Prevalence of Depression and Subjective Job Stress Among Men who have Sex with Men and Transgender Community Health Workers in Pakistan

By Usman Ali¹, Syed Azhar Ali²

Affiliations

1. Department of Psychiatry and Behavioural Sciences, King Edward Medical University, Lahore, Pakistan
2. Department of Psychiatry, CMH Rawalkot, Azad Jammu and Kashmir, Pakistan

doi: 10.29271/jcpsp.2023.07.779

ABSTRACT
Objective: To determine the prevalence of depression, subjective work-related stress and associated factors among men who have sex with men and transgender people working in community-based organisations in Pakistan.
Study Design: Cross-sectional descriptive study.
Place and Duration of the Study: Community-based organisations in Lahore, October 2022.
Methodology: Community-based organisations were contacted and link of the study tool in the Urdu language was shared. The study tool consisted of sociodemographic questions, substance abuse history, Patient Health Questionnaire (PHQ) 9, the General Self-Efficacy Scale (GSE), and the Subjective job stress scale (SJSS). The composite score for each scale was calculated and compared.
Results: A total of 91 men participated in the study. Of them, 52.1% were below 30 years of age. The mean PHQ-9 score was 7.62 (range 0-27), mean GSE score was 32.38 (range 12-40), and mean SJSS score was 10.48 (4-14). While 41.7% of the participants were not depressed, 31.77% had depression of at least moderate severity. About 56.52% of the study participants had an SJSS score of more than ten showing a high level of work-related stress.
Conclusion: There is a high frequency of depression among MSM and TG community health workers. High degree of self-efficacy may protect against depression. There is a need of developing comprehensive referral systems with psychiatric units for these community workers.

Key Words: Community health workers, Homosexual men, Transgender, Depression.

INTRODUCTION

Pakistan is an orthodox sociocultural country, inheriting laws from the British colonial era as well as developing Sharia laws. Under the current Pakistani culture and law, people who have sex outside wedlock are penalised. The Section 377 of the Pakistan Penal Code which was first promulgated during British time in 1860, penalises unnatural or non-heterosexual intercourse with imprisonment. Until recently, the transgender community was not even franchised with fundamental human rights and protection by the law. However, in 2018 the parliament of Pakistan passed the Transgender Persons Protection of Rights Act.¹

In this social and legal context, the men who have sex with men (MSM) and transgender (TG) people face stigma and discrimination in all circles of life. They are left with limited avenues in practical life and have to live a life where they either have to do sex work, begging or dancing for living. Due to increased number of sexual partners either due to sex work or lack of courtship, they are at increased risk of HIV infections. The country’s pool of people living with HIV is 240,000 and about 25% of these people living with HIV belong to the group of men who have sex with men or MSM community.^2,3 This high HIV prevalence may affect the mental health of the MSM community in addition to their different sexual minority status. As stated above, these communities also suffer from stigma and discrimination. According to Integrated Biological and Behavioural Surveillance (IBBS), about 9.7% of non-sex worker transgender (non-SWTG) and 10% of non-sex worker men who have sex with men (non-SW MSM) suffer from detention in the last 12 months nearly 20% non-SW TGs and 15.9% of non-SW MSM report discrimination and 28% of non-SW TG and 32% non-SW MSM report being physically hurt, signifying adverse events these communities face which make them prone to psychiatric morbidity.⁴

To counter the increasing HIV epidemic in Pakistan, the Global Fund to fight against AIDS, TB, and Malaria is extending fiscal support to community-based HIV prevention model.³ According to this model community-based organisations of MSM and TG are working for HIV awareness, prevention, testing, and linkage to HIV treatment centers. However, due to lack of domestic funding, sustainability plan, stigma faced even by community health workers, and personal traumatic experiences compounded by a job with demand of extending psychosocial support to their clients, they may suffer from common mental illnesses themselves such as anxiety, depression, adjustment disorders etc. In medical literature, the prevalence of anxiety and depression is higher among MSM and TGs.^5-7

There is scarcity of research on MSM and TG mental health in Pakistan. A recent study by Rao et al., stated that 43% of transgender people have suicidal ideation and 63.5% had depression.⁸ However, mental health of MSM and TG community health workers is not well explored. The objective of the study was to determine the prevalence of depression, subjective work-related stress, and associated factors among MSM and TGs working in community-based organisations in Pakistan.

METHODOLOGY

A cross-sectional descriptive study was conducted in October 2022. At the time of the study, two hundred and twenty people were employed under the project in community-based organisations.

All consenting participants who identified themselves as either as MSM or TG and currently work at community-based organisations were reached. These community-based organisations were identified from the official website of the National AIDS Control Program (https://nacp.gov.pk/whatwedo/careandsupportservices.html). Ethical approval for conducting the study was taken from the Institutional Review Board (IRB) of the Sheikh Khalifa bin Al Nayhan Hospital, Azad Jammu and Kashmir. Subjects were contacted through managers of the community-based organisation working on HIV prevention of MSM and TG in Pakistan. Consenting individuals fulfilling the inclusion criteria were requested to fill out an online study tool. Those who were not capable of reading and computer-literate were excluded. Those not identifying as MSM or TG were also excluded. Purposive convenient sampling was done.

