Socio-demographic correlates of depression and anxiety among female caregivers living with HIV in rural Uganda

Abstract

Women living with HIV are at increased risk for psychosocial distress, especially among social and economically disadvantaged women living in rural areas. Little is known about how social support and wealth impacts the mental health of women caring for young children in low- and middle-income countries. The purpose of this paper was to assess demographic, socio-economic, and social support correlates of depression and anxiety in HIV-infected+ female caregivers living in rural Uganda. Depression and anxiety were assessed using the Hopkins Symptom Checklist (HSCL-25), two-domains of social support (family and community) were measured with the adapted Multidimensional Scale for Perceived Social Support, and wealth was measured using a checklist of material possessions and housing quality among 288 women. Multivariable linear regression models assessed the association of depression and anxiety with demographic and social predictors. Sixty one percent of women reported clinically significant symptoms of depression or anxiety using the standard HSCL-25 cut-off of >1.75. Lower wealth (p=0.01) and family support (p=0.01) were significantly associated with more depressive symptoms, with greater family support being more protective of depression in the highest wealth group (top 20%) compared to the lowest. More anxiety symptoms were associated with lower wealth (p=0.001), lower family support (p=0.02), and higher community support (p=0.003). Economic and social support factors are important predictors of caregiver mental health in the face of HIV disease in rural Uganda. Findings suggest that interventions should consider ways to increase economic opportunities and strengthen family support for HIV+ caregivers.

INTRODUCTION

Rates of depression and anxiety are high among women living with HIV/AIDS (Hatcher et al., 2012; Kaida et al., 2014). Depression among mothers with young children is associated with multiple negative child behavioral and emotional outcomes (Leis, Heron, Stuart, & Mendelson, 2014), cognitive deficits and developmental delays (Black et al., 2010), and malnutrition (Surkan, Kennedy, Hurley, & Black, 2011). Less is known about depression and anxiety of caregivers of young children in poor and HIV-affected communities. Available studies suggest that socially and economically disadvantaged women living in rural areas may be at increased risk for poor mental health (Caroline Kuo & Operario, 2009; C. Kuo & Operario, 2010).

Female HIV-infected caregivers in Sub-Saharan Africa frequently endure difficult living conditions including raising multiple children in an economically deprived environment while dealing with their own illness. Scant empirical research has examined the impact of social and family support on depressive and anxiety symptoms among this population. The effect of social support may differ in resource-poor settings and across cultures, with the buffering effect of social support varying by living conditions and extent of poverty (Moskowitz, Vittinghoff, & Schmidt, 2013). We aimed to assess the relationship of social support and economic wealth on depression and anxiety symptoms among HIV-infected caregivers living in rural communities in Uganda. Understanding factors associated with depression and anxiety symptoms in women caring for young children may inform psychosocial and economic interventions that optimize maternal and child health.

METHODS

Sample and procedures

This secondary analysis utilizes baseline data from 288 HIV-infected women participating in a randomized controlled trial testing the Meditational Intervention for Sensitizing Caregivers (MISC), a one-year program aimed at enhancing child physical and neuropsychological development (Boivin et al., 2013). Details of the parent study are described elsewhere (Bass, Nakasujja, Familiar-Lopez, Sikorskii, Murray,…& Boivin, 2016). Briefly, inclusion criteria for caregivers were being female, aged 18 or older, predominantly taking care of a child aged 2–5 years (median age=3 years), and willing and able to participate in a year of MISC training.

After informed consent, participants responded to a questionnaire administered by trained Ugandan research assistants in one of three local languages (Dhopadhola, Ateso, or Luganda) in a private setting. The Institutional Review Board of Michigan State University and the School of Medicine Research Ethics Committee at Makerere University approved this study.

Measures

Socio-demographic characteristics

Caregiver demographics included age, education level (e.g. highest level of schooling completed), marital status, occupation, and relation to the child. HIV status was established based on clinical data at the health center.

Caregivers’ depressive and anxiety symptoms were assessed using the Hopkins Symptom Checklist-25 (HSCL-25)(Hesbacher, Rickels, Morris, Newman, & Rosenfeld, 1980; Winokur, Winokur, Rickels, & Cox, 1984) with each symptom being reported for the prior 2 weeks using a 4-point Likert scale ranging from 1 (not at all) to 4 (all the time). The HSCL-25 depression scale has previously been adapted and validated among adults in HIV-affected Ugandan communities (Bolton et al., 2003; Kaida et al., 2014). Average scores were generated for depression (15 item) and anxiety (10 item) subscales; higher scores indicating greater severity. To estimate a cutoff for clinically relevant symptoms, we averaged all 25 items into a single score; an average HSCL-25 score of 1.75 or higher was considered clinically significant (Kinyanda, Hoskins, Nakku, Nawaz, & Patel, 2011; Tsai et al., 2015). Internal consistency (Cronbach’s alpha) was 0.73, and 0.84 for the depression and anxiety subscales, respectively.

