Loneliness, Social Isolation, and Suicidal Ideation and Attempt Among Adolescents Living with HIV: A Cross-Sectional Study in Masaka, Uganda

Abstract

One in six people are aged 10–19 years. Adolescence is a unique and formative time. Physical, emotional, and social changes, including exposure to poverty, abuse, or violence, can make adolescents vulnerable to mental health problems. Protecting adolescents from adversity, promoting socio-emotional learning and psychological well-being, and ensuring access to mental healthcare are critical for their health and well-being during adolescence and adulthood. Globally, it is estimated that 1 in 7 (14%) 10–19 year-olds experience mental health conditions (1), yet these remain largely unrecognized and untreated. Adolescents with mental health conditions are particularly vulnerable to social exclusion, discrimination, stigma (affecting readiness to seek help), educational difficulties, risk-taking behaviors, physical ill-health, and human rights violations.

Introduction

Globally, it is estimated that 1 in 7 (14%) 10–19-year-olds experience mental health conditions, yet these remain largely unrecognized and untreated (Adolescent mental health statistics n.d). Adolescents with mental health conditions are particularly vulnerable to social exclusion, discrimination, stigma (affecting readiness to seek help), educational difficulties, risk-taking behaviors, physical ill-health, and human rights violations (Gupta et al., 2023). Specifically, suicide is a major public health mental health concern worldwide and the third leading cause of death for adolescents ages 15–19 (Adolescent and young adult health n.d). To explore a more contextual background, a study conducted among in-school adolescents living in 59 middle and low-income countries, reports found that the overall prevalence of suicidal ideation was 16.9% and suicide attempt 17.0% respectively (Uddin et al., 2019). In Tanzania, Dunlavy et al. reported that 7% of in-school adolescents had thought about committing suicide, but 6.3% devised a plan to carry out the suicide (Dunlavy et al., 2015).

Psychology today defines loneliness as a state of distress that results when one perceives a gap between one’s desires for social connection and actual experiences of it (Loneliness | Psychology Today, n.d.). Social isolation on the other hand is a lack of a relationship with others with little to no social support or contact (CDC, 2023). From 2020 to-date, the social relationships of children and adolescents was significantly disrupted because of the COVID-19 pandemic mitigation measures such as lockdowns and physical distancing practices. Approximately 90% of the world’s children and adolescents were impacted by school closures (Education: From COVID-19 school closures to recovery | UNESCO n.d).

Adolescents living with HIV (ALHIV), a highly stigmatized condition, are more prone to shame. Furthermore, adolescence is a developmental period of multiple vulnerabilities marked by the onset of physical and emotional maturity (Dahl, 2004), as well as the rise in social evaluations and self-consciousness concerns (Rankin et al., 2004; Somerville et al., 2013; Westenberg et al., 2004). Studies have indicated that adolescents living with HIV have agency and may need to make conscious choices about sharing their status (Nabunya & Namuwonge, 2022). However, these choices are influenced by their experiences in their community. The discrimination and negative judgements they often experience prevent them from disclosing their status. Stigma, discrimination, and psychological distress contribute to the isolation that adolescents and young adults living with HIV experience (Chan et al., 2020; Facts about HIV Stigma | HIV Basics | HIV/AIDS | CDC, n.d.). The limited disclosure itself can lead to them becoming isolated and lonely (Ngwenya et al., 2023). To further highlight this cause, some of the notable predictors of suicide behavior mentioned by Calati et. were social constructs associated with suicidal outcomes which included marital status (being single, separated, divorced, or widowed) and living alone, social isolation, loneliness, alienation, and belongingness (Calati et al., 2019).

Vital information is still needed on the prevalence and risk factors associated with suicide ideation in a resource poor context among vulnerable children and adolescents living with HIV in a low social economic setting: Masaka district, Central Uganda. Thus, this study contributes to the limited literature by examining the relationship between loneliness and social isolation and the mental health outcomes of ALHIV at TASO-Masaka, particularly, suicide behavior. Given that loneliness and social isolation are predictors, findings may inform policy and interventions aimed at addressing suicide behavior within this young vulnerable population as they transition through adolescence and into young adulthood.

