Thesis (Ph.D.)--University of the Witwatersrand, Faculty of Health Sciences, 2012. / Background: the subject of the mental health of young people in Sub-Saharan Africa has
received very little research attention. Despite the fact that many in this region face
ubiquitous material deprivation, childhood adversity, violence, AIDS and orphanhood
which could result in distress, there is very little scientific understanding of the precursors
of psychological distress. Understanding and intervening in young people is important as
psychological distress is believed to precede one of the most common health problems
facing young people, that is, risky sexual behaviours. This thesis aims to document and
describe the prevalence of depressive symptoms in a sample of young people, develop an
explanatory model for factors associated with depressive symptoms and distress, and
explore links with risky sexual behaviours.
Method: This thesis is based on two studies that were both conducted in the Eastern
Cape Province of South Africa. Study 1 was an analysis of cross-sectional and
longitudinal data collected amongst young people aged 15 to 26 who were enrolled in a
cluster randomised controlled trial evaluating an HIV prevention intervention. The study
sample was drawn from volunteers who normally resided in villages and townships in
and around the area within 1.5 hours drive radius of Mthatha. Volunteers were mostly
recruited through schools. In each of the seventy study sites, approximately twenty males
and twenty females were included resulting in the enrolment of 2,801 volunteer
participants.
Quantitative data were collected by a fieldworker-administered questionnaire in 2003/4
and 2004/5, and analysed separately for men and women, using STATA IC 11.0. A crosssectional
analysis of 2003/4 data was undertaken to investigate factors associated with
depressive symptoms. Presence of depressive symptoms was established through a self
report measure - the Centre for Epidemiological Studies on Depression Scale.
Participants who scored above a cut-off point of 16 were considered to have depressive
symptoms. Results for factors associated with the presence of depressive symptoms are
presented in Paper I. The association between baseline depressive symptoms and sexual
risk taking at baseline (2003/4) and twelve months later (2004/5) was explored. Here,
participants with depressive symptoms were treated as an exposed group and were
compared to those who scored below 16 on the symptom checklist within the same
cohort. These results are presented in Paper II.
In Study 2, phenomenological experiences of distress were explored. In-depth face-toface,
one-on-one interviews with forty young people were conducted in isiXhosa between
2007 and 2008. Participants for Study 2 were recruited in Butterworth from the
townships. The sampling approach was a non-random, non-probability approach, with
participants who self-selected and volunteered on the basis of their interest in the research
topic. The sample came from a town that was included in Study 1 and generally shared
similar socio economic conditions, cultural experiences, and history as the other
community sites that participated in Study 1. Criteria for inclusion into the study included
having no known clinical diagnosis of a mental health problem. Participants were aged 16
to 26 years.
Each interview took about forty five minutes to an hour. Data were analysed using the
constant comparison approach and following recommendations for qualitative
phenomenological studies. Findings from this study are presented in two papers. Paper III
of this thesis presents a conceptual model based on discussions of perceived sources of
distress by participants. Paper IV discusses the role of undisclosed paternal identity in
causing distress.
Findings: In Study 1, the prevalence of self-reported depressive symptoms was 21%
among women and 14% among men. Child abuse and neglect (aOR 1.34 95% CI 1.116,
1.55), substance use (aOR 1.98 95% CI 1.17, 3.35), perceptions of less cohesion in the
community (aOR 1.2395% CI 1.07, 1.40), intimate partner violence victimisation
(aOR 2.2195% CI 1.16, 3.00) and sexual violence before the age of eighteen (aOR1.45
95% CI 1.02, 2.02) were associated with depressive symptoms in women. For men,
factors associated with depressive symptoms were child abuse and neglect (aOR
1.61 95% CI 1.38, 1.88), having lost a mother (aOR 2.24 95% CI 1.25, 4.00), alcohol
abuse (aOR 1.63 CI 1.13, 2.35), having been forced by a woman to have sex (aOR 2.36
95% CI 1.47, 3.80) and conflict in the current sexual relationship (aOR 1.07 95% CI
1.01, 1.12).
