Abstract
Background:
In the two decades from 1995 to 2018, approximately 48 farmers committed suicide every day, accounting for over 0.4 million deaths. Despite farmer's mental health being a priority, studies on farmers’ mental health in general and depressive disorders in particular are limited.
Aim:
This study was conducted to find out the prevalence and factors associated with depressive disorders among farmers in Andhra Pradesh.
Materials and Methods:
We conducted a cross-sectional survey among a random sample of 360 farmers. Depressive disorders were measured using the Patient Health Questionnaire (PHQ)-9. Mild-to-moderate depressive disorders were the outcome variable. Factors associated with depressive disorders were identified using binary logistic regression.
Results:
The overall prevalence of depressive disorders was 22.2% (95% CI = 18.0%–26.9%). Female farmers (AOR = 4.16; 95% CI = 1.19–14.57), farmers aged ≥57 years (AOR = 4.90; 95% CI = 1.44–16.63), and single farmers (AOR = 4.96; 95% CI = 2.08–11.80) have greater odds of having depressive disorders.
Conclusion:
Efforts are required to address depressive disorders among farmers focusing on females, older farmers, and households reporting hospitalization. Since depressive disorders are closely associated with suicide attempts, these efforts are essential to avoid suicides resulting from depressive disorders.
Keywords: Depression, epidemiology, farmers, occupational/industrial psychology
INTRODUCTION
Agriculture and allied sectors account for 18.8% of India's gross national product and employ more than 40% of the workforce.[1,2] Farmer's mental health, specifically farmer suicides, is a matter of sociopolitical and policy importance.[3] In the two decades from 1995 to 2018, approximately 48 farmers committed suicide every day, accounting for over 0.4 million deaths.[4] Farmers were also reported to have poor mental health status than the general population.[5,6] Mental disorders are reported to be a key risk factor for suicidal ideation and attempts among farmers.[7] Studies on farmers’ mental health are limited in India. One study reported that farmers’ suicides adversely affected the mental health of the close family members of the victims.[8] Another study reported distress among agriculture workers in India with a depression prevalence of 14.6%.[9] South India including Andhra Pradesh reported higher rates of depressive disorders compared with the rest of India.[10]
The literature indicates that several socio-demographic, economic, health, and lifestyle factors influence the risk of depressive disorders. Studies indicate that females in India have a higher incidence of depressive disorders.[10] A greater prevalence of depressive disorders was documented among older adults.[10,11] Medical reasons such as chronic diseases, recent hospitalization, tobacco, and alcohol use are associated with depressive disorders.[12,13] Depression has a known association with factors such as gender, poverty, and debt.[9] Additionally, socioeconomic factors such as income, education, marital status, and ownership of assets were also observed to be associated with depressive disorders.[14]
As of 2021, over 65% of Indians reside in rural areas with agriculture being a predominant income-generating activity. As per the 2011 census, 59.5% of the working population and over 77.0% of the rural working population of Andhra Pradesh are employed in agriculture.[15] Despite being a priority area from an economic, political, and public health perspective, studies on farmers’ mental health in general and depressive disorders in particular are limited. This study was conducted to determine the prevalence of depressive disorders among farmers in Andhra Pradesh. It also sought to identify the factors associated with depressive disorders among farmers.
METHODS
Study design and sampling
We conducted a cross-sectional survey from March 2022 to April 2022 in three districts of Andhra Pradesh (i.e., Krishna, Prakasam, and Vizianagaram) selected based on the multidimensional poverty index (MPI).[16] The study participants were selected using multistage random sampling [see Figure 1].
Figure 1:
Outline of the sample selection process. Footnotes: MPI = multidimensional poverty index; HH = household
Telugu-speaking men and women aged 18 to 65 years living in the sampled villages for six months before the survey, actively engaged in farming work, and willing to provide informed consent were selected. Telugu farmers who migrated to the study site on seasonal work and those who were reluctant to provide informed consent were excluded.
Sample size
The sample size was estimated based on an anticipated 14.6% prevalence of depressive disorders,[9] 95% confidence level, a precision of 5%, a design effect of 1.5, and a 20% nonresponse rate. The estimated sample size was 345, which was rounded off to 360.