Methods

Sample and Setting

Data from adolescents participating in this study; a 9-month cross-sectional study aimed at assessing the burden and factors associated with suicide behavior (described as suicide ideation and suicide attempt) among adolescents living with HIV in Uganda were analyzed. The study recruited 150 adolescents from The AIDs Support Organization, Center of Excellence – Masaka (TASO – Masaka) located in the political district of Masaka. Inclusion criteria for adolescents are as follows: (1) adolescents aged 12–17 years and (2) living with HIV.

Participant Recruitment

Study participants were identified and recruited from TASO – Masaka. A clinic staff created a list of all eligible families using medical records—noting their eligibility to participate. Next, the clinic staff presented the project idea to adult caregivers of eligible children during appointments. If caregivers were interested, verbal consent to be contacted by research staff who was on site during the adolescent clinic days was requested. Following a meeting with the research staff, interested caregivers were taken through informed consent after which they provide written consent for themselves and for their child to participate. Assent was obtained from the children in absentia of their caregivers to avoid coercion.

Ethical Approval

The study was reviewed by three ethical bodies which included the Uganda Virus Research Institute Institutional Review Board (Reference number: GC/127/962), the Uganda National Council for Science and Technology (Reference number: SS1874ES.), and the TASO Institutional Review Board that warranted the signing of a Memorandum of Understanding between TASO and the principal investigator.

Data Collection

Data were collected using a 45-min interviewer-administered questionnaire. All study related materials were translated into Luganda—the widely spoken language in the study region—and back translated into English to ensure consistency. A certificate of translation was obtained from Makerere University. All interviewers received training in human subjects’ protection and completed Good Clinical Practice (GCP) trainings prior to engaging with study participants.

Measures

All measures utilized in this study have been adapted and tested among adolescents affected by HIV in the study region (Gupta et al., 2023; Mars et al., 2014; Minja et al., 2023; Nabunya & Namuwonge, 2022; Partap et al., 2023; Posner et al., 2011; Pretorius & Padmanabhanunni, 2022; Use of CSSR scale in suicide research in Africa—Google Search n.d.). Measures of mental health functioning included loneliness and social isolation, suicide attempt and suicide ideation, and depression. Loneliness was assessed using the UCLA Loneliness Scale (Russell, 1996). The 20-item scale measures one’s subjective feelings of loneliness as well as feelings of social isolation (3 = I often feel this way and 0 = I never feel this way), with high scores indicating higher levels of social isolation (Cronbach alpha = 0.88).

The adapted 9-item Columbia Suicide Severity Rating Scale (CSSR) (Salvi, 2019) was used to assess for suicide ideation and suicide behavior. Responses were dichotomous in nature (Yes = 1 and No = 0). A “yes” answer at any time to any one of the five suicidal ideation questions from categories 1 to 5. A “yes” answer at any time to any one of the four suicidal behavior questions from categories 6 to 9 (Cronbach alpha = of 0.99). These dichotomous responses were initially analyzed to report prevalence. For the regression analysis, the total scores from the CSSR scale were used as continuous variables to capture the severity of suicidal ideation and behaviors, which allowed us to utilize linear regression models. Depressive symptoms were assessed using the 6-item Kutcher Adolescent Depression Scale (KADS-6) (LeBlanc et al., 2002). Respondents were asked to mark a statement that best described their feelings during the past 1 week, with four response options that correspond to varying levels of symptomology for clinical depression (Cronbach’s alpha 0.71). Responses included hardly ever = 0, much of the time = 1, most of the time = 2, and all of the time = 3. Based on previous literature, variables included in the model as control variables include participants’ age, gender, religion, school enrollment orphanhood status, and family cohesion.

