls and women, necessitating gender-sensitive preventative action and provision [14]. Besides possible pandemic effects, causes of increased low mood and anxiety among girls remain unclear. Researchers have posited possible contributing factors spanning various life domains, echoing ecological systems theory’s framing of health and development as occurring in the context of multiple transactional environments and processes [15]. These potential factors include social media usage, increased sexualisation of adolescent girls, increased academic pressure, and limited school emphasis on low mood and anxiety provision despite already heightened prevalence among girls [4, 5, 16]. There have also been considerable societal shifts in mental health discourses, perhaps increasing willingness to report [17, 18].

These explanations have some theoretical and empirical merit, but understanding of links to adolescent girls’ mental health specifically, and how they explain current rates of low mood and anxiety, is still developing, and research is limited in various ways. For instance, some emerging evidence indicates that perceived sexualisation and objectification [19] and sexual violence experiences in mid-adolescence [20] are associated with low mood and anxiety among girls, though with critical limitations in available data such as limited scope of questioning. Evidence also suggests that girls may experience greater anxiety around specific educational pressures [21], and a qualitative systematic review explored how gendered “imbalances” in education pressures (e.g., over-emphasis on achievement, gendered expectations, heightened personal pressure) appear intertwined with worsened mental health [22], though evidence remains sparse, mixed, and largely cross-sectional [23].

Such explanations require further investigation to consolidate and extend this evidence base. Importantly, explanations have come from researchers without clear input from adolescent girls, limiting capacity to meaningfully explore and address inequalities. From a complex system standpoint, grounded in a theoretical conceptualisation of real-world systems as intricate, dynamic, and non-simplistic, intervention development should begin with contextually embedded understandings of how the target population conceptualises risk factors and needs [24]. This level of information and investigation is, however, frequently overlooked in women’s health issues [12, 14].

Several qualitative studies have engaged adolescent girls on specific issues including some factors explored above (e.g., what ‘problematic’ versus ‘healthy’ social media engagement might mean for wellbeing dimensions such as body image) [25, 26], though few peer-reviewed studies have explored adolescent girls’ understandings of how gendered experiences contribute to mental health including low mood and anxiety. Engaging adolescent girls in discussions may highlight issues including those not anticipated by researchers, and inform ongoing research, policy, and practice priorities. Some studies have used such an approach, highlighting challenges for adolescent girls that appear linked to longstanding mental health disparities. This has commonly included considerable daily pressure and responsibility, and sexual harassment and violence and related fear and restricted freedoms [27–31]. Some highlighted competing societal ‘femininity discourses, including traditional gendered norms, feminist ideals, and male-dominated ideals, that are difficult to assimilate and thus experienced as upsetting and worrying [28, 29].

However, data in these studies were generated over ten years ago, so cannot offer insights around subsequent increased rates of low mood and anxiety observed since.Most were conducted in Sweden, the fourth most gender-equal country according to the 2021 Gender Inequality Index [32]. It is likely that national and local contexts (e.g., in education systems, economic contexts, relevant laws, cultural and religious influences) may influence both gender and mental health experiences [33], and exploration in varied contexts can therefore be locally insightful and, when considering studies collectively,offer transferable global implications. In the UK (27^th in the 2021 Gender Inequality Index [32]), a very small number of studies have produced some insights through asking adolescent girls about wellbeing-related factors, but lacked specific detail regarding low mood and anxiety. For instance, The Children’s Society’s Good Childhood Report [34] explored gender differences in subjective wellbeing, and shared some adolescent girls’ comments around attractiveness expectations, but did not offer in-depth analysis or examine mental health components including low mood and anxiety, limiting specificity in inferences.

We examined the factors potentially related to the high rates of low mood and anxiety from the perspective of adolescent girls themselves, rather than relying on ‘top down’ researcher hypotheses, asking: What do adolescent girls perceive to be causing their population’s high rates of low mood and anxiety? We were guided theoretically by ecological systems theory [15] given that researchers’ hypotheses for current rates of low mood and anxiety span ecological domains, and as use of this theory in qualitative research enables recognition of systematic inequality processes [35].

Design

We adopted a co-produced qualitative design, conducting online focus groups in May–August 2022 with adolescent girls aged 16 to 18 years in England (see Supplementary Materials for reflection on co-production). We pre-registered the study (Research Registry ID: researchregistry7803) and agreed a protocol prior to recruitment (publicly available alongside data generation documents using Open Science Framework DOI 10.17605/OSF.IO/KBTA4).

