Factors associated with severity of depression among women intimate partner violence survivors in Lesotho: A cross-sectional study

Abstract

Background:

Depression has been a persistent public health issue. Less is known about the severity of depressive symptoms among certain populations (i.e., intimate partner violence (IPV) survivors).

Objectives:

This study assessed the factors associated with severity of depressive symptoms among women IPV survivors of Lesotho.

Design:

A cross-sectional design was used.

Methods:

The sample (n = 754) of women IPV survivors was extracted from the 2023 to 2024 Lesotho’s Demographic and Health Survey. The outcome variable was severity of depressive symptoms, a dummy variable (i.e., no to minimal depression vs mild to severe depression). The severity of depressive symptoms was calculated based on Patient Health Questionnaire (PHQ-9), that assessed symptoms such as having had little interest, hopelessness, sleep or appetite problems, and suicidal thoughts in the past 2 weeks. The exposure variables were different types of IPV. We included sociodemographic characteristics (i.e., age, education, wealth index quintile, employment, urban/rural), household compositions (i.e., gender, relationship to head of household, number of children), and other covariates (i.e., chronic diseases, witnessing father’s physical abuse toward the respondents’ mothers, access to healthcare). Descriptive analysis and Pearson chi-squared test of independence were performed. A multivariable binary logistic regression analysis was fitted to predict severity of depressive symptoms among the sample population.

Results:

About 34.85% (n = 252) of sample experienced mild to severe depressive symptoms. The binary logistic regression results showed that the emotional IPV survivors (adjusted odds ratio (aOR) = 1.76), sexual IPV survivors (aOR = 1.70), those from the poorer wealth quintile (aOR = 2.04), those who had chronic diseases (aOR = 1.79), and those who reported “big problem accessing healthcare” (aOR = 1.88) had higher odds of reporting mild to severe depressive symptoms compared to the reference categories. All p-values <0.05.

Conclusion:

Findings suggest that urgent attention is needed to address mild to severe depressive symptoms, especially among poor women IPV survivors with chronic diseases and those who may face challenges in accessing healthcare.

Keywords

depression intimate partner violence mental health Demographic and Health Survey Lesotho

Introduction

Many people around the world have experienced varying degrees of adverse mental health conditions. According to the World Health Organization (WHO), adverse mental health conditions encompass symptoms of depression, psychosocial disabilities, and mental states characterized by distress, functional impairment, risk of self-harm, and mental disorder.¹ In 2019, about 970 million people (i.e., 13%) of the global population were affected by mental disorders, with women constituting about 52.4% of this demographic.¹ The prevalence of mental health disorders in the WHO Africa Region was about 10.9%.¹

Approximately one in three women globally has encountered intimate partner violence (IPV)²; Africa has one of the highest prevalence rates at 45%.^3,4 Intimate partners include former and current dating partners or spouses.² IPV may manifest as physical, emotional, and/or sexual abuse, aggression, and stalking, potentially resulting in many adverse physical, mental, and reproductive health outcomes. Physical consequences of IPV include injuries and exacerbation of chronic diseases, including heightened diabetes risk and deterioration of HIV-related immune cell depletion, or risk of developing pain.^5,6

Prior research also found that having had IPV experiences had negative impact on mental health and bidirectional affects.⁷ For example, Chatterji and Heise⁷ conducted a longitudinal study in Rwanda that showed a bidirectional positive association between depressive symptoms and various forms of IPV against women.⁷ Several other studies also found positive association between IPV and different adverse mental health conditions, including posttraumatic stress disorder (PTSD),^8–10 depression,^9–12 suicidal ideation,^9–11,13 anxiety,^11,14,15 serious mental illness,^16–19 and diminished sleep quality.²⁰ Another study conducted among incarcerated women found that there was a significant association between the cumulative trauma (i.e., repeated or combination of abuses including childhood trauma, IPV, and non-IPV) experiences and common types of mental health conditions such as depression and PTSD.²¹ However, less is known about the relationship between severity of depression and different types of IPV (considering emotional IPV, less severe physical IPV, more severe physical, and sexual IPV) among women population (i.e., non-incarcerated women).

Prior studies related to mental health and IPV in Lesotho

IPV prevalence varies depending on a country’s cultures, country’s policy on violence against women, and individual’s disclosure practices, which can evolve over time.^22,23 Prior research has examined the mental health of Lesotho residents utilizing data from small rural communities. However, none of these studies examined the relationship between different types of IPV and mental health among general women population in Lesotho. Some studies have shown a high prevalence of mental health issues among caregivers of children including depression, anxiety, and psychological distress.²⁴ Additionally, substance use was common among individuals who have experienced emotional abuse.²⁵ In Fernández et al.’s study,²⁵ it was demonstrated that there was a gap in awareness and treatment for mental health and substance use problems among adults.²⁵ Despite these studies identifying factors associated with mental health issues, research that specifically study the relationship between different types of IPV and severity of depressive symptoms with a focus on Lesotho was limited.

