Depressive Symptoms, Alcohol and Drug Use, and Physical and Sexual Abuse Among Men Who Have Sex with Men in Kisumu, Kenya: The Anza Mapema Study
Men who have sex with men (MSM) are disproportionately burdened by depressive symptoms and psychosocial conditions including alcohol and substance abuse as well as physical and sexual abuse. We examined sociodemographic and psychosocial factors associated with depressive symptoms at baseline among a cohort of MSM in Kisumu, Kenya. Depressive symptoms were assessed via the Personal Health Questionnaire 9 instrument and examined dichotomously. We performed multivariable modified Poisson regression with robust standard errors for the binary outcome. Among 711 participants: 11.4% reported severe depressive symptoms; 50.1% reported harmful alcohol abuse; 23.8% reported moderate substance abuse; 80.9% reported any childhood physical or sexual abuse; and 39.1% experienced recent trauma due to same-sex behaviors. In the final multivariable model, severe depressive symptoms were more common for men who were ≥ 30 years old, had completed ≤ 8 years of education, had experienced childhood physical or sexual abuse, and had recently experienced trauma due to same-sex behaviors. Our results demonstrate that comprehensive services capable of identifying and addressing depressive symptoms, alcohol and substance abuse, and physical and sexual abuse must be expanded within this sample of MSM.
KeywordsDepressive symptoms Psychosocial conditions Men who have sex with men MSM Kenya
The authors would like to thank the men of the Anza Mapema Study. Special thanks also go to all research and staff members of the Anza Mapema Study and the Nyanza Reproductive Health Society including Leah Osula, Beatrice Achieng, George N’gety, Caroline Oketch, Violet Apondi, Evans Kottonya, Caroline Agwanda, Ted Aloo, George Oloo, Caroline Obare, Eve Obondi, and Edmon Obat, as well as Donath Emusu, Boaz Otieno Nyunya, and Gaston Djomand. We thank the Centers for Disease Control and Prevention (U01GH000762) and the Evidence for HIV Prevention in Southern Africa (MM/EHPSA/NRHS/0515008) for providing financial support for the Anza Mapema Study. Finally, we thank Dr. Ross Slotten and the Slotten Scholarship in Global Health at the University of Illinois at Chicago for supporting this work.
The Anza Mapema Study was supported through funding provided by the Centers for Disease Control and Prevention (U01GH000762) and by Evidence for HIV Prevention in Southern Africa (MM/EHPSA/NRHS/0515008).
Compliance with Ethical Standards
Conflicts of interest
The authors declare that they have no conflict of interest.
All procedures performed in the Anza Mapema Study involving human participants were in accordance with the ethical standards of the Maseno University Ethics Review Committee, the Institutional Review Board of the University of Illinois at Chicago, and the Human Subjects Division of the University of Washington.
Trained research personnel reviewed all consent materials with the participant and answered any questions related to the Anza Mapema Study. Written informed consent was obtained from all participants enrolled in the Anza Mapema Study.
- 2.National AIDS Control Council (NACC). Kenya HIV estimates-June 2014. Nairobi, Kenya: Ministry of Health; 2014. http://healthservices.uonbi.ac.ke/sites/default/files/centraladmin/healthservices/HIV%20estimates%20report%20Kenya%202014.pdf.
- 3.National AIDS Control Council (NACC). Kenya HIV county profiles. Nairobi, Kenya: Ministry of Health; 2014. http://nacc.or.ke/wp-content/uploads/2015/10/KenyaCountyProfiles.pdf.
- 5.Kimanga DO, Ogola S, Umuro M, et al. Prevalence and incidence of HIV infection, trends, and risk factors among persons aged 15–64 years in Kenya: results from a nationally representative study. JAIDS. 2014;66(Suppl 1):S13–26. https://doi.org/10.1097/QAI.0000000000000124.PubMedPubMedCentralGoogle Scholar
- 6.National AIDS Control Council (NACC). Kenya HIV prevention response and modes of transmission analysis: final report. Nairobi, Kenya: Ministry of Health; 2009. http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1103037153392/KenyaMOT22March09Final.pdf.
- 11.Heusser S, Elkonin D. Childhood sexual abuse and HIV sexual-risk behaviour among men who have sex with men in South Africa. S Afr J Psychol. 2014;44(1):83–96.Google Scholar
- 16.Stahlman S, Sanchez TH, Sullivan PS, et al. The prevalence of sexual behavior stigma affecting gay men and other men who have sex with men across sub-Saharan Africa and in the United States. JMIR Public Health Surveill. 2016;2(2):e35. https://doi.org/10.2196/publichealth.5824.CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Mimiaga MJ, Biello KB, Robertson AM, et al. High prevalence of multiple syndemic conditions associated with sexual risk behavior and HIV infection among a large sample of Spanish- and Portuguese-speaking men who have sex with men in Latin America. Arch Sex Behav. 2015;44(7):1869–78. https://doi.org/10.1007/s10508-015-0488-2.CrossRefPubMedGoogle Scholar
- 23.Mimiaga MJ, OʼCleirigh C, Biello KB, et al. The effect of psychosocial Syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men. J Acquir Immune Defic Syndr. 2015;68(3):329–36. https://doi.org/10.1097/QAI.0000000000000475.CrossRefPubMedPubMedCentralGoogle Scholar
- 32.Pew Research Center. Global views on morality: Kenya. 2014. http://www.pewglobal.org/2014/04/15/global-morality/country/kenya/.