Research team

Our team includes research academics, clinical academics, young people, and youth engagement specialists. Most of us are women, and some of us are from UK ethnic minority and LGBTQ + communities. Several team members bring lived experience of mental health difficulties. We share interests in adolescent mental health, with expertise around gendered experiences, time trends, public health, and social justice. Some bring clinical backgrounds (Authors SP, BD, LAW), and young researchers (Authors PN, JL) have experience working in other research projects and in training and provision in child and youth mental health services.

Participants and sampling

Our target population was diverse adolescent girls aged 16 to 18 years across England. Low mood and anxiety rates are highest in this older age group [7], and we anticipated that they could likely draw on a fuller range of experience than younger adolescents and possess greater critical understanding around complex issues [36].

We interviewed 32 participants across eight focus groups, with 3–5 participants in each group (mean group: 4). We aimed for 40–45 participants, with 5–6 individuals in each group, as is moderate within focus group research [37]. However, data generation timing (alongside exams and the final stages of educational engagement for Summer) meant lower responsiveness from gatekeeper organisations and, in turn, adolescents. Qualitative sample sizes should be guided by features such as the dataset’s richness and detail [38], and we were also working to include diverse voices; given the depth of participants’ contributions and our sample’s diversity, we determined that 32 participants was more than adequate.

We recruited via post-16 education settings (e.g., sixth forms, colleges, vocational training centres) and youth organisations (e.g., charities, youth clubs) in England, contacting key gatekeepers and advertising via networks (e.g., Anna Freud Schools Division, National College Association). We asked interested organisations to share an advert with 5–10 adolescent girls. Interested participants expressed interest and provided demographic information; we intended to use this information to identify a diverse sample, as gendered experiences intersect with other identities such as ethnicity, class, and sexual orientation [39]. However, given slow recruitment, we invited all interested individuals.

Participants were 16 (n = 6), 17 (n = 24), or 18 (n = 2) years old. Of 32 participants, 15 identified themselves as white, 9 as Asian, 4 as Black, 2 as mixed, and 2 as another ethnicity. In terms of sexual orientation, 20 participants indicated that they were heterosexual, 5 as bisexual, 2 as gay or lesbian, 1 as queer, 1 as asexual, 1 as not sure, and 2 preferred not to say. 13 identified as having no religion, 7 as Christian, 6 as Muslim, 2 as Hindu, and the remaining 3 preferred not to say. Half (n = 16) indicated having sought help from mental health services.1 2 participants shared having been eligible for free school meals, and 2 shared having special educational needs. None shared that they were disabled; none shared that they were transgender. Participants were from most regions of England, with 11 from the North West, 10 from the South East, 3 from the East Midlands, 2 from the West Midlands, 2 from London, 3 across the East of England, South West, and Yorkshire, respectively, and 1 who preferred not to say.

Data generation

We used focus groups given our focus on perceptions rather than direct personal experience, and to allow for contrast and clarification of views [40]. One university researcher (RJ) and one young co-researcher (PN, JL) co-led sessions to minimise power differentials, facilitate open, democratic discussions, and draw out insights from their perspective [41].

We brought together participants unknown to each other, rather than existing peer groups, as prior dynamics and shared understanding influence discussions [40]. We conducted groups online, to limit existing relationships, reduce burden on young co-researchers, and lower time and budget, and used Zoom given advantages of cost-effectiveness, user-friendliness, security, and flexibility for varied needs [42]. Sessions lasted 90 minutes, including introductions, ground rules, and debriefing, consistent with guidance [40], with active discussion ranging 63–78 minutes. Focus groups were audio-recorded and transcribed verbatim.

We followed a semi-structured guide (see Box 1) using open-ended questions and follow-up prompts to explore answers, including mechanisms and group variations. We explicitly introduced the concept and evidence of high rates to begin discussions, and then created space for open discussion of participants’ perspectives, introducing ecological system domain concepts, guided by ecological systems theory [15], to elicit varied insights (see prompts 3c/3d) rather than asking about narrow pre-determined experiences. We established ground rules (e.g., listening respectfully, maintaining confidentiality) and managed social dynamics (e.g., dominant/quieter participants).