Data collection
Data were collected employing a survey questionnaire administered to the farmers. The survey questionnaire included items on demographic and socioeconomic variables and nine questions on Patient Health Questionnaire (PHQ)-9. PHQ-9 measures depression as a composite score of nine items with responses ranging from 0 (representing “not at all”) through 3 (representing “nearly every day”).[17] It was used in Indian settings in major Indian languages with acceptable reliability.[18,19] All the questions were translated into the local language Telugu and back-translated to English until they matched the original English version. All the participants approached agreed to participate in the study. There was no refusal. Each survey lasted for about 30 minutes.
Data entry and analysis
Data were cleaned and analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 27. The outcome variable “depressive disorders” was computed from the composite score based on the PHQ-9 scale. The outcome variable was computed as binary variable “mild-to-moderate depressive disorders” and “no depressive disorders.” The binary categorization was necessary since the category “moderate depression” had smaller frequencies (n = 5), and there were no participants who were identified to have “moderately severe” and “severe depression.”
Prevalence measures along with a 95% confidence interval were computed. Chi-squared tests were used to identify the factors associated with depressive disorders. Adjusted odds ratios (AOR) employing binary logistic regression were computed to address confounding bias. Before regression analysis, the assumptions such as independence of errors, absence of outliers, and absence of multicollinearity were ensured. The Hosmer–Lemeshow test had a significance value of 0.745 indicating the model fit.
Ethical consideration
The ethics clearance for this study was obtained from the institutional human ethics committee of a central institution. All the participants approached provided informed consent to their participation and use of data for research purposes. The privacy and confidentiality of participants were maintained.
RESULTS
The study participants majorly included men (n = 324, 90%) and those belonging to the age group of 40–56 years (45.8%; n = 165). More than 68% (n = 245) of the households of farmers had a household income of up to INR 10000, and 63.1% (n = 227) had debt [see Table 1].
Table 1:
Characteristics of the study sample (n=360)
| Variables | Frequency (%) |
|---|---|
| Gender | |
| Male | 324 (90.0%) |
| Female | 36 (10.0%) |
| Age group | |
| 20–39 years | 113 (31.4%) |
| 40–56 years | 165 (45.8%) |
| 57 years and above | 82 (22.8%) |
| Education status | |
| No formal education | 128 (35.6%) |
| Up to 10th standard | 190 (52.8%) |
| 11th standard and above | 42 (11.6%) |
| Household type | |
| Joint family | 132 (36.7%) |
| Nuclear family | 228 (63.3%) |
| Marital status | |
| Married/in union | 332 (92.2%) |
| Single | 28 (7.8%) |
| Religion | |
| Hindus | 214 (59.4%) |
| Non-Hindus | 146 (40.6%) |
| Number of working members | |
| Up to two individuals | 276 (76.7%) |
| Three and above | 84 (23.3%) |
| Household expenditure | |
| Below 5000 INR | 130 (36.1%) |
| INR 5001 and above | 230 (63.1%) |
| Household income | |
| INR 10000 and above | 115 (31.9%) |
| Up to INR 10000 | 245 (68.1%) |
| Currently in debt | |
| Yes | 227 (63.1%) |
| No | 133 (36.9%) |
| Land ownership | |
| Others land | 162 (45.0%) |
| Own land | 198 (55.0%) |
| Current alcohol use | |
| Yes | 168 (46.7%) |
| No | 192 (53.3%) |
| Current tobacco use | |
| Yes | 161 (44.7%) |
| No | 199 (55.3%) |
| Suffering with chronic diseases | |
| Yes | 119 (33.1%) |
| No | 241 (66.9%) |
| Hospitalization in the family in the last one year | |
| No | 276 (76.7%) |
| Yes | 84 (23.3%) |
INR: Indian rupees
Prevalence of depressive disorders
All the participants responded to the items of the PHQ-9 questionnaire, and a composite score of the item-wise responses was used to assess depression [see Table 2].
