Journal of Affective Disorders 171 (2015) 161–166

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Research report

Prevalence and determinants of depressive symptoms among university students in Ghana Kwaku Oppong Asante a,b,n, Johnny Andoh-Arthur c,d a

Discipline of Psychology, School of Applied Human Sciences, University of KwaZulu-Natal, Howard College Campus, Durban 4041, South Africa Department of Psychology, Regent University College of Science & Technology, Accra, Ghana c Faculty of Nursing, Sør-Trøndelag University College, Trondheim, Norway d Department of Psychology, University of Ghana, Legon, Accra, Ghana b

art ic l e i nf o

a b s t r a c t

Article history: Received 7 July 2014 Received in revised form 12 August 2014 Accepted 2 September 2014

Background: Over two million Ghanaians suffer from moderate to mild mental disorders but prevalence levels and determinants among university students remains fairly unknown. A better understanding of depression and its determinants is necessary in developing appropriate interventions in this population group. Method: A convenient sample of 270 students from a public university (132 males and 138 females) were interviewed using a questionnaire to record socio-demographic variables, HIV risk behaviours. Depressive symptoms were measured using Centre for Epidemiological Studies Short Depression Scale (CES-D 10). Multiple logistic regression was used to identify the determinants. Results: The mean age was 22 (SD ¼2.39). Using a cut-off point of 10 of the CES-D10, the overall prevalence of depression was 39.2%; with 31.1% of mild to moderate depression and 8.1% severe depressive symptoms. Significant predictors included lack of social support, religion not having an impact on life, heavy alcohol consumption and traumatic experiences such as being forced to have sex, physically and sexually abused as a child, and beaten by a sex partner. Limitations: Given the cross-sectional nature of the research, the findings are limited highlighting the need for further research. Also, relying on self-report of symptoms could have influenced the outcome. The use of a single university means that there could be regional differences in depression in other universities. Conclusion: Depression occurs in a significant number of students. An appropriate intervention must be implemented to help reduce the burden of depression, especially to those found to be at risk. & 2014 Elsevier B.V. All rights reserved.

Keywords: Depression Risk factors University students Ghana

1. Introduction Depression as a psychiatric disorder characterized by symptoms of persistent feelings of hopelessness, dejection, has been designated as the leading cause of disability and the fourth leading cause of total disease burden worldwide (World Health Organization report, 2002). depressive disorders often start at a young age; they reduce people's functioning and often are recurring (Marcus et al., 2012). Students' academic performance is known to be affected by depression (Blackman et al., 2005) and that a young adult psychological functioning (e.g., depression and anxiety) has also been connected to a youth's ability to perform academically (Blackman et al., 2005; Masten et al., 2005). There are also evidence to show that n Corresponding author at: Discipline of Psychology, School of Applied Human Sciences, University of KwaZulu-Natal, Howard College Campus, Durban 4041, South Africa. E-mail address: [email protected] (K. Oppong Asante).

http://dx.doi.org/10.1016/j.jad.2014.09.025 0165-0327/& 2014 Elsevier B.V. All rights reserved.

individual with depressive symptoms can be predisposed to diseases such as HIV infection, diabetes, and even death from suicide (Garlow et al., 2008; Pitpitan et al., 2012; Nduna et al., 2010). Despite these detrimental effects of depression on students, few studies in Ghana have addressed mental health problems in institutions of higher education. The prevalence of depression varies across cultures (Dorahy et al., 2000), with studies from developed countries reporting higher levels of depression compared to those from developing countries (Kessler and Bromet, 2013). In an extensive review of literature on the prevalence of depression among university students globally, Ibrahim et al. (2013) revealed that reported prevalence rates among students ranged from 10% to 85%. The authors of the same report suggested that depression rates as reported by students are far higher than those found in the general population (Ibrahim et al., 2013). Using the Centre for Epidemiological Studies Short Depression Scale (CES-D10), a study among undergraduate students in Nigeria found a prevalence rate of 32.2% (Peltzer et al., 2013).