Box 1: Focus group questions and prompts used

1. Firstly, what do you think when you hear that teenage girls have been reporting greater levels of low mood and anxiety?

a. What makes you think this?

2. Does this feel true to the experiences of you and your peers during your teenage years? By peers we mean the other girls you have known during your teenage years, such as your classmates.

a. Could you expand on this?/What makes you think this?

3. We want to know what you think might be contributing to that. To start us off, what do you think the top three things might be?

a. Can you tell us a little more about that?

b. How do you think this might contribute specifically to low mood and anxiety /for girls in recent years?

c. Do you think there is anything else in day-to-day life that might be contributing to low mood and anxiety for girls? Examples of domains if needed to help prompt discussion: family and home; school; social relationships with friends, peers, or romantic relationships; digital platforms/interaction and social media; considerations about the future*

d. What about issues at a wider society level? Examples if need to help prompt discussion and clarify what we mean: how we talk about girls and women, systems such as the law.

Ethical considerations

The project received approval from The University of Manchester Research Ethics Committee (Ref: 2022-13633-23090). We established informed consent, providing written information alongside a video with group moderators (RJ, PN, JL). Grouping participants without existing relationships minimised confidentiality risks, and we established ground rules not to share personal information, gave instructions for displaying first names only, and set meeting passwords. We stored data on secure University systems and pseudonymised accounts. We limited potential distress by asking participants not to share anything deeply personal or upsetting and advising that individuals who may find this topic upsetting should not take part, and providing signposting.

Data analysis

We used Braun and Clarke’s reflexive thematic analysis (RTA) [43, 44], wherein researchers construct a thematic representation of dataset patterns and nuances. Given our exploratory design and emphasis on adolescent girls’ perspectives, we analysed inductively rather than through a theoretical framework. That is, we used ecological systems theory [15] to shape data generation questioning and interpret findings post-analysis, rather than actively incorporating this into analysis. We used semantic coding, focusing broadly on explicit statements rather than possible underlying meanings.

We co-produced analysis, undertaken by Authors OD, RJ, PN, and LF. Consistent with RTA, our team approach was grounded in building shared reflexive interpretations and not to narrowly establish 'coder reliability’ [44]. We familiarised ourselves with data, and discussed initial reactions. Authors OD and RJ divided transcripts and systematically coded to identify units relevant to our research question, organised within NVivo Version 12 [45]. Author RJ reviewed this to expand and develop codes to facilitate shared interpretation. Next, analysts met to collaboratively group codes into themes, setting aside some codes (e.g., isolated points, those less directly relevant to the research question). Author OD reviewed and refined themes, regularly debriefing with the team, and consulted Author JL as second young researcher as a sense check. Codes underpinning themes are in Supplementary Materials for transparency, though we highlight that RTA is an interpretive process and analysis is not a definitive reading, but one credible account [44].

[1] To ascertain this we asked “Have you ever sought help from mental health services? We consider mental health services to include a wide range of available services (e.g., a GP, a school counsellor, a psychiatrist, etc.)”.

We developed six main themes, shown alongside their respective subthemes and connections in Fig. 1. Here we explore these themes, drawing upon illustrative quotes accompanied by pseudonyms to evidence and contextualise, and attending to agreement, nuances, and divergences in viewpoints.

Theme 1: Rising rates of low mood and anxiety are unsurprising

We began discussions by introducing evidence of heightened rates of low mood and anxiety among girls relative to boys, including of apparent recent increases. There was consensus that this evidence was unsurprising: “it’s not really a shock, it’s just something we all know” (Sophie). Participants said that evidence echoed what they felt to be true, referencing their own experience, their peers’ experiences, and wider messaging: “it doesn’t shock me because there’s a lot of [my friends] that experience it” (Phoebe); “I heard that mental health problems have been increasing” (Katrina). Some expressed that to experience difficulties like low mood and anxiety is normal among adolescents now: “I’ve definitely seen an increase. It's more of a normal thing for people to go through” (Alex); “I think it is just normal for teenage girls to have low mood” (Isa). Participants pointed to the COVID-19 pandemic as exacerbating issues: “when I think of increasing mental health issues like among teenagers I think of COVID and lockdown and stuff” (Louise).