This study aims to add to the current body of research by examining the factors associated with the severity of depressive symptoms among women IPV survivors in Lesotho. Specific objectives were: (a) to assess the prevalence of various forms of IPV among women in Lesotho, (b) to identify the severity of depressive symptoms experienced by women based on their exposure to different types of IPV, and (c) to examine factors that influence the severity of depressive symptoms among women IPV survivors.

Methods

This study used anonymized data from women aged 15–49 (n = 6413) from Lesotho’s Demographic and Health Survey (LDHS) 2023–2024, which was conducted by the Ministry of Health (MoH) Lesotho with the support from Inner-City Fund (ICF).²⁶ The LDHS used a two-stage (cluster and household) stratified sampling design.²⁵ The data were collected from November 2023 to February 2024.²⁶

Exclusion and inclusion criteria

The inclusion criteria for this study were women in an intimate relationship, those who responded to a domestic violence questionnaire, and those who did not have any privacy concerns for their responses during the interview. Those who did not meet the inclusion criteria were excluded from our analyses.

Survey instrument and data flow

Of the 6413, we initially excluded 3874 women who were not selected for the domestic violence module (Note: only one woman per eligible household was selected),²⁶ and 49 women were not selected due to privacy concerns, resulting in 2490 women who responded to the domestic violence questionnaire. Of the 2490 women, 1699 were married, and 791 were never married. Among the 791 individuals who had never married, 623 were engaged in intimate relationships. Additionally, 168 had never been in an intimate relationship and, therefore, they were excluded from the study. From the remaining sample (n = 2322), who were 15–49 years old, we excluded those who did not report any IPV (n = 1480) leaving our sample to 842. Of them, we excluded participants with missing observations from two variables, that is, witnessing father’s physical abuse (n = 87), and trouble concentrating reading or watching television (TV; n = 1) reducing our final sample to 754. Figure 1 details the sample flow, showing the inclusion and exclusion process.

Figure 1.

Sample flow: Lesotho.

The Institutional Review Board (IRB) of the ICF gave ethical approval to the DHS program.²⁶ This made sure that the survey followed the rules set by the U.S. Department of Health and Human Services for protecting human subjects (45 CFR 46).²⁷ The interviewers were trained to collect the informed consent prior to asking questions.^26,27 For this specific study, the IRB as well as informed consent were not applicable as the data was deidentified and is publicly available upon registration and request from the DHS website.²⁸ The questionnaire used for this study is available in the LDHS final report.²⁶

Outcome variable

The outcome variable of interest was severity of depression with two categories: “0 = no or minimal” and “1 = mild to severe.” The “severity of depression” variable was created based on the 9-item Patient Health Questionnaire (PHQ-9) and aligned with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for depression diagnosis and the term “severity of depression” was used to be aligned with the published LDHS report.^26,27 The 9-item scale asked participants to report on the past 2 weeks’ experience of: (a) little interest/pleasure in doing things, (b) feeling down, depressed, hopeless, (c) trouble falling asleep or sleeping too much, (d) feeling tired or having little energy, (e) poor appetite or overeating, (f) feeling bad about yourself or that you are a failure or let yourself or your family down, (g) trouble concentrating on things such as reading the newspaper or watching TV, (h) moving/speaking slowly that other people could have noticed or moving around a lot more than usual, and (i) have you ever had thoughts of better off dead or hurting yourself. Response options for these 9-item scale were on a 4-point Likert scale: “0 = never,” “1 = rarely,” “2 = often,” and “3 = always.” Responses such as “7 = refused to answer” or “8 = don’t know” were excluded from the analyses. The PHQ score ranges 0–27, with the cut-off values as follows: “score 0 = not at all to score 1–4, minimal depression,” “score 5–9 = mild depression,” “score 10–14 = moderate depression,” “score 15–19 = moderately severe depression,” and “score 20–27 = severe depression.” For this study, we recoded a score of “0 = no or minimal depressive symptoms (i.e., score 1–4)” and a score of “1 = mild to severe depressive symptoms (i.e., score ⩾5).”²⁹

