Journal of Affective Disorders 165 (2014) 120–125
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Research report
Depression among university students in Kenya: Prevalence and sociodemographic correlates Caleb J. Othieno a,n, Roselyne O. Okoth b, Karl Peltzer c,d,e, Supa Pengpid c,e, Lucas O. Malla f a
Department of Psychiatry, University of Nairobi, P.O. Box 19676, 00202 Nairobi, Kenya Department of Psychiatry University of Nairobi, Kenya c ASEAN Institute for Health Development, Mahidol University, Thailand d Human Sciences Research Council, Pretoria, South Africa e University of Limpopo, Turfloop Campus, South Africa f Kenya Medical Research Institute, Wellcome Trust, Nairobi, Kenya b
art ic l e i nf o
a b s t r a c t
Article history: Received 10 April 2014 Accepted 25 April 2014 Available online 4 May 2014
Background: Depression is a common cause of morbidity but prevalence levels among Kenyan university students are poorly understood. A better understanding of depression and its correlates is essential in planning for appropriate interventions in this population group. Method: A random sample of 923 University of Nairobi students (525 male and 365 female) were interviewed using a questionnaire to record sociodemographic variables. Depressive symptoms were measured using Centre for Epidemiological Studies Short Depression Scale (CES – D 10). Results: The mean age was 23 (s.d. 4.0). Using a cut-off point of 10, the overall prevalence of moderate depressive symptoms was 35.7% (33.5% males and 39.0% females) and severe depression was 5.6% (5.3% males and 5.1% female). Depressive illness was significantly more common among the first year students, those who were married; those who were economically disadvantaged and those living off campus. Other variables significantly related to higher depression levels included year of study, academic performance, religion and college attended. Logistic regression showed that those students who used tobacco, engaged in binge drinking and those who had an older age were more likely to be depressed. No difference was noted with respect to gender. Limitations: This was a cross sectional study relying on self report of symptoms and could therefore be inaccurate. Although the study was conducted in the largest university in the country that admits students from diverse backgrounds in the country there could still be regional differences in other local universities. Conclusion: Depression occurs in a significant number of students. Appropriate interventions should be set up in higher institutions of learning to detect and treat these disorders paying particular attention to those at risk. & 2014 Elsevier B.V. All rights reserved.
Key words: Students Depression Risk factors
1. Introduction Although depression is a common health problem and has been shown to have detrimental effects on the students' studies few studies in Kenya have addressed the mental health problems in Kenyan universities. It is estimated that mental, neurological and substance use disorders account for 13% of the total global burden of disease (Ustun et al., 2004; Kessler, et al., 2003; Reddy, 2010; Ferrari et al., 2013) and that depression alone accounts for over 40% of the mental disabilities. Moreover, people with depression have a 40–60% chance of dying prematurely compared to the
n
Corresponding author. E-mail address: [email protected] (C.J. Othieno).
http://dx.doi.org/10.1016/j.jad.2014.04.070 0165-0327/& 2014 Elsevier B.V. All rights reserved.
general population. There is also evidence that depression can predispose people to various diseases such as diabetes, myocardial infarction, HIV infection and death from suicide (Rubin et al., 2009; Nduna et al., 2010). The prevalence of depression varies widely across cultures with developed countries recording higher rates than those of developing countries (Kessler and Bromet, 2013). However, the associated risk factors are largely the same including role transitions and low work performance. Given, that effective treatments for depression is now available, it is unfortunate that case identification and treatment remain low. Hence there is need for stepping up the awareness campaigns and early evidence based intervention (World Health Organization, 2013). Prevalence rates of depression among students vary widely, perhaps as a reflection of the different methodologies and instruments used. For example, using the Center for Epidemiologic
C.J. Othieno et al. / Journal of Affective Disorders 165 (2014) 120–125
Studies Depression Scale a study among 26 third year medical students in Hawaii found a prevalence rate of 59.1% (Thompson et al., 2010). An earlier study using the same instrument but involving multiple sites and a sample of more than 2000 medical students found that 12% had probable major depression and 9.2% had probable mild-moderate depression (Goebert et al., 2009). Among Egyptian university students a survey using a selfreport Arabic language version of Hamilton Rating Scale found that 71% of the students exceeded the cut-off point for mild depression and 37.6 had moderate depression (Ibrahim et al., 2012a, 2012b). In Ethiopia symptoms of depression were recorded in 23.6% of 1176 college students using the Patient Health Questionnaire (PHQ-9) (Terasaki et al., 2009). In contrast, much lower levels of depression were recorded by Adewuya et al. (2006) in Nigeria with only 8.3% of the students meeting the criteria for depression. A study of undergraduate students at Makerere University in Uganda using the Beck Depression Inventory showed that newly enrolled students joining the medicine course were less likely to have depressive symptoms compared to those students joining other general courses – 4% compared to 16.2% respectively (Ovuga et al., 2006). The authors of the same study noted that the average rate of depression in the university population was similar to that in the secondary schools in the same country but lower compared to rates reported from other countries such as Turkey (32.1%) (Bostanci et al., 2005). The few studies on depression among university students in Kenya do not explicitly measure depressive levels. For example, Ndetei (1987) while investigating the association between anxiety and depression among medical and paramedical students focussed only on the symptoms but not the actual diagnosis hence the level of depression is not stated in the study. Nevertheless the author notes that 43% of the students felt a need to seek help for their symptoms (both anxiety and depression) (Ndetei, 1987). Similarly, Kasomo (2013) despite using the BDI did not state the levels of depression in his sample. The focus of that study was to investigate the relationship between loneliness and depression. A study done on paramedical trainees to determine the effectiveness of psychoeducation recorded very high levels of depression among the participants (minimal 20.6%, mild 12.6%, moderate 18.4%, and severe 48.5%) (Muriungi and Ndetei, 2013). 1.1. Objectives We aimed to assess the prevalence of depressive symptoms and to describe the sociodemographic determinants among a sample of University of Nairobi students.