Participants also described a normalisation of mental health among adolescents, who they saw as increasingly comfortable talking about difficult feelings and mental health challenges: “people are more open about things, so they talk about it” (Amina). However, a few participants suggested that poor mental health is idealised: “in a lot of mental health education mental health is romanticized almost. I feel like some people want to have mental health issues” (Beth), and that normalisation only extends so far: “it’s OK not to be OK, until it gets messy” (Alex).

Theme 2: Strict and narrow expectations of how girls and women should look and behave

Participants described sexist stereotypes and expectations as being placed on and internalised by adolescent girls, embedded in a longstanding conceptualisation of women as restricted to particular patterns of behaviour and expression: “men are always seen as the more favoured and they’re more able, they’re more capable. I still think people look at women and think, ‘Oh, you shouldn’t do this, you shouldn’t do that’” (Maya). These included overarching perspectives of what girls and women “should” be as well as specific aspects of behaviour and appearance; i.e., that girls should be quiet and polite, and should aim to be beautiful within narrow, homogeneous standards:

Stuff like makeup and shaving has become so normalized it's no longer a choice that you make, it's kind of… expected. So, you don’t really get to decide what is beautiful to you, but, you're just kind of forced to play into it (Emmy)

Participants explored how such expectations are communicated and reinforced from an early age, such as in childhood toys and media: “if you think like the toys boys and girls are given, a girl would get given a kitchen set, being in a kitchen’s quite quiet, but a boy’ll get given a nerf gun, that's loud” (Ayesha). They highlighted that the media generally portray women in narrow and gendered ways, often with implicit or explicit judgement: “one of the main reasons [for low mood and anxiety] might be the media, because there's quite a large very focus on women's appearance and also personality, especially compared to the men” (Katrina).

Participants reflected on how these expectations are reiterated to adolescent girls by peers and adults, with gendered comments and judgement of them when one is not as not conforming somehow: “you're sort of performing… you have to look a certain way, and smile, or if you don't smile, you get told to smile” (Ayesha). Some reflected feeling that all ways of being are judged for girls, meaning they exist in an impossible space of being:

Abigail: In primary I was the only girl that would play football and I was called a tomboy, the whole of primary literally from year three onwards, and then…

Sunita: Did you ever get told that it was cause you had a crush on the boys?

Abigail: Yeah.

Sunita: Cause-, [splutters] I hate that so much.

Abigail: Yeah, like, either you’re a tomboy of it’s like ‘oh she just wants to be friends with the boys.’ […]

Kira: And leading on from Sunita’s point where girls are made fun of for whatever they like. Like if you're girly then you're made fun for being too girly. But if you're kind of like a tomboy, you’re made fun of that as well, like you're a pick me girl or whatever. So, no matter what you're always going to be judged in some way.

These narratives were explored as permeating and limiting other aspects of day-to-day life for adolescent girls. For example, participants talked about how this permits a normalisation of sexual harassment in adolescent spaces (particularly schools), how options available to them such as sports and STEM subjects (science, technology, engineering, and mathematics) are narrowed, and how girls see coverage of societal issues affecting women being minimised2: “when a boy is like pinching a girl or something like that, and like physically doing things they'll just say it's flirting, and blame the girl” (Sunita).

This pervasive messaging, and the ways that narratives around gender and women permeate day-to-day life, was framed as having a profound impact for adolescent girls, wherein expectations become normalised and unconsciously internalised, leading to feelings of insecurity and becoming deeply bound up with one’s identity, self-concept, and self-worth:

When people think that insecure girls is [sic] just someone who thinks, ‘oh, my hair isn’t good enough’, but it's so much deeper than that and I think a lot of the insecurities within girls that they just don't feel like… a person because of how they've been treated (Sunita)

[Society’s conceptualisation of women as inferior] just makes [girls and women] feel like they're like worthless (Sara).

Theme 3: Educational pressures feel intense and gendered

Participants described educational experiences as restrictive and pressuring, and not always considerate of developmental, wellbeing, and individual needs. They discussed pressure and demand – from teachers, from parents/carers, and implied within systems – around attainment and behaviour, with no room for mistakes, that become especially intense across secondary school and further education (e.g., sixth form, college) around exams and grades,3 making major life decisions, and not only keeping up but being “the best”. They reflected that these can lead to persistent feelings of sadness and worry: “in year 9 I was perfectly fine and then in year 10 I was really sad and really depressed and I had so much anxiety because I really wanted to do well in my GCSEs” (Hanna).

