Abstract
Water insecurity and other social-ecological factors may be associated with depression in low and middle-income contexts (LMICs). This is understudied among urban refugee youth in LMICs, who experience multiple forms of marginalization. We conducted a cross-sectional survey with a peer-driven sample of urban refugee youth aged 16–24 in Kampala, Uganda. We explored: the prevalence of depression (moderate, moderately severe); associations between social-ecological (structural, community, interpersonal, intrapersonal) factors and depression; and associations between an Index of Vulnerability (IoV) comprised of social-ecological stressors and depression. Among n = 335 participants (mean age: 20.8 years, standard deviation: 3.1), in multivariable analyses, longer time in Uganda, water insecurity, lower social support, parenthood, and recent intimate partner violence were associated with moderate depression; and longer time in Uganda, water insecurity, and lower social support were associated with moderately severe depression. IoV scores were associated with moderate depression among men and women, and moderately severe depression among women. The IoV scores accounted for more variance in moderate/moderately severe depression among women than any single indicator; among men, water insecurity was most strongly associated with moderate depression. Future research can explore strategies to address water insecurity and other social-ecological stressors to promote health and wellbeing with urban refugee youth.
| Original language | English (US) |
|---|---|
| Article number | 100306 |
| Journal | SSM - Mental Health |
| Volume | 5 |
| DOIs | |
| State | Published - Jun 2024 |
Keywords
- Depression
- Refugee
- Uganda
- Urban
- Water insecurity
- Youth
ASJC Scopus subject areas
- Social Sciences (miscellaneous)
- Psychology (miscellaneous)
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In: SSM - Mental Health, Vol. 5, 100306, 06.2024.
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}
TY - JOUR
T1 - Applying the Index of Vulnerability approach to understand water insecurity and other social-ecological factors associated with depression among urban refugee youth in Kampala, Uganda
AU - Logie, Carmen H.
AU - Okumu, Moses
AU - Admassu, Zerihun
AU - MacKenzie, Frannie
AU - Kortenaar, Jean Luc
AU - Perez-Brumer, Amaya
AU - Gittings, Lesley
AU - Khan, Naimul
AU - Hakiza, Robert
AU - Kibuuka Musoke, Daniel
AU - Nakitende, Aidah
AU - Katisi, Brenda
AU - Kyambadde, Peter
AU - Taing, Lina
AU - Mbuagbaw, Lawrence
N1 - Vulnerability, a contested term with myriad theoretical underpinnings, involves the nexus of stress exposure, capacity to cope, and consequences of stress and illness (Brown et al., 2017; Leatherman, 2005; Tallman et al., 2019). A vulnerability lens informed by a political-ecology of health involves \u201Can examination of structured inequalities and social relations that underlie poverty, and how they affect not only levels of illness, but also coping capacities and hence the outcomes of poor health\u201D (p. 51) (Leatherman, 2005). Leatherman (2005) describes a space of vulnerability as shaped by contextually specific human-environment interactions that include social relations and meanings of poverty, global-local interactions, institutional policies and practices, resource distribution, access to opportunities, and human agency in stress coping and responses. Water and food insecurity can be understood as life domains shaped by social-ecological inequities that constrain resource access and in turn increase vulnerability to harm (Tallman, 2016). Tallman developed an Index of Vulnerability (IoV) to explore the linkages between social-ecological risks (including food insecurity, water insecurity, low social support, low social status) and poorer mental and physical health in the Peruvian Amazon (Tallman, 2016). This study found that IoV scores were associated with numerous poor health outcomes (e.g., depressive symptoms, poorer perceived health) and were a better predictor than using single life domains, in turn recommending that other scholars adapt the IoV to local contexts (Tallman, 2016).Index of Vulnerability (IoV): Following Tallman's (Tallman, 2016) example of developing a multi-dimensional IoV measure of social-ecological exposures to stressors, we created a similar IoV that included 5 domains that span structural (food insecurity, water insecurity), community (social support), and interpersonal (parenthood, recent IPV) levels. IoV measures were explicitly selected at these social, community, and interpersonal levels that involve a) interactions with institutions and access to material resources (food, water), b) access to social support, and c) relational factors, including IPV and parenthood during young adulthood (itself associated with instability and a need for social support (Naud\u00E9 and Piotrowski, 2023), as well as a potential risk for poorer social and health outcomes in LMIC (Malama et al., 2023; Toska et al., 2017a, 2020)), and not intrapersonal level factors. This