Exposure variables

Exposure variables were different types of IPV where the perpetrators were men, and survivors were women; we created four dichotomous variables using IPV questions in the survey: emotional IPV (no, yes), less severe IPV (no, yes), severe IPV (no, yes), and sexual IPV (no, yes), where “no” equaled “never experiencing” and “yes” encompassed three possible response options where the respondent experienced IPV at any frequency (yes, but not in the last 12 months, sometimes, or often). The “emotional IPV” included the following: if the respondents had ever been (a) humiliated, or (b) threatened with harm, or (c) insulted, or (d) made to feel bad by husband/partner. If the respondents had ever been (a) pushed, shook, or (b) had something thrown, or (c) slapped or punched with fist or hit by something harmful, or (d) arm twisted, or (e) hair pulled by husband/partner, it was coded as “less severe IPV.” The “severe physical IPV” was calculated if the respondent had ever been: (a) kicked or dragged, or (b) strangled or burned, or (c) attacked with knife/gun or another weapon by a husband or partner. The “sexual IPV” included if the respondent had ever been (a) physically forced into unwanted sex, or (b) other unwanted sexual acts, or (c) physically forced to perform the sexual acts that respondents did not want to.

Sociodemographic variables

We included the variables guided by the prior literature.²⁹ Demographic variables included: age of respondents in 5-year groups (i.e., 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49), marital status (i.e., never married, married, living with a partner, widowed, divorced, no longer living together/separated), current employment status (no, yes), education status (i.e., no education, primary, secondary, and higher), and household wealth index in quintile (i.e., poorest, poorer, middle, richer, richest), and place of residency (urban/rural). The household wealth index was calculated based on household assets (such as household construction materials and access to water and toilet facilities) and ownership, such as ownership of TV, computer, microwave, motorcycle, car, etc.³⁰ The details on wealth index calculation for Lesotho are available from the Demographic and Health Surveys (DHS) website.³⁰

Household composition

The household compositions may directly and indirectly impact the quality of life of women including mental health as well.^29,31,32 Therefore, variables related to household composition, such as the sex of the household head (male, female), relationship to the household head (self, wife, daughter, daughter-in-law, and others), and number of children (as a continuous variable), were included.

Other important covariates

We also included other important covariates that had negative impact on a woman’s mental health. They are presence of chronic disease,³³ experienced adverse childhood experiences including witnessing father’s physical abuse,³⁴ and access to healthcare.³⁵

Presence of chronic diseases

The presence of chronic disease (no, yes) was a composite variable created from the following chronic diseases: diabetes, heart disease, hypertension, lung disease, cancer, arthritis, and other chronic diseases not listed, where survey response options were “0 = no” and “1 = yes.” From these variables, we assigned “0 = no chronic diseases” and “1 = yes, at least one chronic disease” for their affirmative responses.

Witnessing father’s physical abuse

Witnessing the father’s physical abuse of the respondent’s mother was also included. It is a dichotomous variable with the responses “0 = no” or “1 = yes” and “8 = don’t know,” but we excluded “don’t know” from our analysis.

Access to healthcare

Respondents’ access to healthcare (0 = no, 1 = yes) was created from four variables: if the respondents reported difficulty getting medical help for themselves because of (a) permission to go, (b) money needed for treatment, (c) distance to health facility, and (d) not wanting to go alone. The responses were “0 = no problem” and “1 = big problem.” The responses “no problem” from all four scenarios were assigned zero, and the responses “big problem” in at least one scenario were assigned one.

Statistical analysis

We described different types of depression and reported the prevalence of whether the women experienced mild to severe depression or not using descriptive statistics. Pearson chi-square (χ²) test of independence was performed. Regardless of the significant association in the Pearson chi-square test of independence, this study included all the relevant and important variables based on the prior literature.^8,31–34 A multivariable binary logistic regression was fitted to examine the relationship between the outcome variable (i.e., presence of mild to severe depression) and other covariates mentioned above. The p-value <0.05 is considered significant for the binary logistic regression results. We applied survey weights (i.e., the domestic violence weight that accounts for complex survey design) for the women’s sample for all our analyses.³⁵ All analyses were performed with Stata 18.5.³⁶ This study applied the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network’s guideline on Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for a cross-sectional study (Supplemental Table 1).³⁷

Results

Of 754 women IPV survivor, 18.88% (n = 133) of them were from age group 35–39 years, 60.67% (n = 476) were married, 47.8% were currently working, 49.32% (n = 366) had secondary education, 24.55% (n = 136) were from richer wealth quintile group, and 56.73% (n = 489) were rural residents. Prevalence details for sociodemographic characteristics are presented in Table 1.

Table 1.

Sociodemographic characteristics (n = 754).

