Abstract
The purpose of this study was to investigate common mental disorders among Tajik migrant and non-migrant wives in a primary care center. Using a cross sectional design, quantitative surveys using standard questionnaires were administered to 300 married Tajik women aged 18–45 in Dushanbe. Descriptive and multivariate analyses described the demographic and mental health patterns, and comparison of key sub-groups, using Chi-square, T-test and regression. 26% of women in primary care had moderate or severe depression, 17% had moderate or severe anxiety and 20% had moderate or severe PTSD. Lifetime physical or emotional abuse was reported in 22% and women with lifetime physical or emotional abuse had higher depression, anxiety and PTSD scores. Significant multivariate associations predicted the following risk factors: for depression (R2=.40): higher number of people you live with, older age of woman, and migrant husband; for anxiety (R2=.41):more direct trauma and older age of woman; for PTSD (R2 =.48):lower number of people you live with, more direct trauma, older age of woman, highernumber of children, non-migrant husband, and lifetime emotional or physical abuse. Mental health interventions are needed in primary care settings for women with common mental disorders, including those exposed to trauma and migration.
Keywords: mental health, wives, migration, primary care
Background
In low and middle income countries (LMICs) women have a disproportionate burden of common mental disorders (CMDs), especially depression, anxiety, and post-traumatic stress disorder (PTSD). According to the global burden of disease, common mental disorders are the leading mental health cause of disability (WHO, 2016). Several studies indicate thatpoor and marginalized populations, especially in LMICs, are at greater risk of getting CMDs (Burns, 2015; Lund et al., 2010). Women in LMICs facing challenging living conditions, poverty, low education, gender inequality, social exclusion, conflict and disasters are exposed to the major social determinants of common mental disorders (Afifi, 2007; Patel, 2007).
Gender inequality and exposure to violence from intimate-partnershave been demonstrated to be risk factors for common mental disorder in women in LMICs, as well as in developed countries(Colombini, Mayhew, & Watts, 2008; Srivastava, 2012). A community survey in Indiafound that gender disadvantage and reproductive health were associated with the prevalence of CMDs among women in a general population (Patel et al, 2006). Gender inequality affects the level of control that women have over their health determinants, based on their social and economic position, access to resources, and support in the society.
Many women in LMICs with CMDs experience intimate partner violence, suicide by poisoning and self-immolation (Haarr, 2007, 2010; Ribeiro et al., 2009). A substantial part of the mental health problems in low and middle-income countries can be attributed to violence (Ribeiro et al 2009).
Migration has become one of the main strategies of economic survival in LMICs and impacts the physical and mental health of those left behind (Yi & Yao, 2014; Roy& Nangia, 2005; Jacka,2012; Edelblute et al.,2014; Sultana, 2014; Wilkerson, Yamawaki, & Downs, 2009; Ullmann, 2012). Most commonly, men leave their country of origin temporarily or permanently in search of jobs, at least initially with the intent of sending money home to their families. Migrant wives of reproductive age are exposed to separation from their husbands, violence both within and outside of the home, and STIs transmitted by their spouses (Amnesty International, 2009; Ellingen, Park, & Thomas, 2008; IOM, 2009). Often, they are left without financial or social support, which makes them vulnerable to depression, suicide, and domestic violence at the hands of husbands or their relatives (IOM, 2015). They experience a high degree of stigma in communities with significant access and resource barriers to mental health services (Semrau et al., 2015).
Tajikistan is a high out migration and low middle income country in Central Asia. Tajikistan is one of the poorest of the former Soviet republics. Women from Tajikistan report high levels of unhappiness and stress, lack of support from husband, poor living conditions, and family problems (OSCE, 2012). Violence in the family is widespread in Tajikistan for both migrant and non-migrant wives. One third to one half of women have regularly been subjected to physical, psychological or sexual violence at the hands of their husbands or their in-laws (Amnesty International, 2009; Haarr,2007). The female suicide rates increased 176% between 2008 and 2010, from 1.9 to 5.2 per 100,000 (UNICEF, 2013).
