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Abstract
Objective The study aims to evaluate anxiety and depression levels and access to mental health services among internally displaced persons (IDPs) in Mogadishu, Somalia.
Design A community-based, cross-sectional survey was carried out in IDP camps. Face-to-face interviews were conducted using a modified Hospital Anxiety and Depression Scale. Data were analysed using SPSS V.25.0, incorporating univariate and logistic regression analyses.
Setting The study was conducted in 10 IDP camps located in the districts of Daynile and Kahda in the Banadir region of Somalia between November and December 2023.
Participants The study included 522 randomly sampled individuals aged 18–70 years living in the selected IDP camps.
Results The study revealed high prevalence rates of anxiety (43.7%) and depression (35.8%) among IDPs in the selected districts. Of those with anxiety, 54% were categorised as borderline cases and 46% as severe cases. Similarly for depression, 72.7% were classified as borderline cases and 27.3% as severe cases. Significant associations were found between anxiety symptoms and variables such as camp residence (OR: 3.872, 95% CI 2.333 to 6.424), female gender (OR: 2.387, 95% CI 1.604 to 3.552), young age (OR: 6.319, 95% CI 4.309 to 9.267), marriage contract (OR: 4.569, 95% CI 2.850 to 7.325), lack of education (OR: 1.92, 95% CI 1.349 to 2.737) and past experiences of trauma (OR: 5.207, 95% CI 3.274 to 8.281). Depressive symptoms were significantly associated with younger age (OR: 1.536, 95% CI 1.069 to 2.208), lack of formal education (OR: 1.661, 95% CI 1.153 to 2.395) and history of trauma (OR: 3.695, 95% CI 2.529 to 5.400). Additionally, the study highlighted a grave shortage of mental health and psychosocial support (MHPSS) services. User evaluations of MHPSS services varied, indicating room for improvement.
Conclusion The study revealed elevated levels of anxiety and depression among IDPs in the districts of Kahda and Daynile in the Banadir region of Somalia, underscored by a critical shortage of MHPSS services, emphasising the need for tailored mental health interventions.
- Cross-Sectional Studies
- Health Services
- Health Services Accessibility
- Health & safety
- Health Surveys
- Anxiety disorders
Data availability statement
Data are available upon reasonable request. The data supporting the findings of this study are available from the corresponding author upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Cross-Sectional Studies
- Health Services
- Health Services Accessibility
- Health & safety
- Health Surveys
- Anxiety disorders
Strengths and limitations of this study
Data collection was carried out by trained and qualified health professionals proficient in recognising anxiety and depression symptoms and fluent in the local language, under the strict supervision of the principal investigator.
The Hospital Anxiety and Depression Scale was used for data collection to evaluate anxiety and depression.
The study employed a large sample size, focusing on vulnerable populations in camps for internally displaced persons.
Reliance on self-reported data may introduce potential bias, and the translation of the survey tool may not fully capture cultural nuances.