- 33.Kenya National Commission on Human Rights (KNCHR). The outlawed amongst us: a study of the LGBT community’s search for equality and non-discrimination in Kenya. Nairobi, Kenya: Kenya National Commission on Human Rights; 2011. http://www.khrc.or.ke/mobile-publications/equality-and-anti-discrimination/70-the-outlawed-amongst-us/file.html.
- 34.Human Rights Watch. The issue is violence: attacks on LGBT people on Kenya’s Coast. United States: Human Rights Watch; 2015. http://www.hrw.org/report/2015/09/28/issue-violence/attacks-lgbt-people-kenyas-coast.
- 36.Tucker A, Liht J, de Swardt G, et al. Homophobic stigma, depression, self-efficacy and unprotected anal intercourse for peri-urban township men who have sex with men in Cape Town, South Africa: a cross-sectional association model. AIDS Care. 2014;26(7):882–9. https://doi.org/10.1080/09540121.2013.859652.CrossRefPubMedGoogle Scholar
- 39.Charlson FJ, Diminic S, Lund C, Degenhardt L, Whiteford HA. Mental and substance use disorders in Sub-Saharan Africa: predictions of epidemiological changes and mental health workforce requirements for the next 40 years. PLoS ONE. 2014;9(10):e110208. https://doi.org/10.1371/journal.pone.0110208.CrossRefPubMedPubMedCentralGoogle Scholar
- 44.Kenya National Commission on Human Rights (KNCHR). Silenced minds: the systemic neglect of the mental health system in Kenya. Nairobi, Kenya: Kenya National Commission on Human Rights; 2011. http://www.knchr.org/Portals/0/EcosocReports/THE_%20MENTAL_HEALTH_REPORT.pdf.
- 45.National Academies of Sciences, Engineering, and Medicine. Providing sustainable mental and neurological health care in Ghana and Kenya: workshop summary. Washington, DC: The National Academies Press; 2016. 10.17226/21793.
- 46.World Health Organization (WHO). Treat all people living with HIV, offer antiretrovirals as additional prevention choice for people at “substantial” risk. Geneva, Switzerland: World Health Organization; 2015. http://www.who.int/mediacentre/news/releases/2015/hiv-treat-all-recommendation/en/.
- 47.World Health Organization (WHO). HIV/AIDS and mental health. Geneva, Switzerland: World Health Organization; 2008. http://apps.who.int/gb/archive/pdf_files/EB124/B124_6-en.pdf.
- 48.Plenty A. Men’s health study: a cross sectional study of HIV among men who have sex with men in Kisumu, Kenya [Thesis on the internet]. Chicago, IL: University of Illinois at Chicago; 2012. http://indigo.uic.edu/bitstream/handle/10027/9323/Plenty_Albert.pdf?sequence=1.
- 49.NOVA Research Company. Questionnaire Development Software (QDS). Silver Spring, Maryland. http://www.novaresearch.com/qds/.
- 53.Bhana A, Rathod SD, Selohilwe O, Kathree T, Petersen I. The validity of the patient health questionnaire for screening depression in chronic care patients in primary health care in South Africa. BMC Psychiatry. 2015;15:118. https://doi.org/10.1186/s12888-015-0503-0.CrossRefPubMedPubMedCentralGoogle Scholar
- 56.Kehbila J, Ekabe CJ, Aminde LN, Noubiap JJ, Fon PN, Monekosso GL. Prevalence and correlates of depressive symptoms in adult patients with pulmonary tuberculosis in the Southwest Region of Cameroon. Infect Dis Poverty. 2016;5(1):51. https://doi.org/10.1186/s40249-016-0145-6.CrossRefPubMedPubMedCentralGoogle Scholar
- 60.Omoro SAO, Fann JR, Weymuller EA, Macharia IM, Yueh B. Swahili translation and validation of the patient health questionnaire-9 depression scale in the Kenyan head and neck cancer patient population. Int J Psychiatry Med. 2006;36(3):367–81. https://doi.org/10.2190/8W7Y-0TPM-JVGV-QW6M.CrossRefPubMedGoogle Scholar
- 62.Kroenke K, Spitzer RL, Williams JB, Lowe B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345–59. https://doi.org/10.1016/j.genhosppsych.2010.03.006.CrossRefPubMedGoogle Scholar
- 64.Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The alcohol use disorders identification test. Geneva, Switzerland: World Health Organization; 2001. http://apps.who.int/iris/bitstream/10665/67205/1/WHO_MSD_MSB_01.6a.pdf.