Age groups	n (%)
15–19	54 (7.10)
20–24	107 (13.05)
25–29	110 (12.08)
30–34	141 (18.30)
35–39	133 (18.88)
40–44	123 (15.91)
45–49	86 (14.68)
Marital status
Never in union	118 (15.51)
Married	476 (60.67)
Living with a partner	15 (2.88)
Widowed	45 (7.44)
Divorced	13 (1.49)
No longer living with a partner	87 (12.01)
Respondents currently working
No	443 (52.17)
Yes	311 (47.83)
Education level
No education	13 (1.01)
Primary	295 (34.87)
Secondary	366 (49.32)
Higher	80 (14.80)
Wealth
Poorest	218 (18.17)
Poorer	140 (16.47)
Middle	143 (18.91)
Richer	136 (24.55)
Richest	117 (21.90)
Place of residence
Urban	265 (43.27)
Rural	489 (56.73)
Relationship to the household head
Self	193 (24.28)
Wife	324 (44.03)
Daughter	106 (14.11)
Daughter-in-law	41 (5.17)
Other	90 (12.42)
Sex of household head
Female	311 (38.42)
Male	443 (61.58)
Number of children, mean (SD)	2.06 (1.54)
Chronic disease
No	587 (73.20)
Yes	167 (26.80)
Witnessed father’s physical abuse toward their mothers
No	379 (51.14)
Yes	375 (48.86)
Access to health: Big problem
No	397 (58.89)
Yes	357 (41.11)

SD: standard deviation.

Among them, more than one-third of the women, that is, 34.85% (n = 252) reported experiencing mild to severe depressive symptoms. Among different depressive symptoms, the experience of feeling down, depressed, or hopeless during the past 2 weeks were the most reported symptoms by 46.02% (n = 353) studied women. This percentage was followed by another depressive symptom: Little interest or pleasure in doing things, representing 36.21% (n = 278). The least reported depressive symptoms included moving or speaking slowly that is noticeable or moving around a lot more, representing 12.11% (n = 98), and having a thought of being better off dead or hurting yourself (i.e., suicidal thoughts), representing 18.93% (n = 135) in women. Prevalence details for each depressive symptom are presented in Table 2.

Table 2.

The prevalence of women reported on individual depressive symptoms and total dichotomized 9-item patient health questionnaire (PHQ-9) score (0–4 = no or less severe depressive symptoms vs 5–27 = mild to severe depressive symptoms; N = 754).

Items included in PHQ-9	No, n (%)	Yes, n (%)
Last 2 weeks: Little interest/pleasure in doing things	476 (63.79)	278 (36.21)
Last 2 weeks: Feeling down, depressed, or hopeless	401 (53.98)	353 (46.02)
Last 2 weeks: Trouble falling asleep or sleeping too much	487 (64.30)	267 (35.70)
Last 2 weeks: Feeling tired or having little energy	488 (67.24)	266 (32.76)
Last 2 weeks: Poor appetite or overeating	473 (65.97)	281 (34.03)
Last 2 weeks: Feeling bad about yourself, you are a failure	576 (76.36)	178 (23.64)
Last 2 weeks: Trouble concentration in reading or watching TV	545 (70.63)	209 (29.37)
Last 2 weeks: Moving or speaking slowly or moving around a lot more	656 (87.89)	98 (12.11)
Last 2 weeks: Thought of better off dead or hurting yourself	619 (81.07)	135 (18.93)
Last 2 weeks: Moderate to severe depression (no or minimal: i.e., PHQ score 1–4, and yes = mild to severe: i.e., PHQ score 5–27)	502 (65.15)	252 (34.85)

Patient Health Questionnaire (nine-items): The score ranges 0–27, with the cut-off values as follows: 0 = not at all, 1–4, minimal depression, 5–9 = mild depression, 10–14 = moderate depression, 15–19 = moderately severe depression, 20–27 = severe depression.²⁶ For this study, we used “no or minimal depression (i.e., score 0–4) = 0” and “mild to severe depression (i.e., score 5–27) = 1.” TV: television.

Among women who experienced any type of IPV, over three-quarters of the women IPV survivors reported experiencing less severe physical IPV (n = 580, 77.35%), and (n = 464, 57.89%) reported emotional IPV. Additionally, more than a quarter reported severe physical IPV (n = 251, 32.1%) and reported sexual IPV (n = 222, 28.15%), respectively (Table 3).

Table 3.

Prevalence of studied women who experienced different types of lifetime IPV (n = 754).

Type of IPV	No, n (%)	Yes, n (%)
Emotional IPV	290 (42.11)	464 (57.89)
Less severe physical IPV	174 (22.65)	580 (77.35)
Severe physical IPV	504 (67.94)	250 (32.06)
Sexual IPV	532 (71.85)	222 (28.15)

Emotional IPV includes (a) being humiliated, or (b) threatened with harm, or (c) insulted, or (d) made to feel bad by husband or partner. Less severe IPV includes (a) being pushed, shook, or (b) had something thrown, or (c) slapped or punched with fist or hit by something harmful by husband or partner. Severe IPV includes (a) kicked or dragged, or (b) strangled or burned, or (c) attached with knife/gun or another weapon by husband or partner. Sexual IPV includes (a) physically forced into unwanted sex, or (b) other unwanted sexual acts, or (c) physically forced to perform the sexual acts that respondents did not want to. IPV: intimate partner violence.