2. Method We obtained permission from the Kenyatta National Hospital and the University of Nairobi Ethics and Research Committee. University of Nairobi is the largest and oldest of the twenty-two public universities in Kenya. It has six consists of six colleges: College of Architecture and Engineering (Main Campus), College of Humanities and Social Sciences (Main Campus), College of Health Sciences (Kenyatta National Hospital), College of Education and External Studies (Kikuyu Campus and Kenya Science Campus), College of Agriculture and Veterinary Sciences (Upper Kabete Campus), and the College of Biological and Physical Sciences (Chiromo Campus). The Research targeted University of Nairobi students. The total student population in the University of Nairobi is 36,991 (22,734 male and 14,257 females) (University of Nairobi, 2013). Each of the 6 colleges participated in the study in order to achieve representativeness and to increase statistical power.
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Proportional stratified sampling was used to ensure that the colleges forming different student subpopulations were represented in the sample in same proportions as the population. The sampling process proceeded in two steps. In the first stage, the number of participants to be obtained from each college was determined using calculations based on probability proportional to size. Next, a sampling frame containing a list of all students was compiled from each college. In the second step, a simple random sample was selected within each college using computer generated random numbers and the available sampling frame. We administered a purpose designed questionnaire to record sociodemographic data including age, sex year of study, socioeconomic status and performance in studies. The Centre for Epidemiological Studies Short Depression Scale (CES – D 10) consists of 10 questions. It has been used in other parts of subSaharan Africa. We used a cut-off point of 10. Those who had a score of 11 and above were considered to probable depression with scores between 11–20 and scores above 20 representing mild-moderate depression and severe depression respectively (Andreasen et al., 1994; Mulrow et al., 1995; Kilbourne et al., 2002). 2.1. Binge drinking was assessed with one question… Traumatic experiences: participants were asked if they had ever been hit by a sex partner, forced to have sex, physically abused as a child, sexually abused as a child and diagnosed as HIV positive. Traumatic experience items were coded as yes/no (Sikkema et al., 2011). For posttraumatic stress disorder we asked seven questions related to the core features of the disorder: reexperiencing, hyperarousal and avoidance. PTSD was considered present if the subject answered yes to more than 4 out of the 7 questions (Kimerling et al., 2006; Sikkema et al., 2011)
3. Results We obtained data from 923 students (525 male and 365 female). The mean age was 23 years (s.d. 4.0). Majority (96.1%) of the students were Black Africans and two thirds residing within the campus. Ninety percent were single. Significantly more females (15%) were married compared to the males (approximately 10%). Nearly half (48%) of the students rated themselves as coming from families that were either not well off or were poor. More males (73.7%) resided within the campus compared to 60% of the females. Female students were more likely to be found living off campus either alone or with parents or guardians. Less than one percent of the students recorded their academic performance as not satisfactory (Table 1). Overall 41.33% of the students scored above the cut off point of 10 on the CES-D 30 scale, with 35.71 having mild – moderate symptoms and 5.62% having severe depressive symptoms. Proportionately more females had depressive symptoms compared to males but the difference was not statistically significant. The difference between the prevalence of binge drinking (defined as drinking of 4 or 5 drinks at a sitting) among the male and female students was not statistically different. However tobacco use was significantly more common among the male students (17.29% versus 8.22%) (Table 2). Although there were only 101 students in the sample who used tobacco nearly all of them had some form of depression (mildmoderate: 73.27% and severe: 10.89). Depression levels also varied according to year of study. The highest levels were recorded among students in the first year followed by those in the third year. Depression levels were also significantly higher among
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Table 1 Characteristics of the University of Nairobi students' sample. Variable
Total N or M
Male % or SD
923
N or M
P
Female % or SD
525
N or M
% or SD
All Social demographic Age o20 20–24 25–29 30 & above
365
200 515 84 56
23.39 60.23 9.82 6.54
122 311 49 24
24.11 61.46 9.68 4.74
78 204 35 32
22.35 58.45 10.03 9.17
0.079
Year of study First Second Third Fourth Fifth Sixth
185 256 195 214 23 1
21.17 29.29 22.31 24.48 2.63 0.11
128 143 107 111 14 1
25.40 28.37 21.23 22.02 2.78 0.20
56 111 85 98 9 0
15.60 30.92 23.68 27.30 2.51 0.00
0.018
College CAVS CAE CBPS CEES CHS CHSS
66 149 150 193 30 333
7.17 16.18 16.28 20.95 3.25 36.16
41 101 93 109 12 177
7.69 18.95 17.45 20.45 2.25 33.21
25 45 57 81 18 147
6.70 12.06 15.28 21.72 4.83 39.41
0.013
Marital status Married Single
90 813
9.96 90.03
35 490
6.67 93.33
54 311
14.79 85.21
0.0001
Religion Traditional religion Christian protestant Christian catholic Hindu Muslim Buddhist No religion Other
32 487 264 11 61 8 38 12
7.17 16.18 16.29 20.96 3.26 36.16 7.17 16.18
15 298 141 5 34 4 26 8
2.82 56.12 25.55 0.94 6.40 0.75 4.90 1.51
16 185 117 6 24 4 12 3
4.36 50.41 31.88 1.63 6.54 1.09 3.27 0.82
0.309
Residence On campus Off campus (on your own) Off campus (with parents and guardians)
616 216 74
67.99 23.84 8.17
387 108 30
73.71 20.57 5.71
219 103 43
60 28.33 11.78
o 0.0001
Family background Wealthy Quite well off Not very well off Quite poor
54 415 363 70
5.99 46.01 40.24 7.76
19 232 219 52
3.64 44.04 41.95 9.96
34 173 140 17
9.34 47.53 38.46 4.67
0.0001
Academic performance Excellent Very good Good Satisfactory Not satisfactory
113 336 275 45 6
14.58 43.35 35.48 5.81 0.77
74 186 162 29 4
16.26 40.88 35.60 6.37 0.88
38 144 109 16 2
12.30 46.00 35.28 5.18 0.65
0.4131
Depression No depression Moderate Severe Seriously hurt during past 12 months Sexually abused as a child Physically abused as a child Involvement in a physical fight PTSD Ever diagnosed with HIV
501 305 48 255 51 80 119 146 26
58.67 35.71 5.62 29 5.95 9.32 13.18 15.67 3.04
297 163 26 200 22 39 83 97 10
61.11 33.54 5.35 28.5 4.44 7.86 15.99 15.39 2.03
196 137 18 53 29 40 10 48 14
55.84 39.03 5.13 30.01 8.38 11.56 8.94 16.10 4.05
0.2598
0.420 0.0273 0.0909 0.027 o 0.0001 0.1296
Substance use Binge drinking Tobacco use
122 101
38.85 13.5
79 74
39.70 17.29
41 25
36.94 8.22
0.7211 0.0006
CAE: College of Architecture and Engineering; CBPS: College of Biological and Physical Sciences. CEES: College of Education and External Studies; CHS: College of Health Sciences, CHSS: College of Humanities and Social Sciences; CAVS: College of Agriculture and Veterinary Sciences.