- 68.Luchters S, Geibel S, Syengo M, et al. Use of AUDIT, and measures of drinking frequency and patterns to detect associations between alcohol and sexual behaviour in male sex workers in Kenya. BMC Public Health. 2011;11:384. https://doi.org/10.1186/1471-2458-11-384.CrossRefPubMedPubMedCentralGoogle Scholar
- 74.RAND Corporation. Social support survey instrument scoring instructions: how to score the survey. http://www.rand.org/health/surveys_tools/mos/social-support/scoring.html.
- 76.Smith N, Lam D, Bifulco A, Checkley S. Childhood experience of care and abuse questionnaire (CECA.Q): validation of a screening instrument for childhood adversity in clinical populations. Soc Psychiatry Psychiatr Epidemiol. 2002;37(12):572–9. https://doi.org/10.1007/s00127-002-0589-9.CrossRefPubMedGoogle Scholar
- 79.Betron M, Gonzalez-Figueroa E. Gender identity and violence in MSM and transgenders: policy implications for HIV services. Washington, DC: Futures Group International, US Agency for International Development Health Policy Initiative, Task Order I; 2009. http://pdf.usaid.gov/pdf_docs/Pnadu585.pdf.
- 80.Betron M. Screening for violence against MSM and transgenders: report on a pilot project in Mexico and Thailand. Washington, DC: Futures Group International, US Agency for International Development Health Policy Initiative, Task Order I; 2009. http://pdf.usaid.gov/pdf_docs/Pnadu587.pdf.
- 81.Egremy G, Betron M, Eckman A. Identifying violence against most-at-risk populations: a focus on MSM and transgenders. Training manual for health providers. Washington, DC: Futures Group International, US Agency for International Development Health Policy Initiative, Task Order I; 2009. http://www.k4health.org/sites/default/files/Identifying_Violence_Against_Most_At_Risk_Populations.pdf.
- 83.Chen W, Shi J, Qian L, Azen SP. Comparison of robustness to outliers between robust poisson models and log-binomial models when estimating relative risks for common binary outcomes: a simulation study. BMC Med Res Methodol. 2014;14:82. https://doi.org/10.1186/1471-2288-14-82.CrossRefPubMedPubMedCentralGoogle Scholar
- 87.Stata Corporation. College Station, Texas, USA. http://www.stata.com/.
- 88.Stoloff K, Joska JA, Feast D, et al. A description of common mental disorders in men who have sex with men (MSM) referred for assessment and intervention at an MSM clinic in Cape Town, South Africa. AIDS Behav. 2013;17(Suppl 1):S77–81. https://doi.org/10.1007/s10461-013-0430-3.CrossRefPubMedGoogle Scholar
- 92.United Nations Children’s Fund (UNICEF) Kenya Country Office, Centes for Disease Control and Prevention (CDC), Kenya National Bureau of Statistics (KNBS). Violence against children in Kenya: findings from a 2010 national survey. Summary report on the prevalence of sexual, physical and emotional violence, context of sexual violence, and health and behavioral consequences of violence experienced in childhood. Nairobi, Kenya: 2012. http://www.unicef.org/esaro/VAC_in_Kenya.pdf.
- 93.Springer KW, Sheridan J, Kuo D, Carnes M. Long-term physical and mental health consequences of childhood physical abuse: results from a large population-based sample of men and women. Child Abuse Negl. 2007;31(5):517–30. https://doi.org/10.1016/j.chiabu.2007.01.003.CrossRefPubMedPubMedCentralGoogle Scholar
- 94.Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9(11):e1001349. https://doi.org/10.1371/journal.pmed.1001349.CrossRefPubMedPubMedCentralGoogle Scholar
- 96.Schilder AJ, Anema A, Pai J, et al. Association between childhood physical abuse, unprotected receptive anal intercourse and HIV infection among young men who have sex with men in Vancouver, Canada. PLoS ONE. 2014;9(6):e100501. https://doi.org/10.1371/journal.pone.0100501.CrossRefPubMedPubMedCentralGoogle Scholar
- 98.Finerty CE. Being gay in Kenya: the implications of Kenya’s new constitution for its anti-sodomy laws. Cornell Int Law J. 2012;45(2):431. http://www.lawschool.cornell.edu/research/ILJ/upload/Finerty-final-version.pdf.
- 101.National Campaign Against Drug Abuse (NACADA). Rapid situation assessment of the status of drug and substance abuse in Kenya, 2012. Nairobi, Kenya; 2012. http://scadkenya.files.wordpress.com/2017/01/rapid-assessment-drug-and-substance-abuse-situation-kenya-20122.pdf.
- 102.Republic of Kenya (ROK). The mental health bill, 2014. Kenya Gazette Supplement No. 61 (National Assembly Bills No. 22). 22 April 2014;2523. http://kenyalaw.org/kl/.
- 103.Jenkins R, Kiima D, Okonji M, Njenga F, Kingora J, Lock S. Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability. Matern Health Fam Med. 2010;7(1):37–47.Google Scholar
- 105.Office of the Press Secretary. Remarks by president Obama and president Kenyatta of Kenya in a press conference. 25 July 2015. http://obamawhitehouse.archives.gov/the-press-office/2015/07/25/remarks-president-obama-and-president-kenyatta-kenya-press-conference.