Prevalence and factors associated with major depression among female sex workers in post-conflict Gulu district: a cross-sectional study

Depression is the leading cause of disability and a major contributor to the overall global burden of disease [1]. By 2017, depression was affecting more than 300 million people worldwide [1]. In addition, depression accounts for 32·4% of years lived with disability and 13·0% of disability-adjusted life-years [2]. Individuals with depression incur very high financial costs in terms of treatment, morbidity, and mortality. The annual cost per case of depression is in the range of £3500–£6600 [3]. Depression is a spectrum of chronic disorders with several sub-categories ranging from major depression (MD) to dysthymia [4]. MD, which is the subject of this study, is characterized by depressed mood, loss of interest and enjoyment, and decreased energy and can be graded as mild, moderate, or severe depending on the numbers and severity of symptoms [4].

A recent meta-analysis revealed the need for more studies on MD among female sex workers (FSWs) in the low- and middle-income countries (LMICs) since MD among FSWs in the LMICs remains understudied [5]. The same report indicates that the magnitudes of MD among FSWs vary across countries with the highest prevalence being among FSWs in Jamaica [93.3%] and the lowest prevalence being among FSWs in Bangladesh (4. 2%] [5]. In Kampala, the capital city of Uganda, 43.2% of FSWs have MD [6]. In conflict-affected settings, there are only a handful of studies on MD among FSWs. Yet the negative socio-economic impacts of conflicts and the traumatic life events in conflict settings [7, 8] are well known to increase the risk of MD. A study among Nepalese FSWs points to a very high prevalence of MD (82.4%) in post-conflict settings [9]. Besides conflict, several other factors like chronic physical illnesses, traumatic life events, loss of loved ones, social adversity, extreme poverty, and female gender all can lead to MD [10, 11]. Specifically, the risk factors of MD among FSWs include exposures to various forms of gender-based violence (GBV), psychological and physical burden of sex work [12, 13], as well as alcohol and drug use [14]. The risk of MD among FSWs in Uganda is even greater because of the illegality of sex work [15] that can lead to stigma, workplace violence, GBV, and depression among FSWs.

If left untreated, MD can lead to profound disability, suicide, and other indirect deaths through causing or worsening of physical illnesses [16]. In addition, poorly treated MD can lead to a reduction in sexual satisfaction [17]. Meanwhile, the use of anti-depressants to treat MD can also lead to sexual dysfunction [18]. Moreover, untreated MD among FSWs can impede the progress made towards HIV prevention because it can lead to a reduction in condom use [19]. Likewise, the HIV-positive FSWs with MD are more likely to have poor adherence to their antiretroviral therapy (ART) with resultant unsuppressed viral load and subsequent transmission of HIV infections to their clients or children [20]. To make matters worse, HIV-negative FSWs with MD may have diminished ability to negotiate for safer sex with their clients and become victims of sexual violence like rape and other risky sexual behaviors [21]. Nevertheless, prevention of MD through raising awareness about mental health, early diagnosis, and management can be cost-saving [22]. To generate information needed by the Ugandan health system for the development of robust mental health interventions for FSWs, we aimed to determine the prevalence and the factors associated with MD among FSWs in the post-conflict Gulu district in Northern Uganda.

Almost half (47.7%) of FSWs in the district had MD. The current magnitude of MD is well above that: in the general population (24.7%) in Gulu [32], among women in the district (29.2%) [32], among FSWs in Southern India (29%) [33], among FSWs in China (31%) [34], and in the general population (10.8%) in conflict-affected settings [35]. However, the current prevalence of MD is comparable to the prevalence of MD among men who have sex with men in Tanzania (46.3%) [36] and the prevalence of MD in the general population in post-conflict South Sudan (50%) [7]. Most FSWs with MD (91.0%) had either severe (50.4%) or moderate (40.5%) depressive symptoms. A similar severity of MD was recorded in the US whereby 89.2% of cases of MD had either severe (49.5%) or moderate (39.7%) depressive symptoms [30]. Moreover, up to 91.0% of FSWs with MD in Gulu require anti-depressants as recommended [35]. This high magnitude of moderate-to-severe cases of MD is a wake-up call to the Ministry of Health and health programmers to urgently develop mental health interventions that screen, prevent, and treat MD among FSWs in the country. In addition, since MD is associated with risky sexual behaviors like condom-less sex, stakeholders need to integrate interventions targeting MD within the existing sexual reproductive health services for FSWs.