students from the college of Education and External Studies and lowest in the College of Health Sciences. With regard to religion the Catholic and Muslim students had comparatively lower levels
of depression in contrast to the students who belonged to the Christian protestant churches and the Hindu religion. Other factors significantly related to depression were living off campus with
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Table 2 Prevalence of depression among a sample of University of Nairobi students. Variable
Total N or M
All Social demographic Age
Depression (mild-moderate) % or SD
923 23.01
4.03
P
Depression (severe)
N or M
% or SD
N or M
305
35.71
48
5.62
22.65
3.21
23.43
3.66
P
% or SD
Gender Male Female
533 373
58.83 41.17
163 137
30.58 36.73
0.1333
26 18
4.88 4.83
0.2278
Year of study First Second Third Fourth Fifth Sixth
185 256 195 214 23 1
21.17 29.29 22.31 24.29 2.63 0.11
62 84 69 72 3 0
33.51 32.81 35.38 33.64 13.04 0.00
o 0.0001
13 10 10 10 0 0
7.03 3.91 5.13 4.63 0.00 0.00
0.0004
College CAVS CAE CBPS CEES CHS CHSS
66 149 150 193 30 333
7.17 16.18 16.29 20.96 3.26 36.16
21 52 46 78 4 104
31.82 34.89 30.67 40.41 13.33 31.23
o 0.0001
4 9 7 5 0 23
6.06 6.04 4.66 2.59 0.00 6.91
o 0.0001
Marital status Married Single
90 813
9.97 90.03
32 266
35.56 32.72
o 0.0001
4 42
4.44 5.17
o 0.0001
Religion Traditional religion Christian protestant Christian catholic Hindu Muslim Buddhist No religion Other
32 487 264 11 61 8 38 12
3.50 53.34 28.92 1.20 6.68 0.88 4.16 1.31
10 176 78 4 16 0 15 3
31.25 36.14 29.55 36.36 26.23 0.00 39.47 25.00
o 0.0001
2 23 12 0 4 0 3 4
6.25 4.72 4.55 0.00 6.55 0.00 7.89 33.33
o 0.0001
Residence On campus Off campus (on your own) Off campus (with parents and guardians)
616 216 74
67.99 23.84 8.17
200 69 28
32.46 31.94 37.84
o 0.0001
38 4 4
6.16 1.85 5.41
o 0.0001
Family background Wealthy Quite well off Not very well off Quite poor
54 415 363 70
5.99 46.01 40.24 7.76
12 133 116 36
22.22 32.05 31.95 51.43
o 0.0001
1 10 32 4
1.85 2.41 8.82 5.71
o 0.0001
Academic performance Excellent Very good Good Satisfactory Not satisfactory
113 336 275 45 6
14.58 43.35 35.48 5.81 0.77
41 114 78 11 3
36.28 33.92 28.36 24.44 50.00
o 0.0001
6 19 15 2 1
5.31 5.65 5.45 4.44 16.66
o 0.0001
Alcohol use Never used alcohol Normal drinker Binge drinking Tobacco use Ever diagnosed with HIV
509 225 122 101 26
57.91 25.59 38.85 13.5 3.04
151 83 42 74 15
29.66 36.88 34.42 73.27 57.69
0.0001 0.399 0.0029 0.0001 o 0.0001
27 17 4 11 5
5.30 7.55 3.28 10.89 19.23
0.0001 0.858 0.0707 0.0268 o 0.0001
parents or guardians, poor family background, poor academic performance and tobacco use (Table 3).
4. Discussion The findings indicate that depressive symptoms are common and affect over 40% of the students. This rate is comparable to figures from other studies (Goebert et al., 2009; Ibrahim et al., 2012a, 2012b), but lower than the rates found in West African students (Adewuya et al., 2006). The high rates of depression also
reflect those found in Kenyan secondary schools and higher institutions of learning in Kenya (Khasakhala et al., 2012). Severe depression was recorded in 5.6% (5.3% males and 5.1% female) which is slightly higher than that reported in a large study among Chinese students (Chen et al., 2013). In addition, we found that depressive illness was significantly more common among the first year students, those who were married; those who were economically disadvantaged and those living off campus. Other variables significantly related to higher depression levels included year of study, academic performance, religion and college attended. Logistic regression showed that those students who used tobacco,
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Table 3 Logistic regression predicting depression. Variable
Crude odds ratio (95% CI)
Adjusted odds ratio (95% CI)
Social demographic Gender Female Age
1.29 [0.99,1.70] 1.03[1,1.07]n
1.09[0.40,2.94] 1.27[1.06,1.59]n
Year of study Second Third Fourth Fifth Sixth
0.85[0.58,1.26] 1[0.66,1.51] 0.91[0.61,1.36] 0.22[0.05,0.67] –
0.47[0.09,2.24] 2.44[0.42,1.63] 0.69[0.12,4.2] 0.71[0.02,1.9] –
College CAE CBPS CEES CHS CHSS
1.14[0.37,1] 0.9[0.49,1.64] 1.24[0.7,2.22] 0.25[0.07,0.74] 1.01[0.59,1.76]
0.18[0.0094,2.59] 0.31[0.02,4.76] 0.34[0.02,5.46] – –
Marital status Single
0.91[0.59,1.44]
–
Religion Christian protestant Christian catholic Hindu Muslim Buddhist No religion Other
1.15[0.56,2.48] 0.86[0.41,1.89] 0.95[0.21,3.87] 0.81[0.33,2.01] – 1.50[0.58,3.97] 2.33[0.61,9.53]
– – – – – – –
Residence Off campus (on your own) Off campus (with parents and guardians)
0.81[0.58,1.12] 1.21[0.74,1.97]
0.36[0.095,1.27] 0.17[0.008,1.48]
Family background Quite well off Not very well off Quite poor
1.66[0.88,3.31] 2.17[1.15,4.34]n 4.21[1.96,9.46]n
5.03[0.54,69] 3.38[0.35,45.8] 1.14[0.025,42.9]
Academic performance Very good Good Satisfactory Not satisfactory
0.92[0.49,1.03] 0.72[0.60,1.42] 0.57[0.26,1.18] 2.81[0.53,20.86]
1.34[0.28,6.55] 1.46[0.29,8.16] 2.9[0.15,26.4] –
Alcohol use Binge drinking (4 or 5 drinks at a sitting)
1.31[0.83,2.09]
3.86[1.27,12.9]n
Tobacco use
1.65 [1.08,2.52]n
1.06[0.25,4.62]
Sexual behavior Number of partners past 12 months
1.05[0.97,1.15]
0.83[0.58,1.19]
Use of condom with partner Less than half of the time Half of the time More than half of the time Every time Ever diagnosed with STI Ever diagnosed with HIV Ever made someone pregnant/been pregnant before 19 years Ever been hit by a sexual partner Ever been forced to have sex Physically abused as a child Sexually abused as a child PTSD