Results from bivariate analysis

Bivariate analysis revealed that a positive association between severity of depression and included variables. Specifically, a significantly larger proportion of women IPV survivors who reported mild to severe depression were observed in the following categories: Women IPV survivors who experienced emotional IPV (χ² = 14.73, p = 0.005), those who experienced sexual IPV (χ² = 13.22, p = 0.003), those with chronic diseases (χ² = 13.39, p = 0.002), and those who reported a big problem for access to healthcare (χ² = 8.94, p = 0.010). The detailed results are presented in Table 4.

Table 4.

Relationship between mild to moderate depressive symptoms and covariates: Results from bivariate analysis (column percent).

Exposure variables and covariates	Outcome variable: moderate to severe depressive symptoms (no, yes)
	n = 502	n = 252	n = 754	χ²	p-value
	No, n (%)	Yes, n (%)	Total, n (%)	χ²	p-value
Emotional IPV
No	223 (47.16)	67 (32.67)	290 (42.11)	14.73	0.005
Yes	279 (52.84)	185 (67.33)	464 (57.89)
Less severe physical IPV
No	110 (20.37)	64 (26.92)	174 (22.65)	4.19	0.068
Yes	392 (79.63)	188 (73.08)	580 (77.35)
Severe physical IPV
No	347 (69.27)	157 (65.44)	504 (67.94)	1.16	0.380
Yes	155 (30.73)	95 (34.56)	250 (32.06)
Sexual IPV
No	376 (76.21)	156 (63.71)	532 (71.85)	13.22	0.003
Yes	126 (23.79)	96 (36.29)	222 (28.15)
Age groups
15–19	37 (6.59)	17 (8.05)	54 (7.10)	6.82	0.670
20–24	71 (13.99)	36 (11.31)	107 (13.05)
25–29	75 (12.7)	35 (10.92)	110 (12.08)
30–34	101 (18.92)	40 (17.15)	141 (18.3)
35–39	85 (17.87)	48 (20.77)	133 (18.88)
40–44	73 (14.17)	50 (19.18)	123 (15.91)
45–49	60 (15.77)	26 (12.62)	86 (14.68)
Marital status
Never in union	79 (14.75)	39 (16.94)	118 (15.51)	1.98	0.943
Married	315 (60.70)	161 (60.61)	476 (60.67)
Living with a partner	10 (3.30)	5 (2.10)	15 (2.88)
Widowed	32 (7.14)	13 (7.99)	45 (7.44)
Divorced	9 (1.61)	4 (1.27)	13 (1.49)
No longer living with a partner	57 (12.50)	30 (11.09)	87 (12.01)
Respondents currently working
No	294 (51.93)	149 (52.62)	443 (52.17)	0.03	0.882
Yes	208 (48.07)	103 (47.38)	311 (47.83)
Education level
No education	11 (1.17)	2 (0.72)	13 (1.01)	6.55	0.326
Primary	198 (33.82)	97 (36.84)	295 (34.87)
Secondary	250 (52.13)	116 (44.06)	366 (49.32)
Higher	43 (12.89)	37 (18.38)	80 (14.8)
Wealth
Poorest	162 (21.00)	56 (12.90)	218 (18.17)	10.35	0.166
Poorer	89 (16.11)	51 (17.15)	140 (16.47)
Middle	93 (18.79)	50 (19.12)	143 (18.91)
Richer	91 (24.71)	45 (24.25)	136 (24.55)
Richest	67 (19.39)	50 (26.58)	117 (21.9)
Place of residence
Urban	163 (39.99)	102 (49.38)	265 (43.27)	6.15	0.076
Rural	339 (60.01)	150 (50.62)	489 (56.73)
Relationship to the household head
Self	123 (23.37)	70 (25.97)	193 (24.28)	2.6	0.800
Wife	217 (43.33)	107 (45.33)	324 (44.03)
Daughter	71 (14.52)	35 (13.34)	106 (14.11)
Daughter-in-law	28 (5.11)	13 (5.28)	41 (5.17)
Other	63 (13.67)	27 (10.07)	90 (12.42)
Sex of household head
Female	199 (37.48)	112 (40.17)	311 (38.42)	0.53	0.549
Male	303 (62.52)	140 (59.83)	443 (61.58)
Chronic disease
No	409 (77.52)	178 (65.13)	587 (73.2)	13.39	0.002
Yes	93 (22.48)	74 (34.87)	167 (26.8)
Witnessed father’s physical abuse toward their mothers
No	257 (51.48)	122 (50.52)	379 (51.14)	0.06	0.826
Yes	245 (48.52)	130 (49.48)	375 (48.86)
Access to health: Big problem
No	276 (62.81)	121 (51.57)	397 (58.89)	8.94	0.010
Yes	226 (37.19)	131 (48.43)	357 (41.11)

IPV: intimate partner violence.