Introduction
Internally displaced persons (IDPs) represent one of the most vulnerable demographics worldwide.1 Currently, there are over 71.1 million IDPs globally, predominantly residing in low-income countries.2 Conflict has led to the displacement of millions in at least two-thirds of African nations. Somalia, marked by both social conflict and natural disasters, faces a staggering humanitarian crisis with one of the world’s largest populations of IDPs, totalling an alarming 3.8 million people.3 Somalia is regularly impacted by natural hazards, including recurrent droughts, floods, cyclones and the emergence of climate-related diseases and epidemics.4 For instance, a fourth consecutive failed rainy season in Somalia since 2020 has plunged the country into a severe drought, endangering the lives of over 7.7 million people.5 Additionally, recent flooding has wreaked havoc on infrastructure, destroying homes, hospitals, schools and roads. Crops have been inundated and livestock have perished, further exacerbating the already dire humanitarian situation in the region.6
This dire situation is primarily attributed to the dual challenges of persistent drought and relentless armed conflict, which have left a devastating imprint on the country’s most vulnerable demographics, especially women, children and minority and marginalised groups.7 8 The IDPs in Somalia encounter targeted violence and political instability, compelling them into camps that frequently lack the necessary resources to address their fundamental requirements.9 These harsh conditions not only threaten their physical well-being but also render them highly susceptible to mental disorders.1 The psychological toll of displacement, coupled with the daily struggle for basic necessities and past traumatic experiences, underscores the urgent need for comprehensive and sustainable interventions.10 Being displaced can worsen existing mental health problems and lead to new mental health conditions. The occurrence of mental health problems among IDPs is influenced by factors such as exposure to past and current traumatic events, food insecurity and the duration of displacement. Scientific investigations conducted in regions such as Ethiopia, Kenya, Nigeria and Georgia have demonstrated that IDPs exhibit a significantly higher prevalence of mental health disorders compared with the non-displaced population.1 11–13
The prevalence of mental disorders among conflict-affected populations is notably significant. According to a comprehensive review conducted by the WHO, encompassing 129 studies across 39 countries, individuals who have undergone war or similar conflicts within the past decade exhibit a high incidence of mental health conditions. This review revealed that approximately one in five individuals (22%) in these populations suffer from disorders such as depression, anxiety, post-traumatic stress disorder, bipolar disorder or schizophrenia.14
The Somali population grapples with unprecedented flooding, resulting in casualties and the displacement of hundreds of thousands from their residences. This surge in internally displaced people within camps follows extensive rainfall across East Africa, presenting an acute humanitarian challenge in the region.15 As per WHO assessment, Somalia faced one of the highest rates of mental health issues globally, affecting one-third of its population with various psychological disorders.16 Internally displaced individuals (IDPs) face various social vulnerabilities and are at risk of developing mental disorders. These vulnerabilities encompass inadequate housing and overcrowding, absence of protection, limited access to clean water, food insecurity, restricted healthcare services, absence of personal documentation and an increasing incidence of forced evictions.17
Furthermore, it is widely acknowledged that despite these concerning statistics, there is a lack of adequate mental health services in the country, especially for vulnerable IDPs in camps who have distinct and pressing needs.11 Mental health status can be assessed through evaluation of anxiety and depression symptoms, considering their severity and intensity levels.18 19 Hence, this study aims to assess the levels of anxiety and depression, as well as the accessibility of mental health services, among IDPs in Mogadishu, Somalia.
Methods
Study design and participants
A cross-sectional survey was conducted in 10 camps located in the two most densely IDP-populated districts of Daynile and Kahda, located in the Banadir region. These districts are home to over 2400 IDP sites and a total population of 1 347 075 individuals, as of October 2022.20 The study targeted IDPs aged 18 years and older, with data collection taking place throughout November and December 2023.
Eligibility criteria
Individuals eligible for inclusion in this study are those aged between 18 and 70 years and residents of the designated IDP camps, contingent on obtaining informed consent. Exclusion criteria encompass individuals unwilling or unable to provide consent, as well as those facing physical or cognitive limitations including acute illness, memory loss or confusion that would interfere with understanding the survey questions and providing informed responses.
Sample size determination
Sample size was determined using single population proportion formula considering the following assumptions: 59.4% of depression prevalence from a previous study in Mogadishu,21 level of significance set at 5% and corresponding confidence level of 95%. The study required a minimum sample size of 371 participants. To accommodate potential non-response, the sample size was adjusted to 522. The sample size was proportionately divided among the selected 10 IDP camps in the district.
Sampling technique
The study focused on 10 camps that were purposively selected based on the CCCM criteria for camp verification. Within these camps, IDP households were chosen through systematic random sampling, considering that all households were registered. The selection process began with a lottery method to identify the initial household, followed by using systematic random sampling for subsequent households. In cases where the chosen household had no eligible participant, the next household was approached. Moreover, when multiple eligible participants were found within a household, a random selection method was applied.