Data Analysis

Data analysis was performed using STATA version 18. We analyzed participants’ demographic characteristics, as well as the independent and outcome variables. We conducted multivariate linear regression models to ascertain the relationship between suicide attempt and ideation and measures of adolescents’ mental health functioning. Statistical significance was set a priori at the 5% level. For each linear regression model, standardized residuals were predicted, and diagnostic tests examined to check the distribution of residuals for non-normality and/or inequality of residuals over levels of predicted values for linear regression models. All models were single level models.

Results

Sample characteristics are presented in Table 1. Half of the study participants were males, N = 75. The median age was 15 years. The highest population by religion were Catholic (53.33%), and 80.67% reported to be enrolled in school. To assess participant’s access to healthcare facilities when need arises, they were asked the distance to the nearest government hospital, 76.67% of whom reported far (over 2 kms, one would not easily walk). Analyzing the sample of 150 participants, the study reveals a 23.33% prevalence of suicidal ideation and an 18% prevalence of suicide attempts, higher among males than females (ideation 26.67% vs 20%; attempt 18% vs 16% respectively). Table 2 highlights the multivariable regression findings with key statistical results including a significant association between loneliness with both suicide ideation and attempts (b = 0.012, 95% CI = (0.005, 0.019, P = 0.001), and b = 0.008, 95% CI = (0.001, 0.016, p = 0.023)).

Table 1.

Sample characteristics

Variable	Males (N=75)	Standard deviation	Total sample (N = 150)	Standard deviation
Age (min/max: 12–17)	15	1.771	15	1.833
Gender		0.000		0.502
Males n (%)	75 (50)		75 (50)
Females n (%)	-		75 (50)
Orphaned child
Father n (%)		0.540		0.537
Yes n (%)	24 (32)		106 (70.67)
No n (%)	49 (65.33)		39 (26)
Don’t know n (%)	2 (2.67)		5 (3.33)
Mother n (%)		0.508		0.463
Yes n (%)	17 (22.67)		33 (22)
No n (%)	56 (74.67)		115 (76.67)
Don’t know n (%)	2 (2.67)		2 (1.33)
Sibling bereavement		0.496		0.485
No n (%)	44 (58.67)		94 (62.67)
Yes n (%)	31 (41.33)		56 (37.33)
Religion		1.018		1.055
Born-Again/Saved Christian n (%)	13 (17.33)		26 (17.33)
Catholic n (%)	41 (54.67)		80 (53.33)
Muslim n (%)	15 (20.00)		29 (19.33)
Orthodox n (%)	0 (0)		2 (1.33)
Protestant n (%)	6 (8.00)		13 (8.67)
Community satisfaction (min/max: 7–40)/mean	24.28	3.910	24.81	4.274
Depression (min/max: 0–18)/mean	10.17	3.177	9.94	3.384
Loneliness (min/max: 20–62)/mean	39.57	10.217	39.21	10.79
Suicide ideation n (%)	20 (26.67)	0.445	35 (23.33)	0.424
Suicide attempt n (%)	15 (20)	0.403	20 (18)	0.386

Table 2.

Regression on suicide ideation and suicide attempt

Variables	Suicide ideation			Suicide attempt
	b (Robust SE)	95% CI	P value	b (Robust SE)	95% CI	P value
Age	0.011 (0.019)	(−0.027, 0.050)	0.567	0.009 (0.017)	(−0.024, 0.042)	0.578
Gender	−0.036 (0.066)	(−0.166, 0.093)	0.581	−0.026 (0.064)	(−0.151, 0.100)	0.688
Religion	0.042 (0.035)	(−0.026, 0.110)	0.226	0.032 (0.032)	(−0.031, 0.095)	0.318
Orphaned child
Father	0.033 (0.069)	(−0.104, 0.170)	0.637	0.085 (0.061)	(−0.035, 0.206)	0.163
Mother	−0.023 (0.067)	(−0.155, 0.109)	0.730	0.103 (0.058	(−0.104, 0.124)	0.859
Sibling bereaved	0.047 (0.070)	(−0.091, 0.184)	0.506	−0.034 (0.061)	(−0.155, 0.088)	0.583
Community satisfaction	−0.009 (0.008)	(−0.025, 0.006)	0.225	−0.010 (0.008)	(−0.025, 0.005)	0.184
Depression	0.013 (0.011)	(−0.008, 0.033)	0.227	0.012 (0.009)	(−0.006, 0.031)	0.192
Loneliness	0.012 (0.004)	(0.005, 0.019)	0.001*	0.008 (0.004)	(0.001, 0.016)	0.023*
Constant	−0.365 (0.432)	(−0.1220, 0.490)		−0.431 (0.357)	(−1.071, 0.426)
R 2	0.1696			0.1334
F value (df)	0.0013 (3.25)			0.0741 (1.80)
N	150			150