framing encourages a move beyond individual-focused understandings of vulnerability toward a consideration of the social production of power and marginality that cause harm and maintain systems of domination (Tallman, 2016; Tallman et al., 2020), aligned with the spaces of vulnerability framework in political-ecology of health analyses (Brown et al., 2017; Leatherman, 2005; Tallman et al., 2019).Factors associated with increased odds of moderate PHQ-9 depression scores (\u226510) in bivariate analyses were length of time in Uganda (longer time resulted in higher odds of depression), higher food insecurity, higher water insecurity, lower social support, having children, and recent IPV experiences (Table 2). In multivariable analysis, after controlling for gender and factors significantly associated with moderate depression in bivariate analyses, the longer time participants had lived in Uganda was associated with higher odds of moderate depression. For instance, participants who lived in Uganda over 10 years (adjusted Odds Ratio [aOR]: 2.91, 95% Confidence Interval [CI]: 1.22\u20136.96; p\u202F=\u202F0.016), and from 6 to 10 years (aOR: 4.12, 95% CI: 1.88\u20139.02; p\u202F<\u202F0.001), had elevated odds of depression compared to those living in Uganda less than 5 years. Structural level: Water insecurity was associated with nearly 8-fold higher odds of reporting moderate depression in adjusted analyses (aOR: 7.71, 95% CI: 3.65\u201316.26; p\u202F<\u202F0.001). Community level: Higher social support was also associated with lower odds of depression in adjusted analyses (aOR: 0.98; 95% CI: 0.96\u20130.99; p\u202F=\u202F0.003). Interpersonal level: Participants with children were almost four times more likely to experience moderate depressive symptoms than respondents with no children (aOR: 4.20, 95% CI: 1.47\u201312.01, p\u202F=\u202F0.007) in adjusted analyses. Participants reporting recent IPV experiences were over three times more likely to report moderate depression than those who did not experience IPV in adjusted analyses (aOR: 3.52; 95% CI: 1.03\u201311.98; p\u202F=\u202F0.044).An important contribution of our study is the adaptation of an Index of Vulnerability (IoV) (Tallman, 2016) to examine multi-level stress exposures linked with urban refugee youth depression, reflecting a political ecology approach to vulnerability (Leatherman, 2005; Tallman et al., 2019). While prior reviews have looked at the prevalence (Blackmore et al., 2020; Bronstein and Montgomery, 2011), intervention approaches (Cowling and Anderson, 2023; Hodes and Vostanis, 2019; Purgato et al., 2018), and social-ecological correlates (Bronstein and Montgomery, 2011; Scharpf et al., 2021; Tam et al., 2017) of refugee youth mental health, few have assessed multi-level risk exposures across life domains. Our finding that the IoV is a better predictor of depression for refugee young women than any singular life domain assessed signals the importance of assessing how this multi-dimensional measure may capture the additive and multiplicative effects of these co-occurring structural, community, and interpersonal level vulnerabilities that reflect a specific space of vulnerability (Leatherman, 2005; Tallman et al., 2019). While evidence exists that each of the individual variables in the IoV are associated with depression, including food insecurity and low social support (Logie et al., 2022c), water insecurity (Cooper-Vince et al., 2017, 2018b; Mushavi et al., 2020), IPV (Meyer et al., 2017a, 2017b), and parenthood during youth (Malama et al., 2023), we demonstrate that refugee young women's risk for depression increases with vulnerabilities experienced across multiple life domains. Value additions of the IoV analyses include: a) offering a simple, interpretable method to communicate findings to a range of stakeholders; b) identifying what IoV domains matter most for each level of depression by gender to inform interventions; and c) building on the standardized IoV approach by showing its applicability to a different context, population, and life domains (Tallman et al., 2019).Despite these limitations, to our knowledge this study is unique in looking at water insecurity and its linkages with depression among urban refugee youth and findings have implications for assessing water insecurity as a social determinant of mental health in Kampala's informal settlements at large, and among refugees in both urban and rural settlements in LMIC. This study is also unique in adapting an Index of Vulnerability to identify social-ecological stressors linked with urban refugee young women's depression outcomes in a LMIC. Findings can inform integration of mental health programming alongside support services for young parents, peer social support programs, IPV screening, and water and food insecurity services.The study was funded by Grand Challenges Canada with additional support by Canadian Institutes of Health Research. Logie was also supported by Canada Research Chairs and Canada Foundation for Innovation. Funders played no role in study design.