Perceived social support was assessed using the Multidimensional Scale for Perceived Social Support (MSPSS) (Dahlem, Zimet, & Walker, 1991; Zimet, Powell, Farley, Werkman, & Berkoff, 1990), previously validated for use in Uganda among HIV-infected and uninfected adults (Nakigudde, Musisi, Ehnvall, Airaksinen, & Agren, 2009) (E. Nakimuli-Mpungu, Musisi, Katabira, Nachega, & Bass, 2011). We adapted the 8 items of the family and friends subscales by asking participants about people in their community, instead of referring specifically to friends. Exploratory factor analysis yielded two factors jointly explaining 55% of the variance: 1) “Family Support” (4 items), and 2) “Community Support”, (3 items). One item (Do you quarrel with members of your family) did not load on either factor, had high uniqueness (.79) and was excluded from further analyses. Each item is scored with a 4-point Likert scale ranging from 0 (never) to 3 (often). Separate scores for family and community support were constructed as averages of items within the scales; higher scores indicate better social support. Cronbach α for the family and community support subscales were.77 and .63, respectively.

An economic wealth index was constructed from a checklist of 8 material possessions (shoes, radio, mattress, blanket, bicycle, motorcycle, cows, goats) and 6 housing quality items (type of roof, availability of water supply, type of fuel used, frequency of meat in diet and food security). Respondents reported presence/absence of each asset at their homes. Top 20^th, middle 60^th, and bottom 20^th percentiles were defined based on factor scores derived from exploratory factor analysis of the 14 items.

Procedures

Statistical analyses

Initial analyses explored the distribution of caregiver demographics and study variables. General linear and logistic regression models were used to assess univariate associations between the demographics, wealth and social support scales and the depression and anxiety outcomes. Multivariable models were used to explore the effect of social support on depression and anxiety symptoms controlling for significant demographic and wealth effects. Multivariate models for the social support scales were modelled separately because of collinearity. Interaction terms were used to assess the extent to which family and social support moderated the association between wealth and depression and anxiety symptoms. All analyses were done using STATA software, version 12 (College Station, 2010).

RESULTS

Demographic characteristics and average depression and anxiety scores are presented in Table 1. Univariate analyses indicated depression severity was significantly associated with being single/divorced (p=0.004) compared to being married and being in the poorest 20%, compared with middle 60% of the wealth index (p=0.001). Educational level, employment, and ARV treatment status were not associated with depression symptoms. Findings were similar for clinically relevant symptoms. For anxiety severity, higher levels of wealth were significantly associated with decreased symptoms. (p=0.001) and more community support was significantly associated with less severity (p= 0.02).

Table 1.

Socio-demographic characteristics, depression and anxiety scores among caregivers living with HIV in Tororo, Uganda (n=288)

Variable	N	%
Marital status
Married	199	69
Single/Divorced	40	14
Widowed	49	17
Education level
None	56	19
Primary	190	66
Secondary	39	13
Technical	3	1
Employment status
Farmer	235	82
Trades/small business/employee	28	10
Professional	12	4
Unemployed/house wife	13	4
Relationship to the child
Biological mother	281	98
Other	7	2
Wealth group
Lowest 20%	41	14
Middle 60%	193	67
Top 20%	53	18
Probable depression or anxiety	176	61
On ARV	232	81
Variable	Mean	SD	Range
Age	33.5	5.8	18–54
Perceived Social Support
Family support	2.1	0.7	0–3
Community support	1.8	0.7	0–3
Depression score	2.0	0.5	1–3.4
Anxiety score	1.8	0.6	1–4

In multivariate models for family support (Table 2), depression symptoms were lower among caregivers reporting greater wealth (p<0.001) and greater family support (p=0.03). Models including the interaction between wealth and family support indicated that greater family support was more protective of depression in the highest wealth group compared to the lowest (p=0.03). Greater wealth was also associated with fewer anxiety symptoms (p=0.001) and family support was no longer significant once wealth was included.

Table 2.