Results from multivariable binary logistic regression

The multivariable binary logistic regression was adjusted for the following: Exposure variables (i.e., emotional IPV, less severe physical IPV, more severe physical IPV, sexual IPV), sociodemographic variables (i.e., age, marital status, education, current employment, wealth index quintile, urban/rural), and other important covariates (i.e., household composition such as gender and relationship to the household head and number of children, presence of chronic diseases, witnessing father’s physical abuse toward their mothers, and whether access to healthcare was a big problem). The results showed that women who experienced emotional IPV (adjusted odds ratio (aOR) = 1.76, p = 0.013) and sexual IPV (aOR = 1.70, p = 0.036) had higher odds to experience mild to severe depression than those who reported no emotional or sexual IPVs. Women from the poorer wealth quintile group (aOR = 2.04, p = 0.032) had a higher odd to report mild or severe depression than those from the poorest wealth quintile. Likewise, those who had chronic diseases (aOR = 1.79, p = 0.011) had a higher odd to experience mild to severe depression compared to those who did not. Finally, the individuals who reported a big problem accessing healthcare had a higher odd of reporting mild to severe depression symptoms compared to those who did not have such problems (aOR = 1.88, p = 0.001). The detailed results are presented in Table 5.

Table 5.

Multivariable binary logistic regression result showing the predictor of mild to severe depressive symptoms among women intimate partner violence survivors (n = 754).

Outcome variable: Severity of depressive symptoms
Reference = no or less severe depressive symptoms	aOR (mild to severe depressive symptoms)	95% CI (LB–UB)	p-value
Exposure variables
Emotional IPV
No	Reference
Yes	1.76	1.13–2.74	0.013
Less severe physical IPV
No
Yes	0.70	0.42–1.16	0.162
Severe physical IPV
No	Reference
Yes	1.23	0.77–1.96	0.421
Sexual IPV
No	Reference
Yes	1.69	1.03–2.78	0.038
Sociodemographic variables
Age groups
15–19	Reference
20–24	0.57	0.20–1.65	0.299
25–29	0.59	0.23–1.51	0.267
30–34	0.49	0.15–1.58	0.233
35–39	0.65	0.18–2.41	0.522
40–44	0.81	0.23–2.89	0.747
45–49	0.39	0.09–1.64	0.199
Marital status
Never in union	Reference
Married	0.89	0.49–1.59	0.685
Living with a partner	0.68	0.15–3.03	0.608
Widowed	1.23	0.41–3.66	0.712
Divorced	0.39	0.05–3.09	0.370
No longer living with a partner	0.84	0.38–1.85	0.659
Respondents currently working
No	Reference
Yes	0.65	0.41–1.04	0.070
Education level
No education	Reference
Primary	1.99	0.18–22.10	0.576
Secondary	1.39	0.12–16.06	0.789
Higher	2.35	0.20–27.86	0.496
Wealth
Poorest	Reference
Poorer	2.08	1.09–4.00	0.027
Middle	1.86	0.91–3.79	0.089
Richer	1.76	0.80–3.86	0.159
Richest	2.61	0.99–6.87	0.052
Place of residence
Urban	Reference
Rural	0.66	0.36–1.20	0.175
Household composition
Relationship to the household head	Reference
Self
Wife	1.43	0.50–4.05	0.502
Daughter	1.04	0.49–2.23	0.910
Daughter-in-law	1.41	0.51–3.90	0.511
Other	0.69	0.32–1.49	0.349
Sex of household head
Female	Reference
Male	0.79	0.37–1.69	0.540
Number of children	0.98	0.81–1.19	0.873
Other covariates
Chronic disease
No
Yes	1.79	1.14–2.79	0.011
Witnessed father’s physical abuse toward their mothers
No	Reference
Yes	1.08	0.76–1.55	0.655
Access to health: Big problem
No	Reference
Yes	1.86	1.28–2.71	0.001
Constant	0.24	0.02–3.59	0.300

aOR: adjusted odds ratio; 95% CI: 95% confidence interval; IPV: intimate partner violence.

Discussion

This study investigated the factors associated with the severity of depression among women IPV survivors in Lesotho. Specific objectives were: (a) to assess the prevalence of various forms of IPV among women in Lesotho, (b) to identify the severity of depressive symptoms experienced by women based on their exposure to different types of IPV, and (c) to examine factors that influence the severity of depression among women IPV survivors.