Participants explored how such pressures may be communicated to and experienced by girls in acute, complex ways. Some felt that this pressure is greater for girls, because high achievement is expected, heightening the emotional impact: “if a boy fails, then, you know, it's not that bad, but I feel like if a girl does, it means a lot more” (Ayesha). As in the previous theme, participants reflected on gendered expectations of classroom behaviour and in how their classroom contributions are valued, which could feel upsetting and diminish their sense of self. A particular issue explored here was ‘male-dominated’ STEM subjects, which were seen to be gendered spaces with low expectations, creating additional pressure and worry around achievement: “if you're in like a male-dominated classroom and you're getting the worst results, it kind of… you just feel like you take all of that on yourself and you just feel like you're letting down other women” (Emmy).

Theme 4: Challenges in peer relationships can add pressure

Challenging aspects of peer relationships were frequently explored as linked to low mood and anxiety. Participants spoke of a culture of comparison among adolescent girls, where it is normalised to compare oneself to others and to judge and feel judged by others, spanning domains including ways of thinking, grades, future life plans, and, most prominently, appearance and self-expression:

It became a competition to see if you could eat the least at lunch basically. So it was a whole table of girls all with tiny little plate of salad on their plate and then if you didn't join in with that you felt like you were being judged, because you were sat there eating pasta or something, and someone was like 'oh my gosh that's so much carbs, you're going to get fat' (Beth).

Participants explored such dynamics as partially rooted in gendered societal narratives and insecurity, and that this comparison and competition can be stressful, encouraging of rumination, and problematic for self-esteem and sense of self: “most people are quite insecure and then they feel the need for competition to validate how they feel” (Liah).

Participants also pointed to conflict with peers, including arguments and fallouts between friends and peers, challenges experienced in romantic relationships and breakups, issues of bullying in a peer context, and feeling isolated, all of which seeps into online and offline worlds and can prompt considerable distress: “the fallout of breakups and arguments can be quite upsetting. I know when I was in secondary school that was the main reason why I was quite upset because I'd have arguments with friends” (Kate); “when girls are mean it's less direct […] so you feel a bit crazy” (Katrina).

Some wondered whether low mood and anxiety among girls could become self-perpetuating through friendships, exploring the possibility of emotional contagion among girls, and how challenging it can be to support a friend experiencing such feelings: “if the numbers of young teenage girls who are having bad mental health or just low mood or anxiety then, if they're going up […] it's just going to kind of like bounce off each other (Liah). However, participants also described friendships as valuable mental health support sources, with the challenges captured in this theme comprising only part of these connections: “the one thing that will always help me is my best friend” (Sunita).

Theme 5: Social media can be a space of comparison and insecurity

This theme is interconnected with several wider themes, as we found that the ways that participants discussed social media framed it as a platform in which the other issues they described (e.g., gendered expectations, challenges with peers) play out or are magnified. Participants framed comparison and insecurity as normalised in social media spaces, and emphasised that platforms with more visual content (e.g., Instagram, TikTok) reiterate expectations for how girls should present themselves. Participants explored how this leads to comparison to peers and to influencers, and normalises a sense of insecurity and conforming to these expectations, as in the earlier quote from Emmy, or from Hanna: “they’re seeing an image over and over again whether it's videos on TikTok or Instagram etcetera, so they feel like that's what they have to look like or else they’re ugly”.

Participants noted how the standards established on social media around one’s appearance and day-to-day life are generally unrealistic: “you see these people with perfect lives and the perfect house and a perfect face” (Kira). They highlighted that it can be difficult to tell what is “real” (particularly for younger adolescents), meaning that adolescent girls are often engaging in unreasonable comparisons: “you only see the best bits of people's lives and sometimes that is really hard to separate out” (Alex). They noted particular ways that platforms function as problematic here, such as normalisation of filters and photoshop, and algorithms that narrow content engagement: “there’s filters that are really realistic, so you wouldn't know” (Abigail); “if you watch dancing videos or makeup and stuff revolving around ‘body’, then you’ll see more of that […] and then you think ‘maybe that’s how my body should look’” (Isa).

Participants therefore raised concerns about adolescent girls being so engaged with these platforms, including during childhood, and linked this normalisation and comparison to low mood and anxiety among adolescent girls: “in your mind you're comparing yourself without even thinking about it and that affects your mood” (Kira); “I think [the increase of low mood and anxiety among girls] is because of different social media apps on different social platforms” (Amina).