1.50[0.90,2.48] 1.54[0.92,2.59] 1.64[0.96,2.79] 1.04[0.72,1.49] 1.93[1.23,3.06]n 5.66[2.38,15.63]n 1.44[0.41,5.28]n 3.25[1.92,5.66]n 4.59[2.87,7.53]n 1.76[1.11,2.81]n 2.39[1.35,4.31]n 2.53[1.22,3.5]n
1.68[0.28,10.7] 1.21[0.16,9.3] 0.98[0.14,6.68] 1.49[0.37,6.48] 2.9[1.73,21.3]n 4.34[2.11,11.17]n 1.20[1.01,5.66]n 5.02[2.11,9.63]n 3.02[1.79,8.70]n 5.56[3.44,16.2]n 4.11[1.07,13.0]n 3.99[1.13,9.5]n
Injury I was attacked, assaulted, or abused by someone
3.52[1.20,11.59]n
5.02[2.4,17.33]n
n
Denotes significance at 5%.
engaged in binge drinking and those who had an older age were more likely to be depressed. Some of these findings are similar to that of other studies among Kenyan adolescents that found high rates of comorbidity with substance use (Khasakhala et al., 2013). However unlike other studies from Kenya that recorded higher prevalence of depression among females we did not find any
difference with respect to gender. Chen et al. (2013) also did not find any differences related to gender. Other similarities with the Chinese study are that older students, those who were economically disadvantaged and those who were dissatisfied with their studies were more likely to be depressed. Economic disadvantage was also shown to be an important determinant of depression in
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American college students (Eisenberg et al., 2007). Unlike some studies we did not find high prevalence of depression among medical students. The highest prevalence was recorded among the students from the College of education and External Studies. This is probably linked to the fact that most of them would be older and larger proportion residing outside campus – both factors were linked to depression in this study. 5. Limitations This was a cross sectional study relying on self report of symptoms and could therefore be inaccurate. Although the study was conducted in the largest university in the country that admits students from diverse backgrounds in the country there could still be regional differences in other local universities. 6. Conclusion The study shows that depression affects a large number of students and identifies groups of students who may be more at risk of developing depressive illness, such as those in the first year of study or those who live outside the campus and students from poor family backgrounds. More studies are needed to explore the risks and how they can be minimized. Appropriate interventions could be put in place using such information. Role of funding source Self funded.
Conflict of interest None.
Acknowledgment To the students who participated in the study, the administration of the University of Nairobi, especially Registrar Academics for facilitating the study; Cherryl Ojjerro, Rachel Maina, Eston Nyakiya, Julius Oduor and Amelia Awoko who assisted with the data collection.
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Ferrari, A.J., Charlson, F.J., Norman, R.E., Patten, S.B., Freedman, G., Murray, C.J., Whiteford, H.A., 2013. Burden of depressive disorders by country, sex, age, and year: findings from global burden of disease study 2010 Burden. PLOS Med. 10, 11. Goebert, D., Thompson, D., Takeshita, J., Beach, C., Bryson, P., Ephgrave, K., Tate, J., 2009. Depressive symptoms in medical students and residents: a multischool study. Acad. Med. 84 (2), 236–241. Ibrahim, A.K., Kelly, S.J., Glazebrook, C., 2012a. Reliability of a shortened version of the Zagazig Depression Scale and prevalence of depression in an Egyptian university student sample. Compr. Psychiatry 53 (5), 638–647 (July). Ibrahim, A.K., Kelly, S.J., Glazenbrook, C., 2012b. Analysis of an Egyptian study on the socioeconomic distribution of depressive symptoms among undergraduates. Soc. Psychiatry Psychiatr. Epidemiol. 4 (7), 927–937 (June). Kasomo, D., 2013. Loneliness and depression among university students in Kenya. Glob. J. Hum., Soc. Sci., Arts Humanit. 13 (4), 10–18. Kessler, R.C., Bromet, E.J., 2013. The epidemiology of depression across cultures. Annu. Rev. Public Health 34, 119–138. Kessler, R.C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K.R., Wang, P.S., 2003. The epidemiology of major depressive disorder. JAMA 289 (23), 3095–3105. Khasakhala, L.I., Ndetei, D.M., Mathai, M., Harder, V., 2013. Major depressive disorder in a Kenyan youth sample: relationship with parenting behavior and parental psychiatric disorders. Ann. Gen. Psychiatry 12 (1), 15. Khasakhala, L., Ndetei, D.M., Mutiso, V., Mbwayo, A.W., Mathai, M., 2012. The prevalence of depressive symptoms among adolescents in Nairobi public secondary schools: association with perceived maladaptive parental behaviour. Afr. J. Psychiatry 15 (2), 106–113. Kilbourne, A., Justice, A., Rollman, B., McGinnis, K., Weissman, S., 2002. Clinical importance of HIV and depressive symptoms among veterans with HIV infection. J. Gen. Intern. Med. 17 (7), 512–520. Kimerling, R., Ouimette, P., Prins, A., Nisco, P., Lawler, C., Cronkite, R., Moos, R.H., 2006. Brief report: utility of a short screening scale for DSM-IV PTSD in primary care. J. Gen. Intern. Med. 21 (1), 65–67. Mulrow, C.D., Williams, J.W., Gerety, M.B., Ramirez, G., Montiel, O.M., Kerber, C., 1995. Case-finding instruments for depression in primary care setting. Ann. Intern. Med. 122 (12), 913–921. Muriungi, S.K., Ndetei, D.M., 2013. Effectiveness of psycho-education on