The study tool consisted of four parts, the first part was related to information regarding sociodemographic variables, the second part consisted of the Urdu version of the Patient Health Questionnaire (PHQ)-9 which is a nine-item questionnaire and widely used to screen and assess the severity of depression. The responses are recorded on a four-point Likert scale. The composite scores from 0-4, 5-9, 10-14, 15-19, and 20-27 correspond with no depression, mild depression, moderate depression, moderately severe depression, and severe depression, respectively.⁹ The third part consisted of General Self Efficacy questionnaire (GSE), a ten-item questionnaire. Responses are recorded on a four-point Likert scale. Higher scores correlate with the greater ability to cope with stressful situations. Urdu version of the scale validated by Tabbassum et al. was used.¹⁰ The last portion of the study tool consisted of the subjective job stress scale (SJSS). The scale is used to gauge self-reported stress due to job. It is a four-item scale where responses are recorded on a Likert scale. Urdu translation of the scale is available.¹¹

After collection of the data, data was cleaned for incomplete entries coded into numerical dummy variables and analysed using the Statistical Package for Social Sciences (SPSS) Version 25.0. Descriptive statistics such as frequencies and percentages were computed as well as mean scores PHQ-9, GSE, and SJSS. The normality of data was tested via Kolmogrov-Smrinov test at alpha level of 0.1. Since the data were non-normally distributed (p-value less than 0.05). Spearman correlation coefficients were computed for PHQ-9, GSE, and SJSS with various sociodemographic variables. The authors assumed significance value or type -1 error value at 0.05.

RESULTS

A total of 91 participants participated in the study. About 52.1% of the participants were below 30 years of age. About two-third of the sample consisted of MSM and one-third were TGs. The means years of working in a CBO was 3.04 years (range 1 month-12 years). Table I shows the sociodemographic characteristics of the participants.

The mean PHQ-9 score was 7.62 (range 0-27), mean GSE score was 32.38 (range 12-40) and mean SJSS score was 10.48 (4-14). Based on PHQ-9 scores, 41.7% of the participants were not depressed and 31.77% had depression of at least moderate severity. Table II shows the frequency of depression based on PHQ-9 scores, mean PHQ-9, GSE, and SJSS scores; 56.52% of the participants had an SJSS score of more than ten showing a high level of work-related stress.

Spearman correlation coefficient was computed for the PHQ-9, GSE and SJSS scores with various sociodemographic variables. None of the sociodemographic variables was associated with depression, self-efficacy measures or subjective job-related stress. However, previous psychiatric illness, history of suicide, deliberate self-harm self-efficacy, and subjective job stress were significantly related to depression severity. Size effect was moderate. Self-efficacy was negatively associated with depression whereas subjective job stress was positively related to PHQ-9 scores (Table III).

DISCUSSION

In this study, 41.7% of the subjects were not depressed. Tomori et al., have conducted a large survey using PHQ-9 to identify the prevalence of HIV in India. According to the survey, 11% of MSM were depressed. However, there was considerable heterogeneity from various Indian states, yet all states had a prevalence of depression more than 4.4% which is the global prevalence of depression according to World Mental Health Report.^12,13

Table I: Sociodemographic characteristics of the participants (n=91).

Serial No.	Sociodemographic variable	Frequency (Percentage)
1	Age
	18-30 years	48 (52.1%)
	31-40 years	32 (34.78%)
	41-50 years	10 (10.86%)
	51 years or more	1 (1.08%)
2	Gender
	Male	59 (64.8%)
	Transgender	32 (35.16%)
3	Mean number of years worked at the CBO	3.04 (± 3.35 years)
4	Income
	30,000 PKR-55,000 PKR	74 (81.31%)
	55,001 PKR-80,000 PKR	11 (12.08%)
	80,001 PKR or more	6 (6.59%)
5	Education
	Up to grade 5	1 (1.08%)
	From grade 5 to 10	27 (29.6%)
	More than grade 10	63 (69.23%)
6	Have regular sexual partner	53 (58.24%)
7	Living
	Alone	13 (14.28%)
	With partner	5 (5.49%)
	With other TGs or MSM	13 (14.2%)
	With family	60 (6.59%)
8	History of psychiatric illness	46 (50.5%)
9	Use of amphetamine-type stimulants before the COVID-19 pandemic	6 (6.59%)
10	Use amphetamine-type stimulants during the COVID-19 pandemic	7 (769%)
11	HIV positive	18 (19.78%)
12	History of deliberate self-harm	5 (5.49%)
13	History of suicide attempts	8 (8.79%)

Table II: Frequency of depression based on PHQ-9 score and mean score of PHQ-9, GSE and SJSS.