Yet, participants reflected that it is easy to overly blame rates of mental health difficulties on social media, and advised caution in treating this association as one-dimensional. They explored perceived positives of social media as a platform for body positivity, mental health conversations, queer communities, and connection and community, and suggested that positive and negative aspects are intertwined: “the increasing connectedness that we have with people all over the world is great, but it's also really bad because you can compare yourself to everyone else, and I think that's really damaging” (Sophie).

Theme 6: There is no easy answer to explain or resolve issues

Throughout discussions there was an underlying narrative of the complexity of the issues explored. Some participants explored the idea that there is not any single factor driving rates of low mood and anxiety among adolescent girls, including recent increases, echoing Nazrin’s earlier comment about social media: “I think there’s a whole lot of different things causing this trend” (Sophie). Participants unpicked the extent to which one can draw overarching conclusions about what affects adolescent girls and their mental health. They explored how many of the issues being discussed did not only affect adolescent girls, also affecting boys and people at other life stages: “yes, girls have body image issues sometimes because of social media, but sometimes young boys have this image of how a man should look like…. that can really degrade their mental health” (Isa). Some emphasised individual differences in experiences, in how people respond to similar factors and experiences, and in support needs, including in relation to intersecting experiences among groups such as those from UK ethnic minority and LGBTQIA + communities: “when it comes to sexuality other people definitely are like the reason for like low mood and bad mental health [because of how they respond]” (Ruby).

Participants reflected on how the issues they discussed were complex and systematic (e.g., misogyny, social media norms), rendering change challenging, and requiring those in positions of power to listen and embrace change: “how can you convince millions of people to develop a different mindset [to] change our thinking?” (Rana); “if politicians actually talk to people who've gone through all of this is still going through it, like we are now” (Alex). Yet, participants emphasised that this change is important, even if it is hard and requires incremental progress: “even if one little certain bit can be tackled then it’s one certain bit that helps like a person” (Chloe).

[2] It is perhaps worth noting here that focus groups took place in the midst of Wade vs. Roe, a landmark piece of legislation affirming a constitutional right to abortion in the United States, being overturned, which received considerable news attention in England and on social media platforms.

[3] It is reasonable to consider that the timing of data generation and age of participants may have affected some of these discussions in terms of exams, whereby 16- to 18-year-olds were exploring these issues shortly after many of them had just experienced a busy period of high stakes exams. It is quite possible that at a different time in the year, the extent of pressure described might have been lesser.

This study offers important insights into girls’ perspectives on potential contributors to their population’s high rates of low mood and anxiety. We present an account from participants that to experience low mood and anxiety as an adolescent girl is ‘normal’, both generally and particularly among current cohorts. Participants explored the reiteration of gendered norms from early childhood and persistent judgement of girls’ presentation and behaviour, and discussed profound implications for identity, self-esteem, and, consequently, mental health. They reflected on restrictive, pressurising educational experiences (including aspects they felt may be acute and complex for girls), which they noted as creating considerable anxiety. They explored challenges in peer relationships, including comparison and conflict, that can be stressful and prompt low mood and anxiety. Finally, participants framed social media as a place where comparison and insecurity are normalised and where various standards, often unrealistic, are reiterated in ways that can affect mood and create worry. The complexity of such issues spanned discussions, with participants guarding against oversimplifying explanations and overlooking individual differences and sociodemographic contexts, and reflecting on how embedded and systemic many issues are.

Some of these factors have been previously evidenced as associated with adolescent low mood and anxiety, including to some degree for girls specifically. Some evidence indicates a relationship between gender norm perceptions and low mood and anxiety [46], and qualitative evidence suggests gender norms can be stressful and elicit upset and worry among girls [28, 29]. Quantitative and qualitative evidence suggests that educational pressure and gendered educational discourses may have specific ramifications for girls [22, 47]. There are complexities around peer relationships and mental health, with evidence that ‘negative’ (e.g., bullying) and ‘positive’ (e.g., peer connection aspects) components of peer relationships can be associated with greater low mood and anxiety [48, 49] and that girls can engage in co-rumination in problematic ways [50]. Evidence on the relationship between social media and mental health remains mixed, yet participants’ accounts of aspects of social media engagement as promoting insecurity (and in turn affecting mental health) echoes theory and evidence that such aspects may be especially problematic for girls [51]. Thus, our study complements the evidence base to corroborate understandings of risk factors for adolescent girls’ low mood and anxiety.