depression, hopelessness, suicidality, anxiety and substance use among basic diploma students at Kenya Medical Training College. S. Afr. J. Psychiatry 19 (2), 41–50. Ndetei, D.M., 1987. The association and implications of anxiety and depression in university medical and paramedical students in Kenya. East Afr. Med. J. 64 (3), 214–226. Nduna, M., Jewkes, R.K., Dunkle, K.L., Shai, N., Colman, I., 2010. Associations between depressive symptoms, sexual behaviour and relationship characteristics: a prospective cohort study of young women and men in Eastern Cape, South Africa. J. Int. AIDS Soc. 13, 44. Ovuga, E., Boardman, J., Wasserman, D., 2006. Undergraduate student mental health at Makerere University, Uganda. World Psychiatry 5 (1), 51–52 (February). Reddy, M.S., 2010. Depression: the disorder and the burden. Indian J. Psychol. Med. 32 (1), 1–2. Rubin, A.G., Gold, M.A., Primack, B.A., 2009. Associations between depressive symptoms and sexual risk behaviour in a diverse sample of female adolescents. J. Pediatr. Adolesc. Gynecol. 22, 306–312. Sikkema, K.J., Watt, M.H., Meade, C.S., Ranby, K.W., Kalichman, S.C., Skinner, D., Pieterse, D., 2011. Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa. J. Acquir. Immune Defic. Syndr. 57 (3), 230–237. Terasaki, D.J., Gelave, B., Berhane, Y., Williams, M.A., 2009. Anger expression, violent behavior, and symptoms of depression among male college students in Ethiopia. BMC Public Health 12 (9), 13 (Januaury). Thompson, D., Goebert, D., Takeshita, J., 2010. A program for reducing depressive symptoms and suicidal ideation in medical students. Acad. Med. 85 (10), 1635–1639 (October). University of Nairobi, 2013. University Population. Retrieved from 〈http://archive. uonbi.ac.ke/statistics/?page=university-population〉. Ustun, T.B., Ayuso-Mateos, J.L., Chaterji, S., Mathers, C., Murray, C.J., 2004. Global burden of depressive disorders in the year 2000. Br. J. Psychiatry 184, 386–392. World Health Organization, 2013. Mental Health Action Plan 2013–2020.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Research report
Depression among university students in Kenya: Prevalence and sociodemographic correlates Caleb J. Othieno a,n, Roselyne O. Okoth b, Karl Peltzer c,d,e, Supa Pengpid c,e, Lucas O. Malla f a
Department of Psychiatry, University of Nairobi, P.O. Box 19676, 00202 Nairobi, Kenya Department of Psychiatry University of Nairobi, Kenya c ASEAN Institute for Health Development, Mahidol University, Thailand d Human Sciences Research Council, Pretoria, South Africa e University of Limpopo, Turfloop Campus, South Africa f Kenya Medical Research Institute, Wellcome Trust, Nairobi, Kenya b
art ic l e i nf o
a b s t r a c t
Article history: Received 10 April 2014 Accepted 25 April 2014 Available online 4 May 2014
Background: Depression is a common cause of morbidity but prevalence levels among Kenyan university students are poorly understood. A better understanding of depression and its correlates is essential in planning for appropriate interventions in this population group. Method: A random sample of 923 University of Nairobi students (525 male and 365 female) were interviewed using a questionnaire to record sociodemographic variables. Depressive symptoms were measured using Centre for Epidemiological Studies Short Depression Scale (CES – D 10). Results: The mean age was 23 (s.d. 4.0). Using a cut-off point of 10, the overall prevalence of moderate depressive symptoms was 35.7% (33.5% males and 39.0% females) and severe depression was 5.6% (5.3% males and 5.1% female). Depressive illness was significantly more common among the first year students, those who were married; those who were economically disadvantaged and those living off campus. Other variables significantly related to higher depression levels included year of study, academic performance, religion and college attended. Logistic regression showed that those students who used tobacco, engaged in binge drinking and those who had an older age were more likely to be depressed. No difference was noted with respect to gender. Limitations: This was a cross sectional study relying on self report of symptoms and could therefore be inaccurate. Although the study was conducted in the largest university in the country that admits students from diverse backgrounds in the country there could still be regional differences in other local universities. Conclusion: Depression occurs in a significant number of students. Appropriate interventions should be set up in higher institutions of learning to detect and treat these disorders paying particular attention to those at risk. & 2014 Elsevier B.V. All rights reserved.
Key words: Students Depression Risk factors
1. Introduction Although depression is a common health problem and has been shown to have detrimental effects on the students' studies few studies in Kenya have addressed the mental health problems in Kenyan universities. It is estimated that mental, neurological and substance use disorders account for 13% of the total global burden of disease (Ustun et al., 2004; Kessler, et al., 2003; Reddy, 2010; Ferrari et al., 2013) and that depression alone accounts for over 40% of the mental disabilities. Moreover, people with depression have a 40–60% chance of dying prematurely compared to the
n
Corresponding author. E-mail address: [email protected] (C.J. Othieno).
http://dx.doi.org/10.1016/j.jad.2014.04.070 0165-0327/& 2014 Elsevier B.V. All rights reserved.