Women in Tajikistan need mental health services but strategies for developing those services must be based on evidence. Our research is the first study of CMDs in Tajikistan. The purpose of this study was to investigate prevalence and correlates of common mental disorders among Tajik migrant and non-migrant wives surveyed in a primary care center.
Methods
This one-year cross-sectional, descriptive study of CMDs in women of reproductive age in a primary care center was implemented in Dushanbe, Tajikistan. This study used a correlational designto investigate CMDs among Tajik women. The first aim of the study was to identify the prevalence and symptoms of CMDs among women in a primary care center. The second aim includes qualitative interviews not reported here.
The research was conducted through the partnership of the University of Illinois at Chicago (UIC), the Prisma Research Center in Dushanbe, and the Tajik State Medical University. Our research was IRB approved by Tajikistan and UIC committees.
Setting
The study was conducted in a primary care center in Dushanbe. This primary care center was a convenient, appropriate place to conduct our study because it is a public health care facility that provides free public access to general medical services (Finch,2008). Although every individual has a right for health services according to the national legislation and insurance system, as public funding for health collapsed after independence, out-of-pocket payments have progressively filled the health financing gap (Falkingham,2004) and became an important source of healthcare revenue in Tajikistan. At this time, the majority of psychiatric care is provided by psychiatrists in specialized settings and hospitals but this service is not developed in primary care settings.
Sampling and Recruitment
A formal power analysis was not conducted. In a preliminary assessment, 24 women of reproductive age (18–45) including migrant and non-migrant wives, were recruited at primary care center in Tajikistan. From this sample 7 were migrant and 17 non-migrant wives. We found that 28% of the migrant wives and 17% of non-migrant wives were depressed. Extending this trend, the sample size of 300 was determined.
Participants were Tajik women residing in Dushanbe. Inclusion criteria were: 1) 18 to 45 years old; 2) married; 3) able to give written informed consent; 4) seeking care at the polyclinic for any health care issue. Individuals with obvious psychotic or serious developmental disorders were excluded from the study because of the likelihood that they would not be able to adequately participate in surveys or in interviews. This was determined based on their ability to answer three questions during the consent procedure to affirm that they understood the research, which should screen out persons who cannot participate due to cognitive challenges.
Recruitment was done by having a fieldworker identify every third woman who met study criteria to participate in the study. If a woman refused, the fieldworkers selected the next woman that met inclusion criteria. The 2.6% women refused to participate in the study. Reasons for refusal included lack of time, small children, and lack of permission from their in-laws or husband.
Recruitment was done in a private room during the woman’s clinic visit. A trained physician and nurse explained the purpose and activities of the study, and selected those who: 1) were confirmed to meet the criteria; and 2) were willing and able to give informed consent. The survey followed immediately after recruitment and consent. Recruitment continued on a daily basis until 300 women were recruited and enrolled.
Measures
We selected and translated the following measures to address our major study constructs:
SF-12(Gandek, et al., 1998)is a tool for measuring self-rated physical and health-related components such as physical functioning, role limitations due to physical and emotional health problems, bodily pain, general health, vitality, social functioning, and mental health, in particular, psychological distress and psychological well-being(Gandek, et al.,1998).
Hamilton Rating Scales for Depression (HAM-D) includes 21 items and had aCronbach alpha of .92 in this study, indicating high internal consistency. This scale includes such depressive symptoms as a depressed mood; feelings of guilt; suicide; early, middleand late insomnia; work and activities; inhibition; agitation; psychic anxiety and somaticanxiety; gastrointestinal somatic symptoms; general somatic symptoms; sexual symptoms; hypochondria; weight loss and ability to understand (Ramos-Brieva, J. A., et al., 1988). The scores from 17 items are summed, with scores between 0 and 6 indicating absence of depression, scores between 7 and 17 indicating mild depression, scores between 18 and 24 indicating moderate depression, and scores over 24 indicating severe depression.