PY - 2024/6
Y1 - 2024/6
N2 - Water insecurity and other social-ecological factors may be associated with depression in low and middle-income contexts (LMICs). This is understudied among urban refugee youth in LMICs, who experience multiple forms of marginalization. We conducted a cross-sectional survey with a peer-driven sample of urban refugee youth aged 16–24 in Kampala, Uganda. We explored: the prevalence of depression (moderate, moderately severe); associations between social-ecological (structural, community, interpersonal, intrapersonal) factors and depression; and associations between an Index of Vulnerability (IoV) comprised of social-ecological stressors and depression. Among n = 335 participants (mean age: 20.8 years, standard deviation: 3.1), in multivariable analyses, longer time in Uganda, water insecurity, lower social support, parenthood, and recent intimate partner violence were associated with moderate depression; and longer time in Uganda, water insecurity, and lower social support were associated with moderately severe depression. IoV scores were associated with moderate depression among men and women, and moderately severe depression among women. The IoV scores accounted for more variance in moderate/moderately severe depression among women than any single indicator; among men, water insecurity was most strongly associated with moderate depression. Future research can explore strategies to address water insecurity and other social-ecological stressors to promote health and wellbeing with urban refugee youth.
AB - Water insecurity and other social-ecological factors may be associated with depression in low and middle-income contexts (LMICs). This is understudied among urban refugee youth in LMICs, who experience multiple forms of marginalization. We conducted a cross-sectional survey with a peer-driven sample of urban refugee youth aged 16–24 in Kampala, Uganda. We explored: the prevalence of depression (moderate, moderately severe); associations between social-ecological (structural, community, interpersonal, intrapersonal) factors and depression; and associations between an Index of Vulnerability (IoV) comprised of social-ecological stressors and depression. Among n = 335 participants (mean age: 20.8 years, standard deviation: 3.1), in multivariable analyses, longer time in Uganda, water insecurity, lower social support, parenthood, and recent intimate partner violence were associated with moderate depression; and longer time in Uganda, water insecurity, and lower social support were associated with moderately severe depression. IoV scores were associated with moderate depression among men and women, and moderately severe depression among women. The IoV scores accounted for more variance in moderate/moderately severe depression among women than any single indicator; among men, water insecurity was most strongly associated with moderate depression. Future research can explore strategies to address water insecurity and other social-ecological stressors to promote health and wellbeing with urban refugee youth.
KW - Depression
KW - Refugee
KW - Uganda
KW - Urban
KW - Water insecurity
KW - Youth
UR - http://www.scopus.com/inward/record.url?scp=85189630411&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85189630411&partnerID=8YFLogxK
U2 - 10.1016/j.ssmmh.2024.100306
DO - 10.1016/j.ssmmh.2024.100306
M3 - Article
AN - SCOPUS:85189630411
SN - 2666-5603
VL - 5
JO - SSM - Mental Health
JF - SSM - Mental Health
M1 - 100306
ER -