Multiple regression models of depression and anxiety symptoms in HIV+ female caregivers and family support (Tororo, n= 288)

Explanatory variables	Outcome: depression score		Outcome: anxiety score
Models with main effects
	Coefficient (SE)	P-value	Coefficient (SE)	P-value
Caregiver education (elementary vs. none)	−0.04 (0.05)	0.40	−0.02 (0.06)	0.69
Marital status (single/divorced vs. married)	0.07 (0.04)	0.07	0.02 (0.05)	0.62
Caregiver age (in years)	−0.004 (0.004)	0.39	−0.001 (0.006)	0.15
Wealth categorya
Middle 60%	−0.27 (0.08)	<.01	−0.23 (0.11)	0.03
Top 20%	−0.40 (0.10)	<.01	−0.44 (0.13)	0.001
Family support	−0.08 (0.04)	0.03	−0.08 (0.05)	0.14
Models with wealth category by family support interaction
	Outcome: depression score		Outcome: anxiety score
	Coefficient (SE)	P-value	Coefficient (SE)	P-value
Wealth categorya*Family support	Difference in slopes for family support by wealth category
Middle 60%	−0.06 (0.12)	0.60	−0.15 (0.15)	0.33
Top 20%	−0.35 (0.16)	0.03	0.59 (0.21)	0.005

^aReference category for wealth is lower 20%

Greater community support (Table 3) was positively associated with higher anxiety symptoms (p=0.02). When interactions are added, findings were similar to those for depression: greater community support (p=0.001) was more protective against less anxiety symptomatology in the highest wealth category (top 20%) compared to the lowest (lower 20%).

Table 3.

Multiple regression models of depression and anxiety symptoms in HIV+ female caregivers and community support (Tororo, n= 288)

Explanatory variables	Outcome: depression score		Outcome: anxiety score
Models with main effects
	Coefficient (SE)	P-value	Coefficient (SE)	P-value
Caregiver education (elementary vs. none)	−0.03 (0.05)	0.57	0.0001 (0.06)	0.90
Marital status (single/divorced vs. married)	0.08 (0.03)	0.03	0.04 (0.05)	(0.38)
Caregiver age (in years)	−0.003 (0.005)	0.43	−0.01 (0.006)	(0.15)
Wealth categorya
Middle 60%	−0.27 (0.08)	<0.001	−0.22 (0.10)	0.04
Top 20%	−0.41 (0.10)	<0.001	−0.45 (0.13)	0.001
Community support	0.06 (0.04)	0.14	0.13 (0.27)	<0.0001
Models with wealth category by community support interaction
	Outcome: depression score		Outcome: anxiety score
	Coefficient (SE)	P-value	Coefficient (SE)	P-value
Wealth categorya*Community support	Difference in slopes for community support by wealth category
Middle 60%	−0.10 (0.12)	0.40	−0.28 (0.15)	0.07
Top 20%	−0.23 (0.14)	0.10	−0.58 (0.18)	0.001

^aReference category for wealth is lower 20%

DISCUSSION

Our findings suggest that low social support and relative poverty are associated with elevated depression and anxiety symptoms. The proportion of women classified with probable clinically relevant depression/anxiety symptoms (61%) was higher than prior reports among HIV-infected adults in Uganda (ranging from 8.1% to 47%) (Kaharuza et al., 2006; Kinyanda et al., 2011; Nakasujja et al., 2010; E. Nakimuli-Mpungu et al., 2011). One reason may be that HIV-infected women in rural communities are frequently affected by poverty and social isolation, increasing their vulnerability to distress (Kidman & Thurman, 2014). Typically, women in these communities are smallholder farmers, with food production mainly for subsistence livelihood. Individuals with HIV disease may be too sick to work, perpetuating a cycle of poverty and unemployment linked to inability to access food and other assets (C. Kuo & Operario, 2010).

The relationship we found between community and family support and depression and anxiety symptoms concurs with other Ugandan studies (Kinyanda et al., 2011; E. Nakimuli-Mpungu et al., 2011) and elsewhere in Sub-Saharan Africa (Brandt, 2009). A recent qualitative study found informal social networks can be an important resource for coping with financial and health adversities among HIV+ individuals (Casale, 2011).

We found that women with higher levels of anxiety reported higher levels of community support. One explanation is that in our study women may seek out community support to deal with crises and enhancing social support may prevent or overcome anxiety symptoms.

A few limitations should be noted. The cross-sectional nature of the data and the lack of an HIV negative reference group preclude causal associations. Although it has been suggested that perceived social support could be more important than received social support (Beals, Peplau, & Gable, 2009), without a longitudinal study we are unable to explore causality or bi-directionality. Finally, although the HSCL-25 has been used in Uganda, the cut-off score has not been validated in this study population.

CONCLUSIONS

Our findings suggest that female caregivers of young children living with HIV in rural Uganda experience the burden of poverty and depression and anxiety. Interventions addressing economic factors and/or social support among HIV-affected populations have shown encouraging results (Etheldreda Nakimuli-Mpungu et al., 2015) and should be explored further.