The HAM-A Rating Scale includes 14 items and had a Cronbach alpha of .90 in this study (Shear et al., 2001). For HAM-A, scores ≤ 7 are considered to represent no/minimal anxiety, 8–14 indicates mild anxiety; 15–23 indicates moderate anxiety, and ≥ 24 indicates severe anxiety.
The PCL-C-14 questionnaire is an abbreviated version of the PTSD Checklist for Civilians and had a Cronbach alpha of .91 in this study (Wilkins, Lang, & Norman, 2011). We have used this version to simplify evaluation based on multiple traumas because symptom endorsements are not attributed to a specific experience.
The Traumatic Events Inventory is a 25 items measure of different types of traumatic experiences adapted by Weine from the Harvard Trauma Questionnaire(Mollica et al, 1992). Because this is an inventory, internal consistency is not calculated.
For demographic characteristics, 22 items were used that were derived from the CAFES survey (Weine, Bahromov, Loue, & Owens, 2013) and Migrant Survey (Weine et al., 2006)questionnaires.
Data Collection
The women completed a face-to-face 60-minute interview using a survey instrument that combined items from the aforementioned existing instruments. Women were paid $5 after completing the survey. Prior to data collection the nurses and the medical personnel involved in the study were trained to administer each measure.
No direct clinical intervention was provided as part of this study.
Analysis
Descriptive and bivariate analyses were used to describethe overall demographic and mental health patterns and compare key sub-groups, using Chi-square, T-tests, and regression analyses. SAS version 9.4 was used for the data analysis (O’Rourke&Hatcher, 2013).
Results
Wives of migrants were less educated than non-migrants’ wives, and lived with more people in comparison with non-migrants’ wives (Table 1). The majority of women from both groups were unemployed. Twenty-six percent of the women in primary carehad moderate or severe depression,17% had moderate or severe anxiety, and 20% had moderate or severe PTSD (Table 2).
Table 1.
Demographic characteristic.
| Full Sample (n=300) | Wife of migrant (n=82) | Wife of non-migrant (n=217) | Test Statistic | |
|---|---|---|---|---|
| AGE | 30.9 (7.1) | 31.0 (6.6) | 30.9 (7.3) | t(298)=.21, p< .8312 |
| EDUCATION | ||||
| Primary | 32 (11%) | 6 (7%) | 26 (12%) |
X2(4, N =300)=8.6, p < .0723 |
| Secondary | 134 (45%) | 45 (55%) | 89 (41%) | |
| College | 23 (8%) | 9 (11%) | 14 (6%) | |
| University (come) | 25 (8%) | 5 (6%) | 20 (9%) | |
| University (graduated) | 86 (29%) | 17 (21%) | 68 (31%) | |
| MARRIAGE/FAMILY | ||||
| # children | 2.2 (1.4) | 2.1 (1.5) | 2.3 (1.5) | t(292)=.41, p< .6835 |
| # people live w/ in Tajikistan | 6.2 (3.8) | 7.1 (4.5) | 5.9 (3.4) | t(292)=.60, p< .0723 |
| LIVING PLACE | ||||
| Owns apartment | 58 (19%) | 22 (27%) | 36 (17%) | X2(4, N=300)=6.19, p < .1854 |
| Family owned home | 162 (54%) | 42 (51%) | 119 (55%) | |
| WORK | ||||
| Full time | 60 (20%) | 15 (18%) | 45 (21%) | X2(3, N =300)=2.39, p <.4949 |
| Part time | 35 (12%) | 9 (11%) | 26 (12%) | |
| Self employed | 16 (5%) | 7 (9%) | 9 (4%) | |
| Not employed | 189 (63%) | 51 (62%) | 137 (63%) | |
| SALARY | 622 (746) | 554 (646) | 654 (501) | t(143)=.68, p<.4983 |
Table 2.