Data collection procedure
The data collection process comprised face-to-face interviews conducted by 10 trained nurses proficient in using the tool. A slightly modified version of the Hospital Anxiety and Depression Scale, translated into Somali, was employed during these interviews. Prior to the official survey, the tool underwent a pretest involving 10 individuals with similar sociodemographic characteristics to the study participants. This pretest was instrumental in identifying areas requiring enhancement in item clarity and data quality. Subsequent refinements were made based on the pretest feedback before the main data collection phase began.
Study instrument
The data collection tool consisted of 32 items categorised into four sections, namely sociodemographic characteristics; anxiety and depression symptoms; trauma exposure questions; and awareness, access, utilisation and barriers to mental health services.
Sociodemographic characteristics
Sociodemographic characteristics consist of seven items, namely gender, age, marital status, length of stay in the IDP camp, level of education, family size and income.
Anxiety and depression symptoms
To evaluate anxiety and depression, the research used the Hospital Anxiety and Depression Scale developed by Zigmond and Snaith.22 This is a 14-question instrument that measures anxiety and depression, with 7 questions for each. Each question is scored between 0 (no impairment) and 3 (severe impairment), with a maximum score of 21 for anxiety or depression. Concerning the total score, values ranging from 0 to 7 were categorised as within the normal range for both anxiety and depression, while values falling between 8 and 10 were deemed borderline, and those between 11 and 21 were classified as abnormal cases for either condition.23 24
Trauma exposure questions
Trauma exposure questions encompass two key components, namely the occurrence of past and current traumatic incidents during both the predisplacement and postdisplacement periods, and the specific nature of those traumatic experiences.
Awareness, access, utilisation and barriers to mental health services
This is composed of nine items in which the initial three items focused on participants’ awareness of mental healthcare, the subsequent three items examined the utilisation of mental health services and the other three items explored challenges in service availability, along with recommendations for improvement.
Data management and analysis
The data collection tool was meticulously developed using KoboToolbox, and editing access was limited to the principal researcher. Subsequently, the tool was distributed to the data collectors through their smartphones. The gathered data were then securely stored in encrypted servers. To maintain data integrity and reliability, thorough cleaning procedures were implemented, identifying and rectifying errors and inconsistencies in the data set. The data were entered into, cleaned and analysed using SPSS V.25.0. Univariate and bivariate analyses were conducted, involving calculations of proportions, frequencies, averages and cross-tabulations to summarise the study variables. To identify predictor variables associated with anxiety and depression symptoms, binary logistic regression was employed. Statistical significance was determined at p<0.05.
Consent to participate
Written consent was obtained from local authorities and camp managers. Prior to participating in the study, individuals selected for recruitment provided verbal consent after being briefed by the research assistants. Participants were assured of the voluntary nature of their involvement and their right to withdraw from the study at any point without facing repercussions. They were also guaranteed complete confidentiality and privacy, emphasising that there would be no consequences for refusal to participate.
Patient and public involvement
None.
Results
Sociodemographic characteristics of the respondents
The survey achieved a 100% response rate, with all eligible participants who were invited agreeing to take part in the study. The study revealed that a substantial majority of the respondents (79.4%) have spent less than 6 months in the IDP camps, indicating a relatively short duration of stay. Similarly, majority of the participants were female, comprising 73.6%, while the age distribution displayed a balanced profile, with 46.4% below 25 years and 53.6% aged 25 years or older, indicating a notable equilibrium across age groups. The marital dynamics of the respondents revealed a substantial proportion in a married relationship (79.9%). A significant percentage (54.6%) also lacked formal education. Furthermore, a significant proportion of participants (71.6%) indicated a family size of up to six members, while a substantial majority (83.3%) reported a monthly family income of US$100 or less. On the employment front, only 11.7% of the respondents were currently employed, indicating challenges in securing job opportunities within the IDP community (table 1).