general population. There is also evidence that depression can predispose people to various diseases such as diabetes, myocardial infarction, HIV infection and death from suicide (Rubin et al., 2009; Nduna et al., 2010). The prevalence of depression varies widely across cultures with developed countries recording higher rates than those of developing countries (Kessler and Bromet, 2013). However, the associated risk factors are largely the same including role transitions and low work performance. Given, that effective treatments for depression is now available, it is unfortunate that case identification and treatment remain low. Hence there is need for stepping up the awareness campaigns and early evidence based intervention (World Health Organization, 2013). Prevalence rates of depression among students vary widely, perhaps as a reflection of the different methodologies and instruments used. For example, using the Center for Epidemiologic
C.J. Othieno et al. / Journal of Affective Disorders 165 (2014) 120–125
Studies Depression Scale a study among 26 third year medical students in Hawaii found a prevalence rate of 59.1% (Thompson et al., 2010). An earlier study using the same instrument but involving multiple sites and a sample of more than 2000 medical students found that 12% had probable major depression and 9.2% had probable mild-moderate depression (Goebert et al., 2009). Among Egyptian university students a survey using a selfreport Arabic language version of Hamilton Rating Scale found that 71% of the students exceeded the cut-off point for mild depression and 37.6 had moderate depression (Ibrahim et al., 2012a, 2012b). In Ethiopia symptoms of depression were recorded in 23.6% of 1176 college students using the Patient Health Questionnaire (PHQ-9) (Terasaki et al., 2009). In contrast, much lower levels of depression were recorded by Adewuya et al. (2006) in Nigeria with only 8.3% of the students meeting the criteria for depression. A study of undergraduate students at Makerere University in Uganda using the Beck Depression Inventory showed that newly enrolled students joining the medicine course were less likely to have depressive symptoms compared to those students joining other general courses – 4% compared to 16.2% respectively (Ovuga et al., 2006). The authors of the same study noted that the average rate of depression in the university population was similar to that in the secondary schools in the same country but lower compared to rates reported from other countries such as Turkey (32.1%) (Bostanci et al., 2005). The few studies on depression among university students in Kenya do not explicitly measure depressive levels. For example, Ndetei (1987) while investigating the association between anxiety and depression among medical and paramedical students focussed only on the symptoms but not the actual diagnosis hence the level of depression is not stated in the study. Nevertheless the author notes that 43% of the students felt a need to seek help for their symptoms (both anxiety and depression) (Ndetei, 1987). Similarly, Kasomo (2013) despite using the BDI did not state the levels of depression in his sample. The focus of that study was to investigate the relationship between loneliness and depression. A study done on paramedical trainees to determine the effectiveness of psychoeducation recorded very high levels of depression among the participants (minimal 20.6%, mild 12.6%, moderate 18.4%, and severe 48.5%) (Muriungi and Ndetei, 2013). 1.1. Objectives We aimed to assess the prevalence of depressive symptoms and to describe the sociodemographic determinants among a sample of University of Nairobi students.
2. Method We obtained permission from the Kenyatta National Hospital and the University of Nairobi Ethics and Research Committee. University of Nairobi is the largest and oldest of the twenty-two public universities in Kenya. It has six consists of six colleges: College of Architecture and Engineering (Main Campus), College of Humanities and Social Sciences (Main Campus), College of Health Sciences (Kenyatta National Hospital), College of Education and External Studies (Kikuyu Campus and Kenya Science Campus), College of Agriculture and Veterinary Sciences (Upper Kabete Campus), and the College of Biological and Physical Sciences (Chiromo Campus). The Research targeted University of Nairobi students. The total student population in the University of Nairobi is 36,991 (22,734 male and 14,257 females) (University of Nairobi, 2013). Each of the 6 colleges participated in the study in order to achieve representativeness and to increase statistical power.
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Proportional stratified sampling was used to ensure that the colleges forming different student subpopulations were represented in the sample in same proportions as the population. The sampling process proceeded in two steps. In the first stage, the number of participants to be obtained from each college was determined using calculations based on probability proportional to size. Next, a sampling frame containing a list of all students was compiled from each college. In the second step, a simple random sample was selected within each college using computer generated random numbers and the available sampling frame. We administered a purpose designed questionnaire to record sociodemographic data including age, sex year of study, socioeconomic status and performance in studies. The Centre for Epidemiological Studies Short Depression Scale (CES – D 10) consists of 10 questions. It has been used in other parts of subSaharan Africa. We used a cut-off point of 10. Those who had a score of 11 and above were considered to probable depression with scores between 11–20 and scores above 20 representing mild-moderate depression and severe depression respectively (Andreasen et al., 1994; Mulrow et al., 1995; Kilbourne et al., 2002). 2.1. Binge drinking was assessed with one question… Traumatic experiences: participants were asked if they had ever been hit by a sex partner, forced to have sex, physically abused as a child, sexually abused as a child and diagnosed as HIV positive. Traumatic experience items were coded as yes/no (Sikkema et al., 2011). For posttraumatic stress disorder we asked seven questions related to the core features of the disorder: reexperiencing, hyperarousal and avoidance. PTSD was considered present if the subject answered yes to more than 4 out of the 7 questions (Kimerling et al., 2006; Sikkema et al., 2011)