Rates of Hamilton depression, anxiety and PTSD.
| NONE | MILD | MODERATE | SEVERE | |
|---|---|---|---|---|
| HAM DEPRESSION | (0–7) | (8–16) | (17–23) | (≥ 24) |
| 141(47%) | 81(27%) | 44 (15%) | 34(11%) | |
| HAM ANXIETY | (0–7) | (8–14) | (15–23) | (≥ 24) |
| 167 (56%) | 80 (27%) | 37 (12%) | 16 (5%) | |
| PCL-C | (0–29) | (30–39) | (40–49) | (≥50) |
| 146(49%) | 92 (31%) | 31 (10%) | 31 (10%) |
Migrants’ wives reported higher direct trauma, indirect trauma and physical abuse past year, and lifetime physical or emotional abuse, compared to non-migrants’ wives (Table 3). The wives of migrant had higher depression in comparison with non-migrants, but there were no differences in anxiety and PTSD (Table 4).
Table 3.
Trauma for wife of migrant and wife of non-migrant.
| TRAUMA | Full Sample (n=300) | Wife of migrant (n=82) | Wife of non-migrant (n=217) | Test Statistic |
|---|---|---|---|---|
| Life time physical or emotional abuse | 65 (22%) | 28 (34%) | 37 (17%) | X2(1, N=300)=10.3, p < .00013 |
| Physical abuse past year | 45 (15%) | 20 (25%) | 25 (11%) | X2(1, N=300)=8.07, p< .0045 |
| Direct trauma | 2.0 (3.1) | 2.7 (3.8) | 1.8 (2.7) | t(296) = −2.2, p< .0312 |
| Indirect trauma | 13.4 (6.4) | 14.6 (5.3) | 13.0 (6.7) | t(291) = −1.90 , p< .0580 |
Table 4.
Average score comparison for wife of migrant and wife of non-migrant.
| Full Sample (n=300) | Wife of migrant (n=82) | Wife of non-migrant (n=217) | Test Statistic | |
|---|---|---|---|---|
| Ham-Depression | 10.8 (10.4) | 14.2 (10.2) | 9.5 (10.3) | t(298)=−3.6, p<.0004 |
| Ham-Anxiety | 8.5 (8.4) | 9.3 (6.5) | 8.2 (9.1) | t(298)=−9.9, p<.3226 |
| PTSD | 31.2 (12.6) | 32.4 (12.2) | 30.8 (12.9) | t(298)=−1.0, p<.3117 |
Table 5 shows the association betweenpast year physicalabuse, migration and CMD’s. The wives of migrants and non-migrants who were physically abused in the past year had significantlyhigher scoresofdepression, anxiety and PTSD in comparison with those who were not physically abused. Among the non-physically abused women, migrant wives had higher depression, anxiety and PTSD in comparison to wives of non-migrants. Among the physically abused women, migrant’s wives had lower depression, anxiety, and PTSD.
Table 5.
Association between abuse and migration and their effect on CMD’s.
| PHYSICAL ABUSE past year |
NO PHYSICAL ABUSE past year |
Test Statistic | |
|---|---|---|---|
| WIFE OF MIGRANT | (N=20) | (N=61) | |
| HAMD =16.0 HAMA =9.8 PCLC =33.8 |
HAMD =14.0 HAMA =9.1 PCLC =32.1 |
t(79)=−1.0 , p<.2992 t(79)=−.57 , p<.569 t(79)=−.23, p<.8152 |
|
| WIFE OF NON-MIGRANT | (N=25) | (N=192) | |
| HAMD =18.1 HAMA =15.0 PCLC =39.7 |
HAMD = 8.4 HAMA =7.3 PCLC =30.0 |
t(216)=−4.7, p<.0001 t(216)=−4.1, p<.0001 t(216)=−3.8, p<.0002 |
|
| Test Statistic | t(43)=.55, p<.5819 t(43)=1.9, p<.0618 t(43)=1.8, p<.0836 |
t(252)=−3.7, p<.0003 t(252)=−1.4 , p<.1627 t(252)=−1.3, p<.1866 |
Significant multivariate associations predictedthe following risk factors for depression, anxiety and PTSD (Table 6):for Depression (R2=.40): higher number of people you live with, older age of woman, and migrant husband; for Anxiety (R2=.41): more direct trauma and older age of woman; for PTSD (R2 =.48): lower number of people you live with, more direct trauma, older age of woman, higher number of children, non-migrant husband, and lifetime emotional or physical abuse.