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K. Oppong Asante, J. Andoh-Arthur / Journal of Affective Disorders 171 (2015) 161–166

An earlier study using a different instrument with a different sample of over 200 medical students found that 23.3% had probable depression (Aniebue and Onyema, 2008). Among Kenyan university students, moderate prevalence rate of 35.7% was found whilst 5.6% reported severe depressive symptoms (Othieno et al., 2014). An equally high level of depression was recorded by Ibrahim et al. (2012) in Egypt with 37% of the students scoring above the threshold for moderate depression. Depression among university students has been associated with various factors. Depression occurs more often in students with the following factors: gender female, higher levels of study/ age, lower socioeconomic status, stressful and traumatic situations such as posttraumatic stress and addictive behaviours such as higher alcohol consumption and tobacco use (Ibrahim et al., 2013; Othieno et al., 2014; Peltzer et al., 2013). Other factors associated with depression include poor academic performance, religiosity/ spirituality, and HIV risk behaviour such as substance use in the context of sex (Berry and York, 2011; Othieno et al., 2014; Peltzer et al., 2013; Agardh et al., 2012). Psychological distress in the general Ghanaian population is high, with 18.7% of the sample reported either moderate (11.7%) or severe (7.0%) psychological distress (Sipsma et al., 2013). Among university students, however, few studies in Ghana had measured depressive levels explicitly. For example, Atindanbila and Abasimi (2011) despite using the Beck Depression Inventory, did not state the levels of depression in their sample when examining the relationship between depression and coping strategies among students in the University of Ghana. Nevertheless, the authors indicated that 16.1% of the students showed signs of mild depression (Atindanbila and Abasimi, 2011). Similarly, Nyarko and Amissah (2014) used the BDI but did not reveal the prevalence of depression. The focus of their study was to examine possible relationship between cognitive distortions and depression among selected university students in Ghana. 1.1. Objectives The above literature shows that we are not fairly well informed of the prevalence of depression and its associated factors within the Ghanaian context. We aimed to assess the prevalence of depressive symptoms and to describe the determinants among a sample of university students in Ghana. The main research questions examined are: (1) what is the prevalence of depression among university students? and (2) what factors are associated with depression among university students in, Ghana? The findings of this study could inform interventions that could target university students who could be at risk for depressive symptoms.

2. Method 2.1. Participants and procedure Samples of 270 university students were conveniently selected from the Department of Psychology of a public university in the Greater Accra Region of Ghana. The sample consisted of 132 males and 138 females, and participation in the study included the following selection criteria: (a) a registered student, (b) voluntary participation in the study and (c) aged 18 years and above. On the days of data collection, any student present in any of the lecture rooms used for psychology lectures participated in the study. Students filled a written consent form, and data collection took place in the lecture rooms after a teaching session had ended in the absence of the researchers. Students were informed to drop the filled questionnaire in a box left in front of the lecture hall. To ensure anonymity, no form(s) of identifiers