3. Results We obtained data from 923 students (525 male and 365 female). The mean age was 23 years (s.d. 4.0). Majority (96.1%) of the students were Black Africans and two thirds residing within the campus. Ninety percent were single. Significantly more females (15%) were married compared to the males (approximately 10%). Nearly half (48%) of the students rated themselves as coming from families that were either not well off or were poor. More males (73.7%) resided within the campus compared to 60% of the females. Female students were more likely to be found living off campus either alone or with parents or guardians. Less than one percent of the students recorded their academic performance as not satisfactory (Table 1). Overall 41.33% of the students scored above the cut off point of 10 on the CES-D 30 scale, with 35.71 having mild – moderate symptoms and 5.62% having severe depressive symptoms. Proportionately more females had depressive symptoms compared to males but the difference was not statistically significant. The difference between the prevalence of binge drinking (defined as drinking of 4 or 5 drinks at a sitting) among the male and female students was not statistically different. However tobacco use was significantly more common among the male students (17.29% versus 8.22%) (Table 2). Although there were only 101 students in the sample who used tobacco nearly all of them had some form of depression (mildmoderate: 73.27% and severe: 10.89). Depression levels also varied according to year of study. The highest levels were recorded among students in the first year followed by those in the third year. Depression levels were also significantly higher among
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Table 1 Characteristics of the University of Nairobi students' sample. Variable
Total N or M
Male % or SD
923
N or M
P
Female % or SD
525
N or M
% or SD
All Social demographic Age o20 20–24 25–29 30 & above
365
200 515 84 56
23.39 60.23 9.82 6.54
122 311 49 24
24.11 61.46 9.68 4.74
78 204 35 32
22.35 58.45 10.03 9.17
0.079
Year of study First Second Third Fourth Fifth Sixth
185 256 195 214 23 1
21.17 29.29 22.31 24.48 2.63 0.11
128 143 107 111 14 1
25.40 28.37 21.23 22.02 2.78 0.20
56 111 85 98 9 0
15.60 30.92 23.68 27.30 2.51 0.00
0.018
College CAVS CAE CBPS CEES CHS CHSS
66 149 150 193 30 333
7.17 16.18 16.28 20.95 3.25 36.16
41 101 93 109 12 177
7.69 18.95 17.45 20.45 2.25 33.21
25 45 57 81 18 147
6.70 12.06 15.28 21.72 4.83 39.41
0.013
Marital status Married Single
90 813
9.96 90.03
35 490
6.67 93.33
54 311
14.79 85.21
0.0001
Religion Traditional religion Christian protestant Christian catholic Hindu Muslim Buddhist No religion Other
32 487 264 11 61 8 38 12
7.17 16.18 16.29 20.96 3.26 36.16 7.17 16.18
15 298 141 5 34 4 26 8
2.82 56.12 25.55 0.94 6.40 0.75 4.90 1.51
16 185 117 6 24 4 12 3
4.36 50.41 31.88 1.63 6.54 1.09 3.27 0.82
0.309
Residence On campus Off campus (on your own) Off campus (with parents and guardians)
616 216 74
67.99 23.84 8.17
387 108 30
73.71 20.57 5.71
219 103 43
60 28.33 11.78
o 0.0001
Family background Wealthy Quite well off Not very well off Quite poor
54 415 363 70
5.99 46.01 40.24 7.76
19 232 219 52
3.64 44.04 41.95 9.96
34 173 140 17
9.34 47.53 38.46 4.67
0.0001
Academic performance Excellent Very good Good Satisfactory Not satisfactory
113 336 275 45 6
14.58 43.35 35.48 5.81 0.77
74 186 162 29 4
16.26 40.88 35.60 6.37 0.88
38 144 109 16 2
12.30 46.00 35.28 5.18 0.65
0.4131
Depression No depression Moderate Severe Seriously hurt during past 12 months Sexually abused as a child Physically abused as a child Involvement in a physical fight PTSD Ever diagnosed with HIV
501 305 48 255 51 80 119 146 26
58.67 35.71 5.62 29 5.95 9.32 13.18 15.67 3.04
297 163 26 200 22 39 83 97 10
61.11 33.54 5.35 28.5 4.44 7.86 15.99 15.39 2.03
196 137 18 53 29 40 10 48 14
55.84 39.03 5.13 30.01 8.38 11.56 8.94 16.10 4.05
0.2598
0.420 0.0273 0.0909 0.027 o 0.0001 0.1296
Substance use Binge drinking Tobacco use
122 101
38.85 13.5
79 74
39.70 17.29
41 25
36.94 8.22
0.7211 0.0006
CAE: College of Architecture and Engineering; CBPS: College of Biological and Physical Sciences. CEES: College of Education and External Studies; CHS: College of Health Sciences, CHSS: College of Humanities and Social Sciences; CAVS: College of Agriculture and Veterinary Sciences.
students from the college of Education and External Studies and lowest in the College of Health Sciences. With regard to religion the Catholic and Muslim students had comparatively lower levels
of depression in contrast to the students who belonged to the Christian protestant churches and the Hindu religion. Other factors significantly related to depression were living off campus with
C.J. Othieno et al. / Journal of Affective Disorders 165 (2014) 120–125
123
Table 2 Prevalence of depression among a sample of University of Nairobi students. Variable
Total N or M
All Social demographic Age
Depression (mild-moderate) % or SD
923 23.01
4.03
P
Depression (severe)
N or M
% or SD
N or M
305
35.71
48
5.62
22.65
3.21
23.43
3.66
P
% or SD
Gender Male Female
533 373
58.83 41.17
163 137
30.58 36.73
0.1333
26 18
4.88 4.83
0.2278
Year of study First Second Third Fourth Fifth Sixth
185 256 195 214 23 1
21.17 29.29 22.31 24.29 2.63 0.11
62 84 69 72 3 0
33.51 32.81 35.38 33.64 13.04 0.00
o 0.0001
13 10 10 10 0 0
7.03 3.91 5.13 4.63 0.00 0.00
0.0004
College CAVS CAE CBPS CEES CHS CHSS
66 149 150 193 30 333
7.17 16.18 16.29 20.96 3.26 36.16
21 52 46 78 4 104
31.82 34.89 30.67 40.41 13.33 31.23
o 0.0001
4 9 7 5 0 23
6.06 6.04 4.66 2.59 0.00 6.91
o 0.0001
Marital status Married Single
90 813
9.97 90.03
32 266
35.56 32.72
o 0.0001
4 42
4.44 5.17
o 0.0001
Religion Traditional religion Christian protestant Christian catholic Hindu Muslim Buddhist No religion Other
32 487 264 11 61 8 38 12
3.50 53.34 28.92 1.20 6.68 0.88 4.16 1.31
10 176 78 4 16 0 15 3
31.25 36.14 29.55 36.36 26.23 0.00 39.47 25.00
o 0.0001
2 23 12 0 4 0 3 4
6.25 4.72 4.55 0.00 6.55 0.00 7.89 33.33
o 0.0001
Residence On campus Off campus (on your own) Off campus (with parents and guardians)
616 216 74
67.99 23.84 8.17
200 69 28
32.46 31.94 37.84
o 0.0001
38 4 4
6.16 1.85 5.41
o 0.0001
Family background Wealthy Quite well off Not very well off Quite poor
54 415 363 70
5.99 46.01 40.24 7.76
12 133 116 36
22.22 32.05 31.95 51.43
o 0.0001
1 10 32 4
1.85 2.41 8.82 5.71
o 0.0001
Academic performance Excellent Very good Good Satisfactory Not satisfactory
113 336 275 45 6
14.58 43.35 35.48 5.81 0.77
41 114 78 11 3
36.28 33.92 28.36 24.44 50.00
o 0.0001
6 19 15 2 1
5.31 5.65 5.45 4.44 16.66
o 0.0001
Alcohol use Never used alcohol Normal drinker Binge drinking Tobacco use Ever diagnosed with HIV
509 225 122 101 26
57.91 25.59 38.85 13.5 3.04
151 83 42 74 15
29.66 36.88 34.42 73.27 57.69
0.0001 0.399 0.0029 0.0001 o 0.0001
27 17 4 11 5
5.30 7.55 3.28 10.89 19.23
0.0001 0.858 0.0707 0.0268 o 0.0001
parents or guardians, poor family background, poor academic performance and tobacco use (Table 3).