Sociodemographic characteristics of the respondents
Prevalence and patterns of anxiety and depression among IDPs
The research findings indicated that 43.7% (228 out of 522) of the participants had encountered symptoms of anxiety during the 2 weeks preceding the study, with 54% categorised as borderline cases and 46% as severe cases. Likewise, 35.8% (187 out of 522) of the subjects exhibited symptoms of depression in the same timeframe, with 72.7% classified as borderline cases and 27.3% as severe cases (figure 1).
Prevalence and levels of anxiety and depression among internally displaced persons in the past 2 weeks.
Factors associated with anxiety and depression symptoms among IDPs
In the binary logistic regression analysis, discernible associations were observed between anxiety and depression symptoms and key variables among vulnerable individuals residing in IDP camps in Mogadishu. Specifically, camp residence duration, sex, age, marital status, education and family size demonstrated statistically significant associations with manifestations of anxiety and depression symptoms in this population.
The odds of experiencing anxiety symptoms were 3.87 times greater among individuals who had been in the IDP camp for less than 6 months (OR: 3.872, 95% CI 2.333 to 6.424). In relation to gender, women exhibited 2.39 times higher odds of developing anxiety symptoms compared with men (OR: 2.387, 95% CI 1.604 to 3.552). In terms of age category, individuals aged <25 years exhibited 6.319 times higher odds of experiencing anxiety symptoms compared with those aged >25 years (OR: 6.319, 95% CI 4.309 to 9.267). In a similar vein, individuals who were married were 4.569 times more likely to experience anxiety symptoms than their unmarried counterparts (OR: 4.569, 95% CI 2.850 to 7.325). Furthermore, individuals lacking formal education demonstrated 1.92 times higher odds of developing anxiety symptoms (OR: 1.92, 95% CI 1.349 to 2.737). Additionally, those with a family size of up to six exhibited significantly higher odds, with a 5.21-fold increase in the likelihood of experiencing anxiety symptoms (OR: 5.207, 95% CI 3.274 to 8.281).
Regarding depression, women exhibited 3.72 times higher odds of experiencing symptoms compared with men (OR: 3.727, 95% CI 2.281 to 6.092). Additionally, individuals aged <25 years demonstrated 1.53 times higher likelihood of experiencing depression symptoms compared with those older than 25 years (OR: 1.536, 95% CI 1.069 to 2.208). The study further unveiled that participants lacking formal education and those with a family size of up to six individuals had 1.66 and 1.83 times the odds, respectively, of experiencing depression symptoms compared with their counterparts (OR: 1.661, 95% CI 1.153 to 2.395; OR: 1.830, 95% CI 1.202 to 2.787). Individuals with a history of trauma were 3.69 times more likely to experience depression compared with those without such experiences (OR: 3.695, 95% CI 2.529 to 5.400). However, the study did not find a significant link between past trauma and anxiety (OR: 1.294, 95% CI 0.915 to 1.830) (table 2).
Binary logistic regression results illustrating the association of anxiety and depression with demographic characteristics among internally displaced camp residents in Mogadishu
Trauma exposure and mental health services availability, awareness and utilisation
According to the study, approximately 24% of the respondents reported experiencing traumatic events before displacement, with the most common being lack of food or water, illness without medical care and exposure to combat situations. Other significant predisplacement traumas included the destruction of property by floods, severe injury or illness of self or loved ones, loss of loved ones and sexual abuse.
In the postdisplacement phase, 28.2% of the respondents reported trauma, with the most common experiences being lack of proper shelter, forced evacuation and feelings of inferiority within the camp. Additional postdisplacement traumas included lack of food or water, ill health without medical care, combat exposure, loss of loved ones, severe injury or sickness of loved ones, property destruction, sexual abuse and imprisonment.
In terms of mental health and psychosocial support (MHPSS) services, a predominant response from the participants (69.7%) signifies lack of such services, while a noteworthy segment expresses uncertainty (21.1%) and a minority recognises their accessibility (9.2%). As per the study findings, in the context of limited MHPSS services, community outreach and awareness initiatives were the most widespread. Following closely are counselling and psychotherapy, support groups and recreational therapy, all of which were offered by humanitarian organisations in the area. Concerning the source of information, healthcare professionals were the primary source of MHPSS services, cited by the majority of those who were aware (58.3%), followed by friends or family members (33.3%) and media (8.4%).