were on the questionnaire and the participants were informed that participation was voluntary and they could withdraw from the study at any stage if they so desire. Ethical approval was obtained from the University of Ghana, after the Head of Department had given permission for the students to participate in the study. Data collection lasted for a period of 30 days. The participants did not receive any form of inducement or reimbursement. 2.2. Measures The questions used to access the variables in this study were structured and formulated based on the previous studies conducted on depressive symptoms among university students in both developed and developing countries. We assessed sociodemographic characteristics (gender, age, marital status, year of study, family background), depression, social support, substance use, traumatic experiences and HIV risky behaviours. 2.2.1. Socioeconomic/family status Socioeconomic/family status was measured by a single statement “How would you rate your family background”. Response options were 1 ¼quite poor (within the lowest 25%), 2 ¼not well off (within the 25–50% range), 3¼ quite well off (within the 50–75% range) and 4 ¼wealthy (within the top 25%). Students were subsequently divided into two groups: poorer (quite poor and not well off) and wealthier (quite well off and wealthy). 2.2.2. Depressive symptoms The Centre for Epidemiological Studies Short Depression Scale (CES-D10) which consisted of 10 questions was used to assess depressive symptoms of the participants. A cut-off point of 10 was set, and those who had scores of 11 and above were considered as having probable depression. A score of 11–20, and scores above 20 represented mild-moderate depression and severe depressive respectively. The CES-D10 has been used extensively in other countries in Sub-Saharan Africa (Othieno et al., 2014; Kilbourne et al., 2002; Peltzer et al., 2013), and had a strong reliability of 0.84 in the Ghanaian context (Utsey et al., 2014). A Cronbach alpha coefficient value of 0.72 was found for this study. 2.2.3. Social support The Multidimensional Scale Perceived Social Support (MSPSS) (Zimetet al., 1988) was used to measure perceived social support along three dimensions: from the family, friends and significant others in the form of a 12-item, self-administered questionnaire. The scale is rated on a 5-point Likert type ranging from 5 (strongly agree) to 1 (strongly disagree). The MSPSS have been found reliable in various different samples internationally including Ghana. Acceptable reliability coefficients have been reported in Ghanaian samples ranging from 0.80 to 0.91 for all the three dimensions (Doku, 2012). The overall Cronbach alpha coefficient for the present study was 0.89. 2.2.4. Traumatic experiences Participants were asked 4 questions including if they had been forced to have sex, sexually abused as a child, beaten by a sex partner and physically abused as a child. These questions were coded as yes/no. 2.2.5. HIV risk behaviours This was assessed with four (4) components of HIV risk namely having multiple sexual partners, protected/unprotected sexual intercourse, alcohol used in the context of sex, and having been diagnosed with an STI. Responses were coded as yes/no

K. Oppong Asante, J. Andoh-Arthur / Journal of Affective Disorders 171 (2015) 161–166

2.2.6. Alcohol consumption This variable was measured by asking participants how often they used alcohol in the past one month. Responses option ranged from 1¼ Never to 5¼daily or almost daily. Participants were subsequently divided into three groups: non-drinkers (never), occasional drinkers (3–4 times a month and once a month), and heavy episodic drinking (3 times or more a week). 2.3. Statistical analysis The questionnaires were checked for completeness and data was entered into Microsoft Excel 2007 spreadsheet. This was subsequently imported into SPSS software version 21, which was to conduct data analysis. The Chi-square (χ2) was used to examine any association between depression and the various explanatory variables. All variables which were statistically significant (po0.05) in the bivariate analysis were included into the logistical regression to

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estimate their impact on depression. The results from the logistic regression analyses are presented as odds ratios (OR) with 95% confidence intervals (CIs). Statistical significance was defined as a two-tailed p-valueo0.05 in all analyses.

3. Results The sample was made of 270 students (132 males and 138 females) with a mean age of 22 years (SD ¼ 2.39). Majority (98%) of the students were not married, and a third of the students were in first year. Over 87% of the students rated themselves as coming from families that were either wealthy or quite well off. Ninety per cent (90%) of the students were Christians, and about 76% considered religion to play a role in their life. Approximately three-quarters of the students lived in an urban area when growing up (Table 1).

Table 1 Socio-demographic factors and prevalence of depression among the sample. Variable

Total N or M

All Socio-demographic Age (years) Gender Male Female Year of study First Second Third year Fourth year Marital status Single Relationship Married Divorced Family background Wealthy Quite well off Not well off Quite poor Area lived growing up Urban Semi-urban Rural setting Religion Christian Muslim Other Social variables Social support Impact of religion on life Plays a major role Relatively important Not so important Not important at all Traumatic experiences Forced to have sex Sexually abused as a child Physically abused as a child Beaten by a sex partner Alcohol consumption Never used alcohol Occasional drinker Heavy episodic drinking HIV risk behaviours Multiple sexual partners Inconsistent condom Alcohol in the context of sex History of STI

Depression (mild-moderate) % or SD

270 21.56

2.39

p

Depression (severe)

N or M

% or SD

N or M

84

31.1

22

8.1

21.89

3.21

21.82

2.70

p

% or SD

132 138

48.9 51.1

44 40

39.3 33.1

0.663

10 12

8.9 9.9

0.670

91 41 79 58

33.8 15.2 29.4 21.6

31 12 25 16

41.3 30.0 38.5 30.2

0.014

9 4 7 2

12.0 10.0 10.8 3.8

0.153

200 62 5 1

74.6 23.1 1.9 0.4

61 19 3 0

36.1 33.3 75.0 0.0

o 0.001

19 2 1 0

11.1 3.5 25.0 0.0

o 0.001

40 190 29 4

15.2 72.3 11.0 1.5

17 57 8 1

43.6 36.1 28.6 50.0

o 0.001

3 15 4 0

7.7 9.5 14.3 0.0

0.002

190 51 23

72.0 19.3 8.7

59 15 3

36.4 32.6 42.1

o 0.001

14 6 1

8.6 13.0 5.3

o 0.001

244 20 6

90.4 7.4 2.2

79 4 1

37.6 22.2 20.0

o 0.001

17 4 1

8.1 22.2 20.0

o 0.001

41.9

8.9

40.54

8.41

41.42

0.002

8.09

196 46 11 4

76.3 17.9 4.2 1.6

66 12 3 2

38.2 30.0 30.0 50.0

o 0.001

12 8 0 1

6.9 20.0 0.0 25.0

0.012

74 64 82 66

27.4 23.7 30.4 24.4

40 32 44 35

57.1 52.5 56.4 58.3

0.025 0.059 0.015 0.127

18 17 19 12

25.7 27.9 24.4 20.0

0.003 0.011 o 0.001 0.671

192 47 14

75.9 18.6 5.5

60 17 3

35.9 37.0 30.0

o 0.001

16 2 3

9.6 4.3 30.0

o 0.001

72 147 92 74

26.7 54.4 34.1 27.4

16 46 29 23

29.6 34.8 37.7 37.1

0.018 0.002 0.005 o 0.001

5 16 7 6

9.3 12.1 9.1 9.7

0.554 0.003 0.088 0.033

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With regards to depression, 39.2% of the students scored above the cut-off point of 10 on the CES-D scale, with 31.1% having mild to moderate depressive symptoms and 8.1 having severe depressive symptoms. More males had depressive symptoms compared to females, but this difference was not large enough to yield a statistical significance. Depression levels also varied according to the year of study. The highest level was recorded in the first year followed by those in the third year. Although there were only 82 students in our study who reported to have been physical abused as a child, nearly all of them have some form of depressive symptoms (58.3% – mild to moderate, and 24.4% – severe) (Table 1). In Table 2, results from logistic regression model on factors associated with depression among students are presented. In the bivariate analyses age, lack of social support, heavy episodic drinking and having experienced traumatic events such as physical and sexual abuse were associated with depression. In the multivariate analyses, after controlling for demographic factors, lacking support, heaving episodic drinking, having been forced to have sex, having been abused physically and sexually as a child, and having been beaten by a sexual partner were found to be associated with depression. Table 2 Odds ratios (OR) and their 95% confidence intervals (CI) for factors associated with depression. Variable

Crude odds ratio (95% CI)

Adjusted odds ratio (95% CI)

1.08(0.96–1.21)



– 0.81(0.48–1.36)

– 0.96(0.53–1.77)

1.71(0.79–3.73) – 1.46(0.66–3.23) 0.77(0.33–1.81)

2.29(0.93–5.67) – 1.33(0.56–3.20) 0.42(0.15–1.18)

1.33(0.74–2.40) –



1.42(00.62–3.24) –

1.15(0.53–2.49)

Urban Semi-urban Rural setting Religion

0.93(0.32–2.72) 0.91(0.35–2.36) –

1.08(0.34–3.46) 1.05(0.37–2.99)

Christian Muslim Other Social variables Social support Impact of religion on life

1.20(0.16–7.01) 1.26(0.21–7.72) –

1.45(0.23–9.12) 1.35(0.18–10.67)

0.96(0.93–0.99)*

0.94(0.91–0.96)*

Plays a major role Relatively important Not so important Not important at all Traumatic experiences

0.27(0.03–2.68) 0.33(0.04–3.48) 0.14(0.01–2.68) –

1.21(0.61–2.14) 0.52(0.31–2.09) 1.65(1.37–5.83)*

Forced to have sex Sexually abused as a child Physically abused as a child Beaten by a sex partner Alcohol consumption

11.58(5.71–23.48) * 8.69(4.28–17.68) * 10.94(5.63–21.25) * 6.99(3.50–13.93) *

9.87(4.87–20.43) * 7.23(3.49–14.99) * 9.39(4.72–18.70) * 6.22(3.10–12.91) *

Occasional drinker Heavy episodic drinking HIV risk behaviours Multiple sexual partners

0.84(0.44–1.63) 1.80(1.49–6.59) *

0.80(0.41–1.78) 1.58(1.39–6.05)

0.70(0.35–1.39) 0.93(0.49–1.77) 1.08(0.62–1.87) 0.70(0.59–1.92)

0.67(0.32–1.42) 0.74(0.36–1.53) 1.08(0.60–1.96) 1.19(0.63–2.23)

Socio-demographic Age (years) Gender Male Female Year of study First Second Third year Fourth year Marital status Single Relationship/married/divorce Family background Wealthier Poorer Area lived growing up

Inconsistent condom Alcohol in the context of sex History of STI n

Denotes significance at 5%.

*

4. Discussion This study was conducted to examine the prevalence and determinants of depression among university students in Ghana. This study found among a sample of university students a 31.1% of mild to moderate depression and 8.1% severe depressive symptoms. The prevalence of depression as found in this study is comparable to the rates found in other studies (Othieno et al., 2014; Ibrahim et al., 2013) but higher than those rates found in university students in West Africa (Peltzer et al., 2013; Aniebue and Onyema, 2008; Adewuya et al., 2006). The high prevalence rate also reflects those found in the large study in Ghana where 21% of adults surveyed had moderate to severe psychological distress (Canavan et al., 2013). According to the WHO (2011), over 2 million Ghanaians suffer from moderate to mild mental disorders and 650,000 suffer from severe illness. The relatively high prevalence rate found among the student sample could lend some support to the assertion made by the Kintampo Health Research Centre which has revealed that about 80% Ghanaians might be suffering from different forms of depression (Kintampo Medical Research Centre, 2012). In this study, severe depression was reported in 8.1% (8.9% males and 9.9% females) which is higher than the one reported in study of depression among a large sample of students enroled in Kenyan and Chinese universities (Chen et al., 2013; Othieno et al., 2014). Unlike what have been reported elsewhere (Adewuya et al., 2006), the gender difference was not statistically significant. Factors such as the type of sample and other variables could have confounded the results. However, studies carried out by researchers among university students in Nigeria and Kenya, reported that the difference between males and females scoring Z10 on the CES-D scale was not significant (Peltzer et al., 2013; Othieno et al., 2014). As found in other studies (Chen et al., 2013, Peltzer et al., 2013; Ibrahim et al., 2012, 2013), this study did not find any age and socioeconomic status differences in depression prevalence. It could be possible that the measurement of socioeconomic status was not sensitive enough, as majority of the students reported that they were from families that are either wealthy or quite well-off. It terms of social factors, the study also revealed that social support and considering religion as having an impact on one's life were found to be protective of depression. This supports previous studies that identified religiosity and social support as protective factors for depression among college students (Peltzer et al., 2013; Berry and York, 2011). Reports of traumatic events including childhood abuse and gender-based violence, and heavy alcohol consumption were identified to be associated with depression. Similar findings were found in previous studies (Gelaye et al., 2009; Peltzer, 2003). Determining the association between experiences of sexual abuse and later outcomes for psychological distress such as depression, anxiety, trauma, is not straightforward (Cashmore and Shackel, 2013). This relationship has been discussed from two main perspectives. One school of thought argues that childhood sexual abuse precedes other mental health problems including depression, anxiety, stress, dissociation, guilt, shame, self-blame, repression, eating disorders, somatic concerns, suicidal ideation and behaviours, sexual problems, and relationship issues (Cashmore and Shackel, 2013; Hall and Hall, 2011). For instance, people with history of traumatic experiences including physical and sexual childhood abuse have reported elevated levels of depression (Penza, Heim, and Nemeroff, 2003). This perspective thus indicates that childhood sexual abuse may increase the risk factor for depression throughout the lifespan, as abuse experiences negatively influence both biological and psychological response to stress (Weiss et al., 1999). Others have suggested that depression serves as an increase risk factor for sexual abuse in male and

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female, an indication that individuals with depressive symptoms are more likely to be forced into unwanted sexual activity (NolenHoeksema, 2001). Our findings seems to confirm the former proposition, which suggests that reported traumatic experiences including childhood sexual abuse may serve as a risk factor to the mental health problems, particularly depression (Gelaye et al., 2009; Penza et al., 2003). In the present study, it is unclear whether university students with probable depressive symptoms had experienced childhood abuse or the symptoms are as a result of a “third variable” such as the social environment. It may as well be that the transition from adolescence to young adulthood may have contributed to depression given the awareness that the transition from adolescence to adulthood is associated with stressful events and many adaptation experiences that may increase symptoms of depression among students (Dyson and Renk, 2006). A combination of both risk factors: social environment and transition into young adulthood, on the occurrence of the depressive symptoms may also be a possibility. Further studies that would explore these pathways clearly will shed light on the relationships between traumatic experiences and depressive symptoms among university students. Studies from sub-Saharan Africa which would examine the contextual dynamics would be of colossal value. This finding calls for an integrated intervention for traumatic experience, alcohol consumption and depression among these university students. Such interventions, must target at risk groups that have the possibility of been diagnosed with clinical depression. Unlike in some other studies (Adewuya et al., 2006; Agardh et al., 2012; Peltzer, 2003), this study did not reveal any association between HIV risk behaviours and depression.

5. Limitations The findings of this study must be interpreted cautiously, as several issues might have introduced bias in this study, primarily the cross-sectional design used for this study. The cross-sectional nature of the research means that cause—and—effect relationship cannot readily be established; however, a cross-sectional study has the advantage of being able to study a large group of people at a single point in time, and thus evaluate prevalence. A crosssectional study is also able to identify correlates and predicts associations. Again only full-time undergraduate students at one university were included and therefore caution should be taken when interpreting the findings and generalizing them to other populations. Also, the study relied on self-report data which could have been subject to social desirability bias. The instrument used in this study could not diagnose depression but only screened for the presence of depressive symptoms. Thus, a proper clinical interview would be required as a follow-up to actually diagnose depression in those identified as having depressive symptoms.

6. Conclusion In conclusion, moderate to severe rates of depression were found among the studied students population. Traumatic experiences including childhood abuse and gender-based violence, lack of social support, and heavy alcohol consumption were identified as risk factors for depression, and should be considered when designing intervention. This should be done with consultation with the student counselling centres, which are predominantly found on university campuses, to enhance a coordinated mental health services for students. Such intervention must target students, especially heavy alcohol drinkers as well as those with traumatic past experiences including both physical and sexual

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abuse. A proper clinical diagnosis would be necessary to help identify those with probable depressive symptoms.

Conflict of interest All authors report no conflicts of interest.

Role of funding source Self-funded.

Acknowledgement We are very grateful to the students who participated in the study.

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Prevalence and determinants of depressive symptoms among university students in Ghana.

Over two million Ghanaians suffer from moderate to mild mental disorders but prevalence levels and determinants among university students remains fair...
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