Factors associated with depression among young female migrants in Ethiopia | BMC Women’s Health

This is part of a larger study of out-of-school Ethiopian girls and young women aged 15 to 24, focusing on migration and the transition to different work roles following migration [12]. This was a large, mixed methods study that included formative qualitative research and a largescale quantitative survey. The quantitative study included questions to assess the mental health of those chosen for interview. The majority of survey respondents were rural-urban migrant females, but we also interviewed a small number of rural parents, rural girls and young women and brokers who help migrants find work. As the issue of mental health was not included in the initial qualitative research, we draw exclusively upon the findings from the quantitative study for the present study. Likewise, parent and broker interviews did not collect mental health information.

The quantitative study spanned six regions of Ethiopia and took place in seven cities: Adama, Addis Ababa, Dessie, Dire Dawe, Harar, Mekelle and Shashemene. These cities were chosen because they were considered to receive a large number of migrants from rural areas. Multiple categories of migrant girls and young women were interviewed. To be eligible for the study respondents had to be age 18 to 24, out-of-school and having left school by age 16, and to have migrated to the city before the age of 18. However, for domestic workers we included an age range of 15 to 24 in order to capture the experience of child domestic workers; at the same time, all our sampled domestic workers were above age 16. Most respondents were sampled through household listings, followed by random selection of eligible household members. Two additional categories of respondents were sampled purposefully: commercial sex workers and bar/café workers.

In each of the study cities, we identified neighborhoods where migrant young women were known to live, mainly low-income areas. These areas were identified based on consultation with local stakeholders and people knowledgeable about the areas, mainly government representatives. We conducted a systematic listing of all households and other structures in the area, such as back rooms of restaurants or establishments where young women may spend the night. Interviewers went house-to-house to list members of the household or structure, in order to identify girls and young women who were eligible for the study. Eligible females were sampled randomly, using the random number generator available in SPSS v.25.

In order to assess respondents by occupation, we asked (1) What type of work for pay have you done in the last three months? and (2) Of these, which is your main source of cash income and/or in-kind payment? The second questions was included in cases where respondents were engaged in more than one type of paid work. Commercial sex workers and bar/café workers are more hidden and stigmatized populations. Bar/café workers are often considered to partially engage in commercial sex work, which results in stigma. These categories of respondents were sampled purposefully, visiting places where targeted respondents were known to congregate (bars, cafes, nightclubs, local brew houses and red-light districts) and approaching potential respondents working in the bar/café or working as commercial sex workers for interview. Once contact was made, interviewers screened respondents for eligibility such as being migrant to the area and being out-of-school.

Survey interviewers were recruited from the study cities to ensure that they possessed relevant language capabilities and understanding of the local culture and community. Our female sample was interviewed by only female interviewers. The survey interviewer training lasted seven days. Interviewers reviewed the questionnaire item-by-item, reviewed ethical procedures including informed consent and actions to be taken in the case of adverse events, and engaged in practice interviews in pairs, ensuring understanding and adherence to skip patterns and general questionnaire administration. A professional counselling firm was also made available to respondents in case they had negative reactions based on the interview or expressed a need for such services.

A structured questionnaire was developed, pretested and translated into local languages Amharic, Oromiffa and Tigrigna. The pretest was undertaken in selected study cities and in locations outside of the study areas. Questionnaires elicited information on demographic and socioeconomic characteristics, education, families and social networks, migration, livelihoods, use of job placement brokers in finding work, mental health, marriage, sexual experience, HIV knowledge and behavior, family planning and pregnancy, and utilization of services. All data was transported from the field and entered in Addis Ababa by trained data entry clerks. Data was converted to SPSS v.25 for analysis. The study received ethical approval from the Population Council’s Institutional Review Board (IRB) and the National Research Ethics Committee in Ethiopia.

Measures

In order to measure symptoms of depression among respondents, we used a modified patient health questionnaire (PHQ-9), asking about symptoms experienced in the two weeks prior to survey. PHQ-9 was developed to assess depression in primary care settings [12]. Several facility-based studies have validated PHQ-9 in Ethiopia [13, 14]. In the current study, respondents were asked the following: “I will read you a list of feeling or experiences one may have. I would like you to tell me if you have experienced this over the last two weeks: 1) Little interest or pleasure in doing daily activities, 2) Feeling down, depressed or hopeless, 3) Feeling tired or having little energy, etc. If the respondent answered ‘yes’ to any item, they were asked a follow-up question about how frequent the experience was: occasionally, on several days or daily. Three statements used in the standard PHQ-9 battery of questions were separated into two items. This is because, during pretest of the questionnaire, respondents found some of the statements confusing, overly complex, or difficult to understand. Compared to previous studies that validated PHQ-9 questions, this observed confusion may be due to the young age or low level of education of our study population. Questions separated into two items were (separation denoted by a. and b.): 1) a. Trouble falling asleep/staying asleep or b. sleeping too much, 2) a. Poor appetite or b. overeating, 3) a. Moving or speaking so slowly that other people could have noticed or b. being so fidgety or restless and move around more than usual so that other people have noticed. During analysis the separated items were back-coded so that the responses fit back to the original PHQ-9 and the total scores ranged from 0 to 27. Each item was scored from 0 to 3 to reflect the existence and frequency of symptoms. An overall score of 0-4 on PHQ-9 was considered no depression, those who scored 5–9 were coded has displaying moderate depression; those with a score of 10 or over were considered to have severe depression [14].

We present the percentage of young women in each category (domestic workers, commercial sex workers, waitresses/bar workers, other occupational categories and those not working) who have moderate or severe depression. We also examine the association between depression and various demographic characteristics as well as the experience of social isolation, patterns of migration and violence. Logistic regression was used to model the odds of experiencing moderate or severe depression. We assessed multicollinearity of the independent variables using ViF, with any value more than 10 indicating the existence of multicollinearity. We also assessed any potential effect of outliers using Cooks Distance. Variables with significant associations in the bivariate analysis were found to be uncorrelated, except for age and marital status which had a weak correlation.

In addition to basic demographic variables such as age, religion and marital status, we explored the association between depression and aspects of girls’ migration and social life. We included measures of early age at migration (below age 15) and having migrated on one’s own, without accompaniment of family members or other acquaintances. In addition, many migrating girls and young women use brokers in the course of migration to assist in securing them jobs. Council research has also demonstrated that some brokers may take advantage of migrating girls, which can result in sexual abuse and putting girls at increased risk for trafficking [15]. We included a measure of social connections and social isolation through the variable reflecting whether or not the respondent reports having friends. Finally, we also included in the model measures of violence such has having been beaten in the last three months and have experienced coerced or forced sexual initiation. Forced sexual initiation was calculated as the percent of girls who experienced first sex through any form of force or coercion, including being physically forced to have sex; their partner using violence to have sex; being locked in a room to have sex against her will; or their partner not taking “no” for an answer. Finally, because commercial sex workers had much higher levels of depression than other occupational categories, we included a covariate reflecting if the respondent was a commercial sex worker.