Based on the evaluation provided by a relatively small group of respondents (10.9%) who either used MHPSS services or had their family members or friends use them, a considerable proportion (42.1%) assessed the services as fair, 21.1% rated the services as good and 10.5% as excellent, while a notable fraction (26.3%) expressed dissatisfaction, assigning a poor rating (table 3).
Trauma exposure and MHPSS awareness among participants
Discussion
The study results revealed that within the 2 weeks preceding the research, 43.7% of the participants experienced symptoms indicative of anxiety. This prevalence surpasses the global25 26 and regional27 averages for anxiety, prompting further consideration of the factors contributing to the heightened levels observed in this specific population. The discrepancy may be attributed to the unique challenges faced by IDPs in the camps, including but not limited to the impact of displacement, past and current trauma experiences, living conditions and the overall context of their situation. The study further disclosed that more than half (54%) of these participants demonstrated symptoms categorised as borderline anxiety, whereas the remaining 46% were classified as experiencing severe anxiety symptoms. The increased occurrence of severe anxiety symptoms can be attributed to the presence of acute stressors, traumatic experiences or pre-existing mental health conditions among the IDPs.
Similarly, 35.8% of the study participants displayed symptoms indicative of depression. Among these, 72.7% were classified as borderline cases, while 27.3% were characterised as experiencing severe depressive symptoms. This aligns closely with analogous studies conducted among global refugee and migrant populations, indicating a coherent trend in the prevalence and classification of depression symptoms within varied displaced communities.28
In terms of associated factors, the study identified statistically significant associations between the duration of residence in the camp, gender, age, marital status, education, family size and the manifestation of anxiety and depression symptoms within this population. The likelihood of experiencing anxiety symptoms was nearly quadrupled among individuals with less than 6 months of residence in the IDP camp. This can be elucidated by considering the short period they had to adjust to challenges associated with recent displacement, the disruption of familiar social structures and the exposure to stressors in a new and often precarious environment. Moreover, women exhibited over two times higher odds of developing anxiety symptoms and almost four times higher odds of experiencing depression symptoms compared with men. This finding aligns with prior research conducted across various regions, corroborating the gender discrepancy in anxiety and depression symptoms observed in numerous studies.29–32 This is attributed to potential hormonal influences, societal expectations and differing stress response patterns that may contribute to the observed gender disparity in anxiety symptomatology.
In terms of age, individuals below 25 demonstrated over six times higher odds of encountering anxiety symptoms and 1.5 times higher odds of experiencing depression symptoms compared with those 25 years or older. An analogous study reported congruent results.33 This can be explained by the fact that with advancing age, there is a simultaneous increase in responsibilities and the associated emotional burden.
Another noteworthy predictor was marital status, with individuals in a marital contract having 4.5 times the odds of experiencing anxiety. This differs from the outcomes of a separate study conducted in Malaysia, where marriage was highlighted as a safeguarding element, showcasing contrasting findings.34 Married individuals may face heightened anxiety due to increased responsibilities and stressors associated with marital life, especially during emergencies caused by extreme climate change impacts, which exacerbate complexities without financial support.
It has been observed that individuals lacking formal education demonstrated nearly a twofold increase in the likelihood of developing anxiety symptoms and over a 1.5-fold increase in the likelihood of experiencing depression symptoms. Other studies yielded comparable results.35 36 This can be elucidated by the notion that individuals with limited educational attainment often face difficulties in obtaining secure and lucrative employment, thereby contributing to financial instability.
Another robust predictor of anxiety symptoms is individuals with family sizes below six, with a fivefold increase in the odds of experiencing anxiety and nearly twofold increase in the odds of experiencing depression symptoms. This could be attributed to the potential increase in stressors and limited support networks within smaller family units, potentially intensifying the vulnerability to anxiety and depression symptoms.