Table 2:
Item-wise responses to the PHQ-9 questionnaire (n=360)
| Over the last 2 weeks, how often have you been bothered by any of the following problems? | Not at all (0) | Several days (1) | More than half the days (2) | Nearly every day (3) | Mean (±SD) |
|---|---|---|---|---|---|
| Little interest or pleasure in doing things | 66.1% | 31.7% | 2.2% | 0% | 0.36(±0.53) |
| Feeling down, depressed, or hopeless | 47.8% | 49.2% | 3.1% | 0% | 0.55(±0.56) |
| Trouble falling or staying asleep or sleeping too much | 40.6% | 51.9% | 6.9% | 0.6% | 0.68(±0.63) |
| Feeling tired or having little energy | 56.9% | 40.8% | 2.2% | 0% | 0.45(±0.54) |
| Poor appetite or overeating | 53.1% | 45.3% | 1.7% | 0% | 0.49(±0.53) |
| Feeling bad about yourself | 82.8% | 16.7% | 0.6% | 0% | 0.18(±0.40) |
| Trouble concentrating on things | 41.1% | 56.9% | 1.4% | 0.6% | 0.61(±0.55) |
| Moving or speaking slowly or restless | 81.1% | 18.1% | 0.8% | 0% | 0.20(±0.42) |
| Thought of hurting yourself | 98.6% | 1.4% | 0% | 0% | 0.01(±0.12) |
| Total score | 3.53(±2.16) |
Among the 360 participants surveyed, 20.8% of the participants were found to have mild depressive disorders on the PHQ-9 scale and 1.4% had moderate depressive disorders. In total, 22.2% (95% CI = 18.0%–26.9%) of the farmers surveyed were found to have mild-to-moderate depressive disorders.
Factors associated with depressive disorders among the farmers
It was observed that females (p < 0.01), older farmers (p < 0.01), single farmers (p < 0.01), non-Hindus (p < 0.01), and those who were suffering from a chronic disease (p < 0.05) were significantly associated with mild-to-moderate depressive disorders [see Table 3].
Table 3:
Factors associated with depression: results of bivariate analysis
| Variables | Depressive disorders |
Chi-square value | P | |
|---|---|---|---|---|
| No | Mild-to- moderate | |||
| Gender | ||||
| Female | 50.0% | 50.0% | 17.86 | <0.001 |
| Male | 80.9% | 19.1% | ||
| Age group | ||||
| 20–39 years | 85.8% | 14.2% | 9.69 | 0.008 |
| 40–56 years | 77.6% | 22.4% | ||
| 57 years and above | 67.1% | 32.9% | ||
| Marital status | ||||
| Married/in union | 79.5% | 20.5% | 7.48 | 0.006 |
| Single | 57.1% | 42.9% | ||
| Religion | ||||
| Hindus | 83.2% | 16.8% | 8.90 | 0.003 |
| Non-Hindus | 69.9% | 30.1% | ||
| Household expenditure | ||||
| Below 5000 INR | 83.1% | 16.9% | 3.31 | 0.069 |
| INR 5001 and above | 74.8% | 25.2% | ||
| Current alcohol use | ||||
| No | 70.3% | 29.7% | 13.27 | <0.001 |
| Yes | 86.3% | 13.7% | ||
| Suffering with chronic diseases | ||||
| Yes | 70.6% | 29.4% | 5.32 | 0.021 |
| No | 81.3% | 18.7% | ||
| Hospitalization in the family in the last one year | ||||
| Yes | 64.3% | 35.7% | 11.54 | 0.001 |
| No | 81.9% | 18.1% | ||
INR: Indian rupees
Binary logistic regression yielded AOR reflecting the strength of the association. It was found that female farmers (AOR = 4.16; 95% CI = 1.19–14.57), farmers ≥57 years (AOR = 4.90; 95% CI = 1.44–16.63), and single farmers (AOR = 4.96; 95% CI = 2.08–11.80) were more likely to report depressive disorders [see Table 4].