^*p < 0.05,

^**p < 0.01,

^***p < 0.001

Discussion

This study delves into the intricate relationship between mental health functioning, specifically loneliness and social isolation, and suicidal behaviors among adolescents living with HIV (ALHIV). Psychology today defines loneliness as a state of distress that results when one perceives a gap between one’s desires for social connection and actual experiences of it (Loneliness | Psychology Today, n.d.). Social isolation on the other hand is a lack of relationship with others with little to no social support or contact (CDC, 2023). Suicide behavior disorder is chiefly characterized by a self-initiated sequence of behaviors believed at the time of initiation to cause one’s own death and occurring in the last 24 months (Frontiers | DSM-5 suicidal behavior disorder: A systematic review of research on clinical utility, diagnostic boundaries, measures, pathophysiology and interventions n.d) Suicidal ideation, or suicidal thoughts, is the thought process of having ideas or ruminations about the possibility of completing suicide (ICD-11 for mortality and morbidity statistics n.d). The findings contribute to the growing body of literature on mental health disparities among this vulnerable population. Our results align with global concerns about the rising rates of suicidal ideation and attempts among adolescents (Oppong Asante et al., 2017; Uddin et al., 2019). The prevalence of suicide ideation and attempts in our study population is consistent with findings in other settings, emphasizing the need for comprehensive mental health support for ALHIV. The impact of loneliness and social isolation on mental health outcomes has been widely acknowledged (Loneliness: Clinical import and interventions—Stephanie Cacioppo, Angela J. Grippo, Sarah London, Luc Goossens, John T. Cacioppo, 2015 n.d; Palmer 2019).

Theoretical Alignment with the Modified Stress Diathesis Model

The modified stress diathesis model posits that suicidal behavior results from the interaction between inherent vulnerabilities (diathesis) and external stressors. Our study’s findings can be interpreted within this framework. Diathesis variables captured by our study include HIV status mental health conditions which include depression and loneliness that were identified as significant predictors of suicidal ideation and attempts. These conditions represent psychological vulnerabilities that increase the risk of suicidal behavior. Demographic factors including age and gender also contribute to the diathesis. Stressors variables (external factors) include stigma and discrimination: ALHIV face significant stigma both within their communities and from within their own families. Next is social isolation and loneliness: the COVID-19 pandemic has intensified social isolation, disrupting social networks and increasing feelings of loneliness. Our results showed a strong association between loneliness and both suicidal ideation and attempts, highlighting the critical role of social connections in mental health. Last is traumatic events: Although not directly measured in this study, exposure to traumatic events is a known risk factor for suicidal behavior. Future research should include variables related to trauma exposure to better understand their impact on ALHIV.

