Youth unemployment and Mental Health: Prevalence and determinant factors of depression among unemployed young adults in Gedeo zone, Southern Ethiopia


 Background: The high rate of unemployment among young adults (aged 18 to 30 years) is a public health concern. The risk of mental health problems like depression is higher among the unemployed than among the employed. However, little is known about the prevalence and determinants of depression among unemployed young adults in Ethiopia. Hence, this study is aimed to assess the prevalence and determinant factors of depression among unemployed young adults in Gedeo zone, Southern Ethiopia. Methods: Community based cross sectional study design was conducted among 1419 unemployed young adults in Gedeo zone, Southern Ethiopia from May to July, 2019. Systematic random sampling technique was used to select study participants. Data on socio-demographic characteristics of unemployed young adults was collected by using structured questionnaire and presence of depression was assessed by Patient Health Questionnaire-9 (PHQ-9). Data was coded and entered into Epi-Data version 3.1 and analyzed by SPSS version 20. A multivariable logistic regression analysis was carried out to identify factors associated with depression, and variables with p-values < 0.05 were considered as statistically significant. The strength of the association was presented by adjusted odds ratio with their 95% confidence interval. Result: The overall prevalence of depression among unemployed young adults in the present study was 30.9% (95% CI: 28.4%, 33.1%). Of the total study participants with depression, 249(17.5%) had mild depression, 158(11.1%) had moderate depression, and 32(2.3%) had severe depression. Being male (AOR=1.40, 95%CI: 1.10, 1.80), long duration of unemployment (≥1years) (AOR=1.56, 95%CI: 1.21, 1.99), low self-esteem (AOR=1.32, 95%CI: 1.03, 1.68), poor social support (AOR=1.98, 95%CI: 1.34, 2.93), and current alcohol use (AOR=1.86, 95%CI: 1.33, 2.59) were significantly associated with depression among unemployed young adults. Conclusion : Our study revealed a high prevalence of depression among unemployed young adults, with three out of ten unemployed young adults having significant depression. Being male, long duration of unemployment, low self-esteem, poor social support, and current alcohol use were statistically significant with depression. Therefore, our study suggest that Policy makers, program planners, and other concerned bodies should establish appropriate strategy for prevention, early detection and management of depression among unemployed young adults.

usually perceived as a very stressful life event [14][15][16]. In their systematic literature review and meta-analytic study, Paul and Moser [17] reported that unemployed person does not have an access to the five latent functions of employment like structured time, social contact, collective purpose, social status and activity. The Authors indicate that the absence of these factors causes depression. Unemployment is measured using the following three criteria: (1) without work (2) available for work and (3) seeking work [18]. However, this definition varies in the context of developed and developing countries. In the developed countries where the labour market is largely organized and labour absorption is adequate, unemployment is measured based on the standard definition of the seeking work criteria that is having taken active steps to search for work during specified reference period (i.e. during last one week).
On the other hand, in developing countries like Ethiopia, where there is no strong labour market information, labour absorption is inadequate and where the labour force is predominantly self-employed, the standard definition with its emphasis on seeking work criteria is somewhat restrictive and might not fully capture the prevailing employment situation. The relaxed definition which measures unemployment in relation to" without work" and "availability for work" criterion is found to be more plausible in most developing countries.
The number and rate of unemployed people, in both developed and developing countries, is currently increasing than ever before. According to International Labour Unemployment has been shown to have wide range effects on mental health from which depression is the most common mental health problems particularly among young people.
The estimated prevalence of depression among unemployed young adults varies across the studies due to different methods, tools and sample size. A systematic literature review and meta-analysis study (237 cross-sectional studies and 87 longitudinal studies) found prevalence of depression among unemployed individuals with range from 13-14% [17].
Based on the cross-sectional study conducted among 426 unemployed people in United State of America by using the Center for Epidemiological Study Depression Scale (CES-D), the reported prevalence of depression was 29% [21]. According to recent cross-sectional study from Greece conducted among 1064 unemployed young adults by using Depression Anxiety Stress Scale (DASS-21), the reported prevalence of depression was 32.2% [22].
Another cross-sectional study conducted in Spain among 244 unemployed young adults by using Zung's self-rating depression scale (SDS) showed the prevalence of depression with its severity: 41.8% slight depression, 42.2% moderate depression and 9.3% severe depression [23]. Similar study done in Korea among 124 unemployed young adults by using Beck Depression Inventory-II (BDI-II) found prevalence of depression 39.5% [24]. Another cross-sectional study done in Bangladesh among 304 unemployed young adults by using Depression Anxiety Stress Scale (DASS-21) showed prevalence of depression 49.3% [25].
Unemployment among young people has been described as having serious consequences for future lives of young adults and for society at large. Previous studies have suggested that unemployed young people are more likely to have poor physical health [37,38], engage more frequently in criminal behaviors [39], increased risk of smoking [40], increased risk of alcohol consumption and substance abuse [39,41]. Moreover, unemployment among young people has been associated with higher mortality rates due to suicide [39,42] and alcohol-related mortality [43]. Furthermore, unemployment among young adults results substantial crises in psychological, social and economic perspectives, some of them are: increasing crime rates and violence, dependence on family, low self esteem, poor social adaptation, depression and loss of confidence [44].
Despite the increasing rate of unemployment, in turn, which increase the risk of mental health problems (i.e. depression) among unemployed young adults, there is less attention given for this major public health issue in African countries, particularly in Ethiopia. To the best of our knowledge no study has been conducted to assess prevalence and determinant factors of depression among unemployed young adults in Ethiopia as well as in the study area. Therefore, the present study will assess prevalence and determinant factors of depression among unemployed young adults in Gedeo zone, Southern Ethiopia. The findings of this study will help health programmers and policy makers at large to design preventive strategies and intervention programs of mental health problems for unemployed young people.

Study design and period
Community based cross sectional study was conducted to assess prevalence and determinants of depression among unemployed young adults in Gedeo zone, Southern Ethiopia from May to July, 2019.

Study Area
The study was conducted in Gedeo zone, Southern, Ethiopia. Gedeo zone, located in the southern part of the country, is one of the 14 Zones of South Nation, Nationalities and

Study Populations
All unemployed young adults aged 18-30 years old who were graduated from college or university and living in the study area (in the selected districts and town administration of the zone) for at least six months prior to the study were study population. Unemployed young adults who were severely ill and unable to communicate during study period were excluded.

Sample Size determination and Sampling procedures
In this study, sample size was calculated using EPI-Info version 7 statistical software (Epiinfo/StatCalc) by taking the following assumptions: 80% power, 95% confidence interval, 15% proportion of depression among exposed group (female) and 9.6% among unexposed group (male) [46] and 10% non-response rate. Thus, the total sample size required for the study was 1452. Out of the six districts and two town administrations of Gedeo zone, two districts (Bule district and Gedeb district) and two town administrations (Dilla town and Yirgacheffe town) were selected randomly by using lottery method. Then from each selected town administration and town of selected district three kebeles (the smallest administrative unit in Ethiopia) were selected randomly by using lottery method. To fix a sampling frame, we conducted census of households with unemployed young adults prior to actual data collection for one week by eight data collectors and numