| dc.description.abstract | Background: More than half of the world’s refugees reside in non-camp settings, including urban areas. Refugees in urban areas often face acculturation challenges, stigma, overcoming stereotypes, and living in fear of being repatriated. Depression is one of the most frequent mental disorders experienced by refugee populations as a result of such challenges. In Uganda, the prevalence of mental disorders among urban refugees in general remains unknown and there is little epidemiological data to inform practice and policy in relation to the refugees’ mental health needs in urban areas. The aim of the present study was to examine the association between stigma and depression among urban refugees. Methods: Using snowball sampling method, we conducted a descriptive cross-sectional study among 343 refugees residing in Mbarara Municipality, Southwestern Uganda. The Discrimination and Stigma Scale and the Patient Health Questionnaire were used to assess stigma and depression respectively. Using SPSS, means, standard deviations and ranges were calculated to determine the prevalence of stigma and depression. Multiple regression analysis was used to examine the associations between stigma and depression. Results: Participants in our study experienced high levels of enacted stigma (n=293, 85%) and internalized stigma (n=239, 70%). Most of the participants experienced both internalized and enacted stigma (n=288, 84%). The overall prevalence of depression was 96% (n=329) of which 16% (n=53) was mild, 17% (n=59) was moderate, 41% (n=141) was moderately severe and 22% (n=76) was severe depression. There was a significant positive correlation between stigma and depression (β= 0.37, p<.001). Conclusions: Urban refugees experience high levels of both enacted and internalized stigma. There is a strong association between stigma and depression. Interventions aimed at reducing stigma could subsequently reduce depression among refugees living in urban areas. Background There is an increasing number of refugees who are choosing to settle in urban centers rather than refugee settlements, even when this leaves them without access to UNHCR support (1). The urban 2
refugees are a largely ‘hidden’ population, and little is known about their numbers, profiles, status, location and livelihoods (2). The main factors pushing refugees from camps include security threats, limited livelihood opportunities, harsh climatic conditions and violence in the camps, often related to tensions between different clans, ethnic and political groups (Pavanello, Elhawary, & Pantuliano, 2018). In Uganda, the refugee policy gives them (refugees) ‘freedom of movement’, ‘gainful employment’, and ‘treatment without discrimination nor stigmatization (4). This policy makes it easy for refugees to quit camps and settle in any part of the country including towns. Refugees in urban areas often face challenges of insufficient disposable income, housing, feeding and daily utilities. In addition, they face acculturation challenges, stigma, overcoming stereotypes, and living in fear of being repatriated (5). Furthermore, they commonly experience migration stress and trauma, loss of homes and livelihoods, violence, torture, and family separation (6). As such, it is no surprise that the prevalence of stigma, depression and post-traumatic stress disorder (PTSD), continue to be high among refugee populations (Baranik, Hurst, & Eby, 2018, Close et al., 2016). Stigma has been associated with poor health outcomes of refugees (9). It is characterized by cognitive, emotional, and behavioral components often conceptualized as internalized or enacted stigma affecting a particular trait, among individuals (10). Enacted stigma is the negative attitudes held by members of the public about devalued people whereas self-stigma occurs when people internalize those public attitudes and suffer numerous negative consequences as a result (11). Refugee status is a highly stigmatized driver which affects the health seeking behaviour of forcibly displaced populations (12). Lindert, Ehrenstein, Priebe, Mielck, & Brähler, (2009) reported stigma to be associated with higher levels of depression 44% in first generation Iraqi refugees in Canada compared to estimates of prevalence in the general population reported to be between 8 and 12% (8). Depression is a mood disorder that involves a persistent feeling of sadness and loss of interest. It is one of the most frequent mental disorders experienced by refugee populations as a result of war and living difficulties after migration (14). Negative mental health consequences are more common among refugees as a result of war and living difficulties after migration; however, there is a small body of research that has investigated the 3
stigma of being a refugee as an essential risk factor for the development of mental health problems in post-conflict societies, especially depression (15). Our study aimed to determine the prevalence of stigma and depression among urban refugees and to examine the association between stigma and depression among urban refugees in Mbarara municipality, Southwestern Uganda. We hypothesized that there would be high prevalence of stigma and depression and that stigma would positively correlate with depression among urban refugees in Southwestern Uganda. Methods Study Design, Population and Measures We conducted a descriptive cross-sectional study among 343 refugees residing in Mbarara Municipality, Southwestern Uganda using snowball sampling method between the months of May and November 2019. Our study participants were only those who had lived in Mbarara municipality for at least 12 months prior to the study and were aged 14 years and above. Would be participants with severe psychological disorders and identifiable symptoms of alcohol intoxication during the time of data collection were excluded. To determine our sample size, we adopted a 31% prevalence of stigma found by a study of Baranik et al., (2018) in a mixed methods study about the stigma of being a refugee, among Afghanistan refugees living in the US. The Discrimination and Stigma Scale (DISC-12) was used to measure stigma. To suit our sample, the scale was modified and the words “mental health problems” were substituted with words “refugee status”. The scale measures unfair treatment of people because they are seen to be different from others for any reason (16). Therefore, the substitution of words did not affect the validity of the scale. The scale consists of 34 items, four subscales and scores on a 4-point scale from 0 (not at all), 1 (a little), 2 (moderately) and 3 (a lot). For the current study we considered the first two sub scales of the DISC-12. Subscale 1 measured enacted stigma (Item 1–22) and subscale 2 measured internalized stigma (Item 23–26). A higher score indicated greater experience of stigmatization tendencies reported by a participant. The DISC -12 is reported consistent with a Cronbach’s alpha of 0.78 (17). In the present study the DISC-12 had 0.93 Cronbach’s alpha. The Patient Health Questionnaire (PHQ-9) was used to measure depression. The PHQ-9 is a brief, 4
easily administered and scored screening questionnaire that can be used to improve the recognition rate of major depression and facilitate treatment (18). An advantage of the questionnaire is its exclusive focus on the nine diagnostic criteria for the newly revised DSM-5 depressive disorders (19). The scale is up to a score of 27 with each item with options of not all (0), several days (1), more than half the days (2) and nearly every day (3). A score of 1 – 4 is interpreted as minimal depression, 5 – 9 mild depression, 10 – 14 moderate depression, and 15 – 19 moderately severe depression and 20 – 27 severe depression. Since its development, the PHQ-9 has established itself as a practical tool for use in assisting with “depression diagnoses, depression severity, and depression outcome”. The PHQ-9 is reported as “excellent” with a Cronbach’s alpha of 0.89 and 0.86 in the primary care and obstetrical clinical studies respectively (20). The PHQ-9 possessed a 0.91 Cronbach’s alpha in the present study. All instruments were directly administered to the participants in their own residence or places considered by both the research team and the selected participant as being safe and confidential. | en_US |