In our study, we observed a significant association between loneliness and both suicide ideation and attempts. This echoes previous research highlighting the profound psychological effects of social disconnection, especially among adolescents facing the dual challenges of HIV stigma and the disruptions caused by the COVID-19 pandemic (Calati et al., 2019; Ngwenya et al., 2023). Furthermore, the unique challenges faced by ALHIV, including stigma and discrimination, compound their susceptibility to mental health issues (Rukundo et al., 2020). Our study supports existing literature, emphasizing the need for interventions that address the intersectionality of HIV-related stigma, loneliness, and mental health outcomes. Notably, our findings underscore the importance of tailored mental health interventions for ALHIV. The association between loneliness and suicidal behaviors persists even after controlling for various demographic factors, highlighting the specific impact of social isolation on mental well-being. The study’s strengths lie in the utilization of established measures adapted for ALHIV populations (Minja et al., 2023; Nabunya et al., 2022).

Despite these strengths, our study has limitations. The small sample size may affect generalizability of study results. The cross-sectional design restricts causal inferences, and the reliance on self-reported data introduces the possibility of social desirability bias in addition, we acknowledge the potential for underreporting due to stigma and legal implications. Secondly, the study participants recruited into the study were from one health facility which underscores generalizability of study findings. To ensure robustness, future research should employ robust experimental and longitudinal designs to strengthen causal claims. Lastly, future research should consider including variables related to trauma exposure and post-traumatic stress disorder to provide a more comprehensive understanding of the risk factors for suicidality among adolescents living with HIV.

In conclusion, this study underscores the critical role of addressing loneliness and social isolation in mental health interventions for ALHIV. By recognizing and mitigating these factors, tailored support programs can enhance the well-being of adolescents living with HIV and contribute to global efforts in combating the rising tide of mental health challenges among this demographic.

Implications for Policy and Practice

Polices around attempted suicide in Uganda are stringent. Much has been written on the subject of suicide in Uganda, in particular the need to decriminalize it. However, very little is devoted to the issue of whether, in the first place, this offence is grounded in the principles of criminal law. In addition, hardly any literature is devoted to the exploration of defenses capable of being relied on to ensure that when persons who attempt suicide are charged, due regard is given to the mental health issues surrounding their conduct (Lubaale, 2017). Uganda does not have a national suicide prevention strategy that is integrated within the overall mental health policy. Without a suicide prevention strategy, the Government cannot put in place strategies/mechanisms to promoting access to comprehensive services of those at risk, or affected by suicidal behavior, those at risk at individual and community levels (Integration of suicide prevention strategy into the mental health policy in Uganda: Policy brief – UNIPH 2018).

The stark connection between elevated levels of loneliness and increased risk of suicide ideation and attempts carries profound implications for public health interventions targeting adolescent mental health. The findings accentuate the urgency of addressing loneliness as a potent risk factor, advocating for community-based initiatives fostering social cohesion and support. Community social programs may be of benefit adolescents in creating social capital and networks. In addition, assessment of suicide behavior should be included into routine care to be able to understand to capture any participant information in this regard for prompt interventions. Secondly, to be able to design and implement a workable policy, suicide attempts must first be decriminalized by policy makers in order to capture the magnitude of those affected by the problem which will pave way to create sustainable workable strategies to curb suicide within the community.

Conclusion

These results contribute to the understanding of mental health disparities among ALHIV and emphasize the need for comprehensive support services. The study’s findings have direct implications for policy and practice, urging the integration of mental health interventions, including suicide screening services, into routine care for ALHIV. The prevalence of mental health conditions among ALHIV is a significant concern, as evidenced by the study’s findings.

Abbreviations

ALHIV

Adolescents living with HIV

ART

Anti-retroviral therapy

CI

Confidence interval

CSSRS

Columbia Suicide Severity Rating Scale

GCP

Good clinical practice

HIV

Human immunodeficiency virus

ICC

Intraclass correlation

ICHAD

International Center for Child Health and Development

KADS

Kutcher Adolescent Depression Scale

NICHD

National Institute for Child Health and Development

UNCST

Uganda National Council for Science and Technology

UNAIDS

Joint United Nations Program on HIV/AIDS

TASO

The AIDS Support Organization

Data Availability

Due to the sensitivity around the data, it will not be deposited in a data repository. However, the data used for the analysis in this article can be availed upon submitting a reasonable request to the corresponding author.