Depression, anxiety, and psychological distress among caregivers of young children in rural Lesotho: Associations with food insecurity, household death and parenting stress

Compromised mental health has far-reaching implications for the functioning of individuals, communities, and countries, contributing to increased years lived with disability, greater healthcare expenditures, and reduced economic opportunities. Recognizing these costs, mental health and well-being are specifically addressed in the global development goals for 2030. Despite an increased global focus on mental health in recent years people from low and middle-income countries (LMICs) continue to experience pervasive structural and social challenges that compromise their mental health. Mental health links prominently with other public health issues that persist in LMIC settings such as economic deprivation, HIV/AIDS, and gender ScienceDirect's AI-generated Topic Pages" class="topic-link" style="box-sizing: border-box; margin: 0px; padding: 0px; background-color: transparent; text-decoration: underline 1px rgb(46, 46, 46); color: rgb(46, 46, 46); word-break: break-word; text-underline-offset: 1px;">inequality 

LMICs carry 80% of the disease burden associated with depressive disorders, and 76% of the world's suicides take place in these countries. In addition, one in every four women in LMICs experience perinatal anxiety, suggesting higher prevalence rates compared to high-income countries. While studies from LMICs are limited, evidence from ScienceDirect's AI-generated Topic Pages" class="topic-link" style="box-sizing: border-box; margin: 0px; padding: 0px; background-color: transparent; text-decoration: underline 1px rgb(46, 46, 46); color: rgb(46, 46, 46); word-break: break-word; text-underline-offset: 1px;">systematic reviews shows that anxiety and depressive disorders are highly correlated. Despite this substantial burden, efforts to increase and improve service delivery for people affected by poor mental health in these settings remain inadequate. While the lack of equity around prevention and treatment exists between countries, there is also the issue of equity within countries – especially between urban and rural areas within LMICs (WHO). As an example, research from South Africa demonstrated rural-urban and spatial differences (hotspots of mental ill health) in the prevalence of depression status, with those in urban areas showing lower levels of depression compared to those living in rural areas.

Structural factors such as health infrastructure or social protection policies are important for mental health in that they determine the distribution of resources within a population and who has access to them. ScienceDirect's AI-generated Topic Pages" class="topic-link" style="box-sizing: border-box; margin: 0px; padding: 0px; background-color: transparent; text-decoration: underline 1px rgb(46, 46, 46); color: rgb(46, 46, 46); word-break: break-word; text-underline-offset: 1px;">Governance and policies related to education and health, as well as the social environments that shape gender norms and women's status in society, are key drivers that determine why, how, and for whom good mental health is unattainable. Poverty leads to a heightened risk of poor mental health by increasing exposure to risk factors such as adverse life events, food insecurity, and limited ScienceDirect's AI-generated Topic Pages" class="topic-link" style="box-sizing: border-box; margin: 0px; padding: 0px; background-color: transparent; text-decoration: underline 1px rgb(46, 46, 46); color: rgb(46, 46, 46); word-break: break-word; text-underline-offset: 1px;">education and employment opportunities. Women may be especially prone to poor mental health in contexts characterized by poverty, where they are often responsible for the care of young children and the upkeep of their household. Fulfilling caregiving responsibilities under highly challenging circumstances intensifies vulnerability, particularly in gender-unequal societies where women have limited economic agency.

For mothers and other caregivers who fulfill the primary parenting role, good mental health is a critical resource to support the health and well-being of children in their care. Caregiver mental health is central to the provision of responsive caregiving which forms the basis of quality caregiver-child interactions and promotes optimal child development. Mental health problems such as maternal depression can compromise child development across a range of domains, including physical and cognitive development, and later mental health outcomes for the child. Identifying caregivers in need of support is therefore crucial for both parental functioning and child wellbeing.

While there is a growing body of evidence on perinatal mental health in LMICs, less is known about parent mental health past the first year of childbirth. Most research has studied the mental health of mothers, while in many LMICs young children are cared for by other family members, such as grandparents. This is especially relevant in sub-Saharan Africa, where the HIV epidemic has significantly increased the number of orphans and vulnerable children. In addition, many parents from rural communities migrate to urban areas for work, leaving their children behind in the care of extended family.

Lesotho is a small, low-income country in southern Africa, where more than half the population (59.7%) live in extreme poverty. The country has the second-highest adult HIV prevalence rate globally, at 23.8%. One in four children are orphans, and over one-third of children do not live with either parent. Lesotho has no stand-alone ScienceDirect's AI-generated Topic Pages" class="topic-link" style="box-sizing: border-box; margin: 0px; padding: 0px; background-color: transparent; text-decoration: underline 1px rgb(46, 46, 46); color: rgb(46, 46, 46); word-break: break-word; text-underline-offset: 1px;">governmental policy or policy plan for mental health, and human resources allocated to mental health are scarce. Research about community-level mental health or access to services in the country has been extremely limited. A small lowland town with a sample of 356 adults, reported the prevalence of depression at 12.4% and ScienceDirect's AI-generated Topic Pages" class="topic-link" style="box-sizing: border-box; margin: 0px; padding: 0px; background-color: transparent; text-decoration: underline 1px rgb(46, 46, 46); color: rgb(46, 46, 46); word-break: break-word; text-underline-offset: 1px;">generalized anxiety disorder at 6.2%, using a structured psychiatric interview. More recently, depression has been studied in Lesotho using the Patient Health Questionnaire-9 (PHQ-9) screening tool among men who have sex with men, adult patients on antiretroviral treatment (69% female;  and TB-HIV patients (53% male). These studies reported moderate-severe depression symptoms at a rate of 16%, 29.8%, and 28.8%, respectively. Using the PHQ-9, depression has also been studied among inmates living with HIV (88.3% male) from three correctional institutions in Lesotho with 53% reporting mild-severe symptoms of depression. To the best of our knowledge, mental health among women and caregivers of young children in Lesotho has not previously been studied.

In this research paper, we examine the prevalence of depression, anxiety, and ScienceDirect's AI-generated Topic Pages" class="topic-link" style="box-sizing: border-box; margin: 0px; padding: 0px; background-color: transparent; text-decoration: underline 1px rgb(46, 46, 46); color: rgb(46, 46, 46); word-break: break-word; text-underline-offset: 1px;">psychological distress among caregivers of young children (ages 1–5 years) across 34 rural villages in Lesotho, and investigate the covariates of these mental health problems.