According to the study findings, almost half of the respondents (47.7%) disclosed exposure to traumatic events. A notable percentage of participants reported encountering various traumatic events, with the most prevalent being lack of food or water, inadequate shelter, ill health without access to medical care and forced evacuation. This can be explained by the fact that camp life has a multitude of challenges, including resource scarcity, substandard living conditions and limited access to essential services, creating an environment where individuals are more susceptible to traumatic experiences.
The study findings indicated that majority of the camp residents (69.7%) lacked access to MHPSS services. This result aligns with the findings of another study conducted in IDP camps in Nigeria.37 All mental health services available, including counselling, psychotherapy, support groups and recreational therapy, were offered by humanitarian organisations in the area. These services were predominantly delivered by humanitarian organisations supporting displaced individuals, specifically focusing on livelihood support, health and nutrition. Based on the responses from a relatively small subset of participants, either those who personally availed MHPSS services or had their family members or friends access them, it is noteworthy that more than half were not well satisfied with the services provided. This might be attributed to insufficient accessibility, possibly arising from constraints in availability, awareness or outreach initiatives.
Strengths and limitations
Data collection was conducted by trained and qualified health professionals who were adept at recognising symptoms of anxiety and depression and fluent in the local language. This process was carried out under the strict supervision of the principal investigator. Similarly, the study adopted the Hospital Anxiety and Depression Scale to evaluate anxiety and depression. This scale is a validated tool widely used for assessing anxiety and depression in various settings. Moreover, the study used a large sample size, focusing on vulnerable populations in IDP camps, an area that has often been under-researched. However, the reliance on self-reported data may introduce potential bias, and the translation of the survey tool might not fully capture cultural nuances. The sampling strategy, while systematic, may not capture the full diversity of the IDP population, and the study could benefit from a more indepth exploration of trauma and mental health service barriers.
Conclusion
The study uncovered significant insights into the mental health of IDPs in Mogadishu, Somalia. A substantial proportion of the participants experienced symptoms of anxiety (43.7%) and depression (35.8%) within the 2 weeks preceding the research. The prevalence of severe symptoms suggests the presence of acute stressors, traumatic experiences or pre-existing mental health conditions among the IDPs. Factors such as short duration of residence in IDP camps, female gender, younger age, marital status, lack of formal education and smaller family size were identified as key predictors of anxiety and depression symptoms.
The study recommends the development and implementation of tailored mental health interventions for individuals in IDP camps. These interventions should provide targeted counselling, coping strategies and support services to help individuals adjust to the new environment and navigate the stressors associated with recent displacement. Additionally, there is a need for gender-sensitive mental health programmes that address the specific needs and stressors faced by female individuals in IDP settings.
Data availability statement
Data are available upon reasonable request. The data supporting the findings of this study are available from the corresponding author upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethical approval was secured from the Institutional Review Board (IRB) of SOS College of Health Sciences, Mogadishu, Somalia (ref: 2023/SOS-IRB/CHS/P005). Additionally, written consent was obtained from local authorities and camp managers. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors express their gratitude to all individuals and organisations whose support and contributions were instrumental in the completion of this study.
Footnotes
Contributors All authors contributed significantly to the conception, design, execution and interpretation of the study. HAD conceptualised the design and overall study; wrote the results; made the analysis and interpretation; and wrote the result, discussion and conclusion sections. MAO, HAH and AAO wrote sections of the manuscript and led the literature review part, participated in the analysis and reviewed the final manuscript. YAJ wrote sections of the manuscript and led the literature review part, participated in the data collection and reviewed the final manuscript. AMA participated in literature review and data analysis, wrote the results section and reviewed draft of the manuscript. FIM wrote sections of the manuscript and led the literature review part, participated in data collection and analysis, and reviewed the final manuscript. All authors read and approved the final manuscript. MOA participated in writing the manuscript and led the literature review part, participated in data collection and reviewed the final manuscript. All authors read and approved the final manuscript. HAD is responsible for the overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.