Our study adds insights and nuances that deepen this evidence base and can direct further research. This includes contributing evidence where youth insight on the link between a given factor and low mood and anxiety is lacking, such as academic attainment, where much qualitative evidence in mental health implications stems from adults supporting adolescent girls, rather than girls themselves [22]. This finding reiterates the need for researchers, policymakers, and practitioners to engage carefully with questions of how academic pressure is affecting young people [52], including girls in particular. Another insight relates to how structural issues are experienced by girls in England; for instance, frustrations with gendered norms, and the depth of implications for self-concept, are well-established in feminist literature [53], but offer important insight into the depth of how these norms are felt by the current generation of adolescent girls in England. This highlights the need for schools and other community and youth settings to focus attention on addressing systemic gender norms, such as gendered discourses in classrooms and the ways that sexual harassment are inherently permitted [54]. Notably, some of the explanations raised by our participants are not necessarily entirely specific to current cohorts. Reiteration of gender norms is an evolving rather than new challenge, and difficult aspects of peer relationships are common in adolescent friendship and can contribute to psychosocial development [55]. Yet certainly some factors, such as academic pressure and social media, can evolve substantially over time, and all such factors can be relevant for understanding the persistent gender gap in low mood and anxiety and apparent increases over time.

As explored in the final theme, participants drew attention to the interwoven, complex nature of various issues, and cautioned against reductionism. This interwovenness was most clear for comparative aspects of social media, which appeared to act as an additional platform for other processes (e.g., gendered expectations and comparison to peers) to play out and be magnified. This echoes discussions around how social media functions intersect with wider developmental contexts of adolescence, fostering a focus on body image and appearance at a time of identity exploration and heightened investment in peer approval [51], and demonstrates a need for responses that match this complexity.

Spanning several of the explanations put forth were proposed mechanisms via stress and pressure as well as self-appraisal. This is important, as it has been consistently suggested that worsened low mood and anxiety among girls are grounded in ‘chronic strain’, or a prolonged, persistent experience of daily stressors that, cumulatively, create a continuous state of tension leading to worsened mental health [1, 56]. For self-appraisal, evidence generally indicates that girls experience lower self-esteem than boys, especially in adolescence, although this is dependent upon conceptualisation, domain, and nuances such as the extent of internalisation of external norms [57]. Participants’ consistent identification of similar underlying mechanisms emphasises the need for further understanding of the mechanisms by which both individual and compounded risk factors are associated with heightened low mood and anxiety among girls.

This study holds critical policy and practice significance, offering insights that can be explored contextually and in conjunction with wider evidence to extend and enhance systems and interventions to best meet girls’ needs. Structurally, for instance, our discussions with girls suggest a need to challenge the gendered discourses communicated to children and adolescents; review the educational pressures of UK secondary education; provide education and support relating to peer relationships; and evaluate social media functionality and engagement for young people. More directly, our analysis highlights a need for those working with adolescent girls to create supportive, open spaces for nuanced conversations about the challenges they face, together with opportunities to bolster self-esteem and coping capacities. In research, policy, and practice, efforts to progress the agenda to improve girls’ mental health can be best achieved through engagement with girls as key contributors to decision-making, as has been a key strength in our study; see, for instance, guidance and publications around conceptualising and reporting on co-produced health interventions and services [58, 59].

This study offers a conceptually and methodologically important contribution to evidence on gendered inequalities in low mood and anxiety. A key strength is our emphasis upon youth voice, both through a qualitative design eliciting adolescent girls’ perceptions and through our co-production of the study with young women, both of which are rarely included in work in this area. Participants appeared enthused in sharing their views and found resonance in collectively unpacking these, leading to rich data with important implications for ongoing research and for public health efforts. Young researchers played a critical role in designing, guiding, and interpreting discussions, and had invaluable input in contextualising and making sense of the challenges that participants raised. The study can therefore impart youth voice into efforts to unpack gendered mental health inequalities and demonstrates the fruitfulness of engagement with adolescent girls within this area.