Our investigation identified less severe physical IPV as the most prevalent form, but the White et al. study found emotional IPV to be the most prevalent type.¹⁰ This finding underscores the potential value of a country or culturally specific study examining the relationship between varying degrees of mental health and different types of IPV for future research and interventions.

Among the different depression symptoms, 46.02% of studied women reported feeling down, depressed, or hopeless and 18.93% reported suicidal thoughts. Also, among different types of IPV, more than three-quarter (77.35%) of women reported less severe physical IPV, followed by emotional IPV (57.89%), severe physical IPV (32.06%), and sexual IPV (28.15%), respectively. These findings suggested that severe depressive symptoms and IPV are still public health issue that required urgent attention to prevent further worsening of situation. Interestingly, our study’s findings regarding the most common IPV were contradicted by a prior study conducted by White et al.¹⁰ This finding may be attributed to cultural difference.

Our study also found that women who experienced emotional and sexual IPV had a higher odd of mild to severe depression. Our finding aligns with the finding from previous systematic reviews by White et al.¹⁰ in which the authors found that women who experienced different types of IPV had differing levels of adverse mental health conditions, including depression, anxiety, and sleep disorders.¹⁰ Furthermore, our study agrees with findings from Radell et al.³⁸ which found that emotional violence was associated with depression.³⁸

Depression may indeed originate from relational issues between intimate partners. A prior study by Tuthill et al.³⁹ demonstrated a positive association between depression and relationship factors such as lower intimacy and relationship satisfaction, indicating that these factors may serve as a causative pathway to either IPV or depression.³⁹ Moreover, previous research has indicated that individuals with violent experiences could have PTSD, which, if left untreated, can result in mental and medical issues.⁴⁰ Our findings necessitate additional investigation into the potential mediating role of various relationship problems on IPV and mental health. Additionally, Oram et al.⁴¹ found that mental health conditions may serve as risk factors for IPV.

Our findings of a higher odds of mild to severe depression among poorer women compared to those who were from the poorest wealth quintile group contradicts with some research in the United States.⁴² Makram et al.⁴² reported a positive association between a higher poverty ratio and overall mental health outcomes including depression, anxiety, stress, and bipolar disorders.⁴² Also, it was reported that the severity of depression was highest among the individuals from lower-wage categories compared to those from the higher-wage categories.⁴³ Future research on income and mental health is needed, especially among those who experienced IPV, considering other important covariates such as comorbid conditions, country, culture, and specific geographic areas.

This study found that women IPV survivors who had chronic diseases had a higher odd of reporting mild to moderate depression symptoms compared to those who did not have chronic diseases. This could also have bidirectional effect as there was evidence that those who experienced IPV had were more likely to experience chronic diseases,⁶ chronic pain,⁴⁴ and chronic fatigue syndrome,⁴⁵ and stressful experiences (i.e., worries and fear about their safety and loss of marriage and support).⁴⁶ Having had IPV experience and living with a chronic condition may have compounded effects on severity of mental health conditions which warrant a need for further research.^6,45,47

The fact that individuals who reported a big problem (i.e., permission to go, money needed for treatment, distance to health facility, and not wanting to go alone) in accessing healthcare showed a higher likelihood of mild to severe depression is as expected. Our findings align with the prior study’s findings of challenges in accessing healthcare by women IPV survivors including financial concerns, community stigma, and lack of trust to healthcare providers.⁴⁷ A prior study with women IPV survivors conducted by Sorrentino et al.⁴⁶ reported that client-centered mental healthcare, including flexibility and responsiveness was needed.⁴⁶ All these findings suggested that further research is needed, including health insurance coverage and availability of quality healthcare professionals for mental health treatment.

This study did not find any significant association between the place of residence and mild to moderate depression, contradicting prior research findings.^48,49 The research by Duthé et al.⁴⁸ indicated a positive relationship between urban poverty and major depressive episodes contradicts an earlier study from South Africa that reported lower depression rates among urban residents compared to their rural counterparts. Meanwhile, another study by Onuh et al.⁴⁹ found that low depression status was somewhat similar in urban (82.2%) and rural (81.3%) residents.⁴⁹ These inconclusive findings on the relationship between urban–rural residents and adverse mental health issues warrant further research. Perhaps it might be beneficial to consider the availability of green spaces or natural environments while evaluating mental health issues in urban and rural locations.⁴¹ A prior study by Makram et al.⁴² reported that regardless of urban and rural, the individuals living in areas with a higher nature score (based on green spaces including parks, trees, noise and air pollution, etc.,) showed a lower likelihood of depression. It seems prudent to consider other environmental factors that may influence differences in such urban–rural-related findings.