Serial No.	Depression severity	Frequency (percentages)
1	Mean PHQ score	7.62 (range 0.-27)
2	No depression, PHQ score 0-4	38 (41.7%)
3	Mild depression, PHQ score 5-9	24 (26.37%)
4	Moderately depression, PHQ score 10-14	13 (14.28%)
5	Moderately depression, PHQ score 15-19	9 (9.89%)
6	Severe depression, PHQ score 20-27	7 (7.6%)
7	Mean GSE score	32.38 (range 12-40)
8	Mean SJSS score	10.48 (range 4-14)

Table III: Correlation of the PHQ-9, GSE score and SJSS score.

Serial No.	Variable	PHQ-9 score	p-value	GSE score	p-value	SJSS score	p-value
1	History of psychiatric illness	.411**	.000	.244	.020*	.019	.860
2	History of deliberate self-harm	.242*	.022	.147	.166	-.38	.721
3	History of suicide attempts	.258*	.015	.174	.105	-.81	.453
4	GSE score	-.291*	.005	-		-
5	SJSS score	.265*	.011	-.035	.739	-
**Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).

In the same study, various cultural identities within MSM had different prevalence estimates for depression. Being older, married or widowed/divorced, having recent sex work, unprotected anal sex in the prior 6 months, having more male sex partners, and alcohol and injection drug use were associated with higher prevalence of depression. Xiao et al., have recently conducted a meta-analysis and reported pooled prevalence of depression from eighteen different studies. Most of the studies included in the analysis were from USA and none from Muslim country and only one from a South Asian country. Xiao et al. reports 41% prevalence of depression among MSM who are HIV negative and 49% among MSM who are HIV positive.^13,14 For a long time within mental health professionals, the concept of disease and sin has confused the diagnostic system and practising clinicians. People who had different sexual orientations or gender identities were labelled with various diagnostic labels. However, the third version of the Diagnostic and Statistical Manual (DSM) in 1970s de-pathologised homosexuality.¹⁵ Most recently, there has been a revision in the International Classification of Diseases (ICD), and transgender identity is removed as a mental disorder.¹⁵ Though these different sexual orientations and gender identities are now universally accepted as variations in human behaviour and outside the premise of mental disorders classification. The day-to-day stigma, discrimination and harassment these communities face manifest itself as compromised mental health. There is a wealth of data from various countries which shows that TGs and MSM have higher burden of mental illnesses.^5-7

To the best of the authors’ knowledge, this is the first study done in Pakistan to identify the prevalence of depression. However, given the smaller sample size and the fact that the study participants were community health workers, working during time of COVID-19 pandemic, the results must be interpreted with caution. The only other study from Pakistan was reported by Azeem et al. In this study, 63.5% of the transgender community had depression.⁸ This percentage is almost similar to the one reported in this study.

In literatures, there is wealth of evidence which relates mental health to self-efficacy. Not only it mediates poor mental health but also poses barriers to access to mental healthcare.^16,17 In the present analysis, the level of depression was negatively correlated with generalised self-efficacy scores at a statistically significant level and positively correlated with subjective job stress. However, the correlation is moderate and hence there are other factor which predicts, mediate or moderate the influence of self-efficacy on subjective job stress, which are not included in this model. Another contributing factor could be situational stress due to COVID-19 which predicts job stress.^18-20 However, there are no reports on self-efficacy, job stress, and depressions in MSM and TG community workers. This reflects health research inequalities where problems of marginalised communities remain under-researched and thus under addressed. The association is not counterintuitive.

Research also shows that job stress and poor self-efficacy predict poor staff performance and poor staff performance predicts high turnover.^21,22 Community-based programs which recruit marginalised communities suffer significant barriers related to capacity and turnover. In community-based programs such as the one under discussion, there are substantial investments in staff recruitment, retention, and capacity building.^23-25 A high turnover may jeopardize program investment. Strengthening self-efficacy thus can be a potential point of intervention, which can help reduce depression and stress related to work, improve job performance, and reduce staff turnover.

The major limitation of this study was the limited sample size, cross-sectional designs, and purposive sampling. Hence, extrapolation based on these results warrants caution. Furthermore, the sample size was limited due to small reference population for carrying out latent variable modelling techniques for predicting mediators and moderator role of depression and self-efficacy on job-related stress. However, this is one of the earliest reports on the topic. Qualitative evidence and program evaluations may reveal further insight.

CONCLUSION

There is a high frequency of depression among MSM and TG community health workers. High degree of self-efficacy may protect against depression. There is also a relationship between depression and poor generalised self-efficacy and subjective job stress.

ETHICAL APPROVAL:
Ethical approval for conducting the study was taken from the Institutional Review Board (IRB) of the Sheikh Khalifa bin Al Nayhan Hospital, Azad Jammu and Kashmir.

COMPETING INTEREST:
The authors declared no competing interest.

AUTHORS’ CONTRIBUTION:
UA: Design the study, conducted field data collection, SPSS analysis and manuscript writing.
AA: Design the study, conducted literature review, contributed to data verification and manuscript writing.
All the authors have approved the final version of the manu-script to be published.

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