However, this is a perception-based study undertaken in group contexts where some points may have been dominant or unelicited, and was ‘light touch’ in that we met participants once and asked them not to share things that might feel upsetting or personal. Thus, we cannot necessarily clarify the specific nature of potential contributing factors (i.e., how these function statistically in risk analysis) or specificity to adolescent girls (e.g., that the issues explored are not similarly experienced by boys), timing may have affected the focus and depth of discussion (e.g., educational pressures may feature less heavily beyond exam season), and points may have been unexplored. This study can be complemented by more immersive qualitative investigation such as one-to-one interviews or ethnographic exploration in schools and other community and youth spaces, and longitudinal research examining risk factors and mechanisms for low mood and anxiety over time. Though we saw engagement with girls from varying ethnic and religious backgrounds and from LGBTQIA + communities, those who have been eligible for free school meals or who are disabled or transgender were less represented. Further exploration with adolescent girls from particular backgrounds and communities will be valuable, particularly given the intersectional nature of inequality.

Identifying and understanding the potential contributors to low mood and anxiety as perceived by adolescent girls themselves – namely narrow expectations for girls and women, intense educational pressures, challenges in peer relationships, and comparison and insecurity in social media – is a critical contribution to literature given limited evidence of their views, particularly in a UK context and in recent years. Our study can direct future research in numerous ways, including providing youth-informed direction for epidemiological research examining risk factors, and more targeted research to illuminate the contexts, processes, and mechanisms wherein particular experiences are associated with low mood and anxiety for girls. We recognise principles of equifinality and multifinality and acknowledge that many adolescent girls face a range of wider psychosocial factors that contribute to their mental health. Yet key issues raised here resonate with broader concerns within the field of youth mental health, such as research priorities for youth public mental health recently established through a co-produced transdisciplinary project [60]. Research, policy, and practice efforts in the area therefore have the potential to yield substantial benefits for a wide-ranging audience, but also should be approached with a nuanced understanding of gender-specific contexts and processes, particularly to inform and mobilise a strategic response to high rates of low mood and anxiety among girls.

RTA

Reflexive thematic analysis

Ethics approval and consent to participate: The study received ethical approval from The University of Manchester Research Ethics Committee (Ref: 2022-13633-23090) and was performed in accordance with the Declaration of Helsinki. Participants provided informed opt-in consent and researchers monitored ongoing consent throughout focus groups.

Consent for publication: Not applicable; we are not sharing identifiable data.

Availability of data and materials: Data cannot be made available due to ethics and privacy restrictions in line with the nature of our consent and assent with our participants and their parents/carers. All data generation materials from the project are publicly available via the Open Science Framework: https://osf.io/kbta4. We have shared a list of all codes underpinning our themes in the Supplementary Materials of this article.

Competing interests: The authors have no competing interests to declare that are relevant to the content of this article.

Funding: The study was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (project reference NIHR135295). The views expressed in this article are those of the author(s) and not necessarily those of the NIHR.

Author contributions: OD: conceptualization, funding acquisition, methodology, analysis, writing (original draft), supervision; RJ: methodology, investigation, data curation, analysis, writing (reviewing and editing), project administration; PN: methodology, investigation, analysis; LF: conceptualization, funding acquisition, methodology, writing (reviewing and editing), JL: methodology, investigation; SP: methodology, writing (reviewing and editing); RE: methodology, writing (reviewing and editing); BD: methodology, writing (reviewing and editing); LN: methodology, resources; LAW: methodology, writing (reviewing and editing); GN: data curation.

Acknowledgements: We extend our thanks to the adolescent girls who took part in this study and shared their perceptions and experiences with us and with each other, and to the organisations who worked with us to connect with these participants. We also thank the adolescent girls who guided the development of the original design of this study.

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Adolescent girls’ explanations of high rates of low mood and anxiety in their population: A co-produced qualitative study

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Abstract

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Aims

Methods

Design

Research team

Participants and sampling

Data generation

Ethical considerations

Data analysis

Analysis

Theme 1: Rising rates of low mood and anxiety are unsurprising

Theme 2: Strict and narrow expectations of how girls and women should look and behave

Theme 3: Educational pressures feel intense and gendered

Theme 4: Challenges in peer relationships can add pressure

Theme 5: Social media can be a space of comparison and insecurity

Theme 6: There is no easy answer to explain or resolve issues

Discussion

Strengths and Limitations

Conclusion and Implications

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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