Methods: We conducted a community-based study with a respondent driven sample of refugee and displaced youth aged 16-24 years living in five informal settlements (Nsambya, Katwe, Kasanga, Kabalangala, Rubanga) of Kampala, Uganda. Economic insecurity was assessed by developing a latent construct including low education (<high school), perceptions of living in an unsafe community, and food insecurity. Sexual violence exposure was assessed through self-reported experiences of lifetime sexual violence. Social support was assessed using the Multidimensional Scale of Perceived Social Support. Depression was assessed using the Patient Health Questionnaire (PHQ-9). We conducted structural equation modeling (SEM) using the weighted least squares estimation method to identify direct and indirect effects of economic insecurity on depression via experiences of sexual violence and social support.
Results: Among participants (n=445; mean age=19.59, SD=2.60; young women: 74.8%; young men: 25.2%), nearly three-quarters of young women (73.9%; n=246) and half (49.1%; n=55) of young men reported any depressive symptoms. Following PHQ-scoring guidelines, 28.8% of young women, and 16.1% of young men, met diagnostic criteria for depression. Nearly one-quarter (23.7%; n=91) of young women, and more than one-tenth (13%; n=12) of young men, reported experiencing lifetime sexual violence. SEM results indicated that economic insecurity was directly associated with increased depression (β=0.154, p<0.010) and lifetime sexual violence (β=0.161, p<0.001). Lifetime sexual violence was negatively associated with social support (β= -0.275, p<0.001), and positively associated with depression (β=0.130, p<0.010). Lifetime sexual violence and social support partially mediated the relationship between economic insecurity and depression. Economic insecurity had an indirect association with depression through a chain of mediators (economic insecurity→lifetime sexual violence→reduced social support→increased depression: β=0.016, p=0.007; and economic insecurity→lifetime sexual violence→depression: β=0.021, p=0.038). The final SEM had acceptable fit indices (χ2/df ratio=2.39; RMSEA=0.05; 90% CI: 0.047, 0.065; CFI=0.957; TLI=0.943).
Conclusions: Findings provide insight into the social and health sequelae of economic insecurity among urban refugee youth, and pathways through which economic insecurity is associated with depression by increasing sexual violence exposure and reducing social support. Our findings reveal the salience of a syndemics approach to address the ways that social inequalities (e.g. poverty, sexual violence) interact to exacerbate social (reduced social support) and health (depression) disparities among urban refugee youth in Kampala.