Several factors were found to increase the odds of MD among FSWs. Importantly, the odds of MD among FSWs with life stress were 11 times higher than that among FSWs without life stress. This is because, in conflict-affected settings, women are more exposed to life stress since they are the primary caretakers of families and the greatest victims of the conflicting parties [35]. Specifically, the FSWs may get stress from sex work-related violence and the constant fear of being arbitrarily arrested by the police [37]. The current finding is in agreement with a previous report showing that life stress can lead to depression mediated through several biological and social factors like coping strategies [38]. Thus, health programmers should screen FSWs for life stress to ensure early detection of stress. In addition, mental health programmers need to build the capacity of FSWs to cope with life stress and mitigate their vulnerability to MD. It is worth noting that almost nine out of every ten (89.7%) FSWs joined sex work because of poverty. It is well known that many FSWs suffer from depression due to poverty [5]. FSWs who live in poverty are at higher risk of exposure to life stress and need economic empowerment programs. In addition, FSWs who were verbally abused by their clients were almost three times more likely to suffer from MD. This finding is in agreement with studies among FSWs in India [33] and transgender Latinos in Los Angeles [39]. In a country like Uganda where verbal abuse towards FSWs is common [40], FSWs are at higher risk of MD due to acute stress reactions, psychological distress, and anxiety that follows verbal abuse [41]. Further analysis also revealed that FSWs living with HIV were almost three times more likely to suffer from MD than their HIV-negative counterparts. This is in line with a systematic review showing that MD is prevalent among people living with HIV in East Africa [42]. The high prevalent of MD among people living with HIV is not unique to FSWs and is mediated through multiple HIV-related factors like opportunistic infection, perceived HIV-related stigma, hospitalization, and food insecurity among people living with HIV [42]. This increased risk of MD among FSWs living with HIV is alarming because an HIV-positive FSW with MD is unlikely to adhere well to ART resulting in unsuppressed viral load and transmission of HIV infections to clients or infants [20, 43]. Therefore, the Ministry of Health and the health care programmers should consider setting up interventions that provide counseling to FSWs living with HIV to address the several HIV-related factors that put them at greater risk of MD. Lastly, study findings revealed that the odds of MD increase with the participant’s age. This agrees with previous findings from conflict-affected Sri Lanka and other conflict-affected settings [10, 35]. However, in the general population in non-conflict settings, the occurrence of MD did not differ with age [44]. In addition, further analysis indicated that numbers of past pregnancies (r = 0.50) showed collinearity with age. The effect of age on MD could be due to the increasing burdens associated with pregnancies and their outcomes on the lives and work of FSWs. Thus, the ministry of health and the health care programmers need to provide targeted mental health prevention programs that best address the mental health needs of the older FSWs. Besides, the presence of multiple factors associated with MD among FSWs underlines the urgent need for multiprong mental health interventions for the FSWs operating in post-conflict settings.

Conversely, FSWs who provided sexual services from the clients’ homes had lower odds of MD. To the best of our knowledge, no previous study ever reported on the relationship between provision of sexual services from the clients’ homes and MD. However, a Canadian study on the relationship between place of sex work and mental illnesses reported that FSWs who provided sexual services in the outdoor/public spaces and the informal indoor spaces were at an increased risk of mental health problems [45]. We postulate that the decrease in GBV among FSWs who provide sexual services from the clients’ homes [40] may be responsible for the reduction in the odds of MD in this sub-group of FSWs. However, there is a need for further studies to understand the exact relationship between MD and specific places of sex work. Secondly, we noted that the use of a non-barrier family planning method significantly reduces the odds of MD among FSWs. Perhaps this is possible because an effective family planning method is known to protect FSWs against unintended pregnancies that would otherwise come with a lot of anxieties and several negative consequences on the life and work of FSWs. This finding agrees with one previous study reporting a reduction of MD among women using family planning [46]. However, others studies did not find any relationship between the use of a family planning method and MD [47, 48]. Yet another study reported mixed outcomes depending on the type of contraception used [49]. Thus, there is a need for more robust longitudinal studies to understand this phenomenon better. Lastly, daily intake of alcohol also reduced the odds of MD among FSWs. At a low level, alcohol may relieve MD symptoms among FSWs because the social nature of alcohol intake can act as a coping strategy against sex work-related stress [50]. However, two longitudinal studies did not find any effect of alcohol on the occurrence of MD [51, 52]. Therefore, much as alcohol appears to reduce MD risk in this study, current finding should be interpreted with caution since alcohol use is known to predispose FSWs to condomless sex [53] that exposes them to sexually transmitted infections, unwanted pregnancy, and induced abortion. Further, chronic and excessive alcohol intake can lead to mental disorders like suicide [54], depression, dementia [55], and can lead to non-recovery from mental disorders [56]. Thus, there is a need for robust studies to understand any causal relationship between MD and alcohol use.

This current study underscores the high magnitude of MD driven by multiple sex work-related factors like the presence of a psychosocial stressor, living with HIV, experiencing verbal abuse from clients, and older age. The high magnitude of MD cases poses significant public health ramifications at the individual and societal levels. Therefore, there is a need for urgent interventions from the government, the development partners, other health care programmers to address the mental health needs of FSWs in the post-conflict Gulu and beyond. These mental health services may take the form of screening, diagnosis, counseling, and treatment.