Findings on the associations between depressive symptoms and risky sexual behaviours
show that women with depressive symptoms at baseline were more likely to have dated a
man five years or older than them in their lifetime (aOR 1.37 95% CI 1.03-1.83), had
transactional sex (aOR 2.60 95% CI 1.37-4.92) and experienced intimate partner violence
(IPV) at baseline (aOR 2.56 95% CI 1.89-3.46). Women with depressive symptoms were
more likely to have experienced IPV a year later (aOR 1.67 95% CI 1.18-2.36) after
adjusting for baseline IPV experiences. At baseline, in men, an association between
depressive symptoms and perpetration of intimate partner violence (aOR 1.50 95% CI
0.98-2.28) and rape was evident (aOR 1.81 95% CI 1.14-2.87). Men who had depressive
symptoms were also less likely to report correct condom use at last sex, at both baseline
and twelve months later (aOR 0.50 95% CI 0.32-0.78 and aOR 0.60 95% CI 0.40-0.89).
Study 2 showed that family-based adversity, most notably perceptions of mother’s
distress, conflict over financial resources, undisclosed paternal identity and parental
substance abuse caused distress in young people. A culture of silence in families on
issues considered pertinent by participants, such as paternal identity appeared to intensify
distress. From this study, sexual relationship problems, including intimate partner
violence, an unacknowledged pregnancy, and violent transactional sexual relationship
themes dominated women’s narratives of distress. In their narratives, men described
violence and sexual risk taking as expressions of anger directed towards women. They
described using substances and sexual philandering as ways to express distress, and as
coping mechanisms, although they in turn became sources of distress.
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Discussion, conclusions and recommendations: This research reports a high prevalence
of depressive symptoms among young people in South Africa and supports international
patterns of a higher prevalence in women than men. Findings presented in this thesis have
important implications as they show that structural factors that cause different forms of
disempowerment are implicated in some of the psychological distress experienced by
young people. For instance, gender power inequity, violence, cultural expectations of
respect from youth and women, compounded by financial dependence on relatives were
sources of vulnerability especially in the face of maternal orphanhood. When ones
mother was perceived to be under distress and honest and effective communication
within families was lacking this caused distress.
Depressive symptoms were associated with risky sexual behaviours commonly found
among rural young people such as intimate partner violence, boys’ sexual victimisation
by women, relationship conflict and involvement in transactional sex. Though HIV
prevalence among young men is lower than in women in South Africa, consistent failure
to use a condom at last intercourse among men with depressive symptoms may ultimately
increase risk for HIV infection. Hence, sexual health youth-friendly clinics should be
aware of the links between depressive symptoms and sexual expression.
The strength of this thesis is in the mixed method approach to exploring psychological
distress through qualitative and quantitative data. The quantitative study used a large
sample and had a prospective component, which enabled the impact of depressive
symptoms on sexual risk-taking to be studied in temporal sequence. This is valuable and unusual in a dataset. However, it has a volunteer sample and its findings cannot
necessarily be generalised to all young South Africans. Nevertheless, there is no reason to
expect the associations described to significantly differ from those that would be found in
a non-volunteer sample. Qualitative research is inherently non-generalising, but the
methodology used here enables a depth of understanding an exposure of nuance that is
not attainable through quantitative methods.
Prevention of depressive symptoms among young people in South Africa should start
with interventions to reduce exposure to childhood adversity. Some of this distress could
be reduced if relationship violence was prevented for women, pregnancies acknowledged
and disputes resolved on time by the putative fathers. This research suggests that a
reduction in young people’s depressive symptoms could have positive benefits for
reduction of HIV risk taking behaviours.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/14740 |
| Date | 10 June 2014 |
| Creators | Nduna, Mzikazi |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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