Although we did not find any significant relationship between women who witnessed their father’s physical abuse toward their mothers and mental health issues, a prior study in Peru found significant association between witnessing a father’s abuse toward their mothers and different types of IPV.⁵⁰ Studies also suggested that adverse childhood experiences (i.e., prior to the age of 18) such as neglect, abuse, and household dysfunction had a positive relationship with IPV victimization, as well as perpetration.^51–55 Our present study’s data cannot ascertain the exact age at which participants witnessed their father’s abuse toward their mothers; however, exploring the association between the exact age range of witnessing father’s physical abuse toward their mothers in future research is justified.

Limitation

This study examined the relationship between different types of IPV and mental health outcomes using the most recent nationally representative women’s data from Lesotho; however, certain limitations existed. First, cross-sectional studies exhibit antecedent–consequent bias, meaning causation cannot be established.⁵¹ Therefore, the sequence of onset between IPV and depression symptoms remains indeterminate due to the potential for a bidirectional effect.⁵¹ Second, there could be social desirability bias because of the self-reporting nature of the survey and potential victimization for both conditions in Lesotho’s society, which could lead to underreporting. Third, in our study, we used more general terms such as “depressive symptoms” or “mental health conditions” rather than the term “disorders” because of the self-reported nature of data used in this study, necessitating caution in interpretation and generalization.

Conclusion

The present study examines the factors that affect mild to severe depressive symptoms based on different types of IPV in Lesotho women. Overall, a significant proportion of women in intimate partner relationships exhibited mild to severe depressive symptoms, highlighting an urgent and immediate intervention to address the depression irrespective of its severity to prevent worsening lifelong impact. Further research is warranted to investigate different severity of depression and different subtypes of IPV. Also, having considerable prevalence of IPV means the current efforts are not enough. These findings suggest that current interventions and policy required to review and addressing IPV issues is urgently needed to prevent mental health problems among women. All these findings suggest that current available resources for mental health treatment, safe spaces, and employment opportunities for IPV survivors should be reviewed and improved accordingly. Despite many efforts globally and in Lesotho, urgent and immediate attention is required to lower IPV and depression rates among Lesotho women.

Practical implications and future research directions

Despite many efforts including interventions and research,^23,56–58 further research should focus on accessibility, affordability, and availability of mental health services for women of different age groups,^23,56 especially for women IPV survivors⁵⁷ and those with chronic diseases. Perhaps, IPV screening services should be in place with other health services to provide patient-centered trauma-informed care for women who may have been exposed to IPV. Additionally, alternative mental health services such as home-based, telehealth, or internet-based interventions to reach those who may have challenges accessing health services should be reviewed and considered.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251387843 – Supplemental material for Factors associated with severity of depression among women intimate partner violence survivors in Lesotho: A cross-sectional study

Supplemental material, sj-docx-1-whe-10.1177_17455057251387843 for Factors associated with severity of depression among women intimate partner violence survivors in Lesotho: A cross-sectional study by Wah Wah Myint, Aishatu Yusuf, Elfreda Samman, Angela Nguyen, Sara E. Mendez and Heather R. Clark in Women's Health

Footnotes

Acknowledgements

The authors would like to thank the DHS program (Shireen Assaf). Social Science Researcher and Data Analyst) for sharing the codes ().

ORCID iDs

Wah Wah Myint

Aishatu Yusuf

Elfreda Samman

Angela Nguyen

Ethical considerations

For this specific study, we used de-identifiable, publicly available secondary data, in compliance with Helsinki Declaration, and therefore, ethical approval for the present study is not applicable. However, the original study received ethical approval from the Institutional Review Board (IRB) of the Inner-City Fund (ICF).²⁶ The ICF IRB ensures that the DHS-Lesotho survey complies with the U.S. Department of Health and Human Services (HHS) regulations for the protection of human subjects (45 CFR 46).

Consent to Participate

For this specific study, we used de-identifiable, publicly available secondary data, in compliance with Helsinki Declaration, and therefore, obtaining informed consent from participants for the present study is not applicable.

Consent for publication

Not applicable.

Author contributions

Wah Wah Myint: Conceptualization, data curation; investigation; formal analysis; validation; visualization; writing – original draft; and writing-review and editing.

Aishatu Yusuf: Conceptualization; investigation, visualization; and writing – review and editing.

Elfreda Samman: Conceptualization; investigation, visualization; and writing – review and editing.

Angela Nguyen: Visualization; Writing – review and editing.

Sara E. Mendez: Visualization; Writing – review and editing.

Heather R. Clark: Visualization; Writing – review and editing, and supervision.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

We used the deidentified publicly available data which can be downloaded from the .

Supplemental material

Supplemental material for this article is available online.

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