4. Discussion The findings indicate that depressive symptoms are common and affect over 40% of the students. This rate is comparable to figures from other studies (Goebert et al., 2009; Ibrahim et al., 2012a, 2012b), but lower than the rates found in West African students (Adewuya et al., 2006). The high rates of depression also
reflect those found in Kenyan secondary schools and higher institutions of learning in Kenya (Khasakhala et al., 2012). Severe depression was recorded in 5.6% (5.3% males and 5.1% female) which is slightly higher than that reported in a large study among Chinese students (Chen et al., 2013). In addition, we found that depressive illness was significantly more common among the first year students, those who were married; those who were economically disadvantaged and those living off campus. Other variables significantly related to higher depression levels included year of study, academic performance, religion and college attended. Logistic regression showed that those students who used tobacco,
124
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Table 3 Logistic regression predicting depression. Variable
Crude odds ratio (95% CI)
Adjusted odds ratio (95% CI)
Social demographic Gender Female Age
1.29 [0.99,1.70] 1.03[1,1.07]n
1.09[0.40,2.94] 1.27[1.06,1.59]n
Year of study Second Third Fourth Fifth Sixth
0.85[0.58,1.26] 1[0.66,1.51] 0.91[0.61,1.36] 0.22[0.05,0.67] –
0.47[0.09,2.24] 2.44[0.42,1.63] 0.69[0.12,4.2] 0.71[0.02,1.9] –
College CAE CBPS CEES CHS CHSS
1.14[0.37,1] 0.9[0.49,1.64] 1.24[0.7,2.22] 0.25[0.07,0.74] 1.01[0.59,1.76]
0.18[0.0094,2.59] 0.31[0.02,4.76] 0.34[0.02,5.46] – –
Marital status Single
0.91[0.59,1.44]
–
Religion Christian protestant Christian catholic Hindu Muslim Buddhist No religion Other
1.15[0.56,2.48] 0.86[0.41,1.89] 0.95[0.21,3.87] 0.81[0.33,2.01] – 1.50[0.58,3.97] 2.33[0.61,9.53]
– – – – – – –
Residence Off campus (on your own) Off campus (with parents and guardians)
0.81[0.58,1.12] 1.21[0.74,1.97]
0.36[0.095,1.27] 0.17[0.008,1.48]
Family background Quite well off Not very well off Quite poor
1.66[0.88,3.31] 2.17[1.15,4.34]n 4.21[1.96,9.46]n
5.03[0.54,69] 3.38[0.35,45.8] 1.14[0.025,42.9]
Academic performance Very good Good Satisfactory Not satisfactory
0.92[0.49,1.03] 0.72[0.60,1.42] 0.57[0.26,1.18] 2.81[0.53,20.86]
1.34[0.28,6.55] 1.46[0.29,8.16] 2.9[0.15,26.4] –
Alcohol use Binge drinking (4 or 5 drinks at a sitting)
1.31[0.83,2.09]
3.86[1.27,12.9]n
Tobacco use
1.65 [1.08,2.52]n
1.06[0.25,4.62]
Sexual behavior Number of partners past 12 months
1.05[0.97,1.15]
0.83[0.58,1.19]
Use of condom with partner Less than half of the time Half of the time More than half of the time Every time Ever diagnosed with STI Ever diagnosed with HIV Ever made someone pregnant/been pregnant before 19 years Ever been hit by a sexual partner Ever been forced to have sex Physically abused as a child Sexually abused as a child PTSD
1.50[0.90,2.48] 1.54[0.92,2.59] 1.64[0.96,2.79] 1.04[0.72,1.49] 1.93[1.23,3.06]n 5.66[2.38,15.63]n 1.44[0.41,5.28]n 3.25[1.92,5.66]n 4.59[2.87,7.53]n 1.76[1.11,2.81]n 2.39[1.35,4.31]n 2.53[1.22,3.5]n
1.68[0.28,10.7] 1.21[0.16,9.3] 0.98[0.14,6.68] 1.49[0.37,6.48] 2.9[1.73,21.3]n 4.34[2.11,11.17]n 1.20[1.01,5.66]n 5.02[2.11,9.63]n 3.02[1.79,8.70]n 5.56[3.44,16.2]n 4.11[1.07,13.0]n 3.99[1.13,9.5]n
Injury I was attacked, assaulted, or abused by someone
3.52[1.20,11.59]n
5.02[2.4,17.33]n
n
Denotes significance at 5%.
engaged in binge drinking and those who had an older age were more likely to be depressed. Some of these findings are similar to that of other studies among Kenyan adolescents that found high rates of comorbidity with substance use (Khasakhala et al., 2013). However unlike other studies from Kenya that recorded higher prevalence of depression among females we did not find any
difference with respect to gender. Chen et al. (2013) also did not find any differences related to gender. Other similarities with the Chinese study are that older students, those who were economically disadvantaged and those who were dissatisfied with their studies were more likely to be depressed. Economic disadvantage was also shown to be an important determinant of depression in
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American college students (Eisenberg et al., 2007). Unlike some studies we did not find high prevalence of depression among medical students. The highest prevalence was recorded among the students from the College of education and External Studies. This is probably linked to the fact that most of them would be older and larger proportion residing outside campus – both factors were linked to depression in this study. 5. Limitations This was a cross sectional study relying on self report of symptoms and could therefore be inaccurate. Although the study was conducted in the largest university in the country that admits students from diverse backgrounds in the country there could still be regional differences in other local universities. 6. Conclusion The study shows that depression affects a large number of students and identifies groups of students who may be more at risk of developing depressive illness, such as those in the first year of study or those who live outside the campus and students from poor family backgrounds. More studies are needed to explore the risks and how they can be minimized. Appropriate interventions could be put in place using such information. Role of funding source Self funded.
Conflict of interest None.
Acknowledgment To the students who participated in the study, the administration of the University of Nairobi, especially Registrar Academics for facilitating the study; Cherryl Ojjerro, Rachel Maina, Eston Nyakiya, Julius Oduor and Amelia Awoko who assisted with the data collection.
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