Table 6.
Regression model for CMD’s.
| SIGNIFICANT MULTIVARIATE ASSOCIATIONS | BETA | P VALUE |
|---|---|---|
| DEPRESSION (HAM-D) (R SQUARED = .40) | ||
| Number of people you live with in Tajikistan | 0.72 | .0031*** |
| Older age | 0.50 | .0001*** |
| Husband is a migrant | 4.1 | .016** |
| ANXIETY (HAM-A) (R SQUARED = .41) | ||
| Direct trauma | 0.61 | .0042*** |
| Older age | 0.41 | .0046*** |
| PTSD (PTSD-CL) (R SQUARED = .48) | ||
| Number of people you live with in Tajikistan | −0.84 | .0156** |
| Direct trauma | 0.81 | .0021*** |
| Older age | 0.56 | .0012*** |
| Number of children | 2.42 | .0187** |
| Husband is a migrant | −8.7 | .0004*** |
| Emotional or physical abuse | 6.5 | .0094** |
Significant at the 0.05 probability level.
Significant at the 0.01 probability level.
Significant at the 0.001 probability level
Discussion
Our research is the first cross-sectional correlational descriptive study of CMDs in women in primary care in Tajikistan. This study shows that more than ¼ of women not previously diagnosed with mental disorders in a primary care center in Dushanbe had moderate or severe depression and that being a migrant wife is a risk factor for depression and mitigates against PTSD.
These findings of high rates of CMDs underlie the importance of detecting CMDs among women in primary care in LMICs. These results are consistent with a prior study in Tajikistan (Falkingham, 2004) and indicate the need for appropriate mental health interventions. Mental disorders are a global problem and their late diagnosis contributes to the development offurther mental health and health complications. Tajikistan, with the backing of the World Health Organization (WHO), has embarked in a plan for building mental health services including in primary care.
The findings of high rates of trauma exposure and the association between trauma exposure and CMDs indicate that prevention of violence against women and its mental health consequences should be a priority concern in Tajikistan and other LMICs. This is consistent with research conducted by the WHO among 24,000 womenin 10 countries, which showed that the lifetime prevalence of violence against women was from 15% to 70% lifetime and that women who were abused had nearly 4 times the rate of mental health disorders(WHO, 2005).
Given the high rate of migration in Tajikistan and other LMICs, we thought it important to compare mental disorders among migrant and non-migrant wives. The higher rate of depression among migrant wives may be explained by a lack of male support and companionship, increased burden of responsibility for their children, and increased family and housing problems. Other studies have found higher mental health symptoms among migrant wives such as in Nepal (Gartaula, Visser & Niehof, 2012) and Mexico (Wilkerson, Yamawaki, & Downs, 2009). The lower rate of PTSD among migrant wives maybe explained by less exposure to violence from their migrant husbands.
Limitations
This study had several limitations. Cut-off scores were based upon the literature. Functional impairment wasnot assessed. No treatment was provided for the women who were identified as a being at high risk of mental disorders.
Conclusion
In a primary care center more than ¼ of women not previously diagnosed with mental disorders had moderate or severe depression and being a migrant wife is a risk factor for depression and mitigates against PTSD. Mental health interventions are needed in primary care settings for women with common mental disorders, including those exposed to trauma and migration.
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