Table 4:
Factors associated with depressive disorders: results of binary logistic regression analysis
| Variables | Prevalence of mild-to- moderate depression (95% CI) | AOR | 95% CI |
P | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Gender | |||||
| Male (ref) | 19.1 (15.1-23.7) | ||||
| Female | 50.0 (34.1-65.9) | 4.16 | 1.19 | 14.57 | 0.03* |
| Age group | |||||
| 20–39 years (ref) | 14.2 (8.6-21.4) | ||||
| 40–56 years | 22.4 (16.5-29.2) | 1.74 | 0.99 | 3.06 | 0.06 |
| 57 years and above | 32.9 (23.4-43.5) | 4.90 | 1.44 | 16.63 | 0.01** |
| Marital status | |||||
| Married/in union (ref) | 20.5 (16.4-25.0) | ||||
| Single | 42.9 (25.8-61.2) | 4.96 | 2.08 | 11.80 | 0.00** |
| Household expenditure | |||||
| Below 5000 INR (ref) | 16.9 (11.2-24.0) | ||||
| INR 5001 and above | 25.2 (19.9-31.1) | 2.23 | 1.08 | 4.60 | 0.03* |
| Current alcohol use | |||||
| Yes (ref) | 13.7 (9.1-19.4) | ||||
| No | 29.7 (23.5-36.4) | 2.58 | 1.47 | 4.53 | 0.00** |
| Hospitalization in the family in the last one year | |||||
| No (ref) | 18.1 (13.9-22.9) | ||||
| Yes | 35.7 (26.0-46.3) | 2.19 | 1.06 | 4.54 | 0.04* |
AOR: Adjusted odds ratio, CI: Confidence interval, ref: Reference, NCD: Noncommunicable disease, INR: Indian rupees, *significant at P value ≤0.05, **significant at P value ≤0.01
DISCUSSION
Our finding of 22.2% of mild-to-moderate depressive disorders was higher than the 14.6% reported among farmers in Maharashtra.[9] The prevalence of mild-to-moderate depression in our study was greater than that of 3.9% identified among the general population in Andhra Pradesh[10] and 15.9% identified in another south Indian population.[20] Overall, our findings indicate that farmers have a greater prevalence of depressive disorders.
Female farmers, although a small proportion in our sample, had a significantly higher prevalence of depressive disorders. The gender demarcation of depression prevalence among farmers is similar to the general population.[10] Older farmers were found to have a higher prevalence compared with younger farmers, similar to the general population.[10] An earlier systematic review indicated that old-age conditions influence farmer's mental health.[21] Single farmers who were never married were significantly more likely to have depressive disorders, a finding that is in agreement with other literature.[22]
Our findings indicate that low incomes coupled with hospitalization and associated expenditure increase the risk of depressive disorders among the farming community. High health expenditures are documented to have a significant association with depression and suicidal ideation.[23] Out-of-pocket expenditure (OOPE) by households contributes to more than 55% of current health expenditure in India.[24] OOPE is significantly higher in uninsured households and communities living in rural areas with limited access to healthcare facilities. OOPEs are high for chronic diseases, respiratory diseases, and injuries,[25] which are known to be associated with farm work. Farming in India, being a low per capita income-generating activity, could expose households to financial distress in health emergencies. Another finding of our study that farmers belonging to households with an expenditure of more than 5000 INR per month (approx. 62.8 USD) reported more depressive disorders supports this argument.
Our finding of greater odds of depression among nonusers of alcohol is contrary to existing literature that alcohol and depression are strongly correlated.[26] This deviation from the general observations can be attributed to i) the high prevalence of mild-to-moderate depressive disorders, ii) the high percentage of alcohol users, and iii) the cross-sectional nature of the study.
Our study limitations include its cross-sectional nature, and noninclusion of external variables such as rainfall patterns, harvest, and market price of farm produces, all of which are known to be associated with anxiety and depression among the farming community. Moreover, 90% of our study samples are males, which could be a limitation. Nevertheless, our study provides crucial insight into the general prevalence of depressive disorders, the role of the individual, and healthcare factors in influencing depression among farmers. Future studies may explore the impact of social, economic, healthcare, and associated factors on farmer's mental health.
CONCLUSIONS
The high prevalence (22.8%) of mild-to-moderate depressive disorders calls for focused efforts. There is a need for the provision of mental health and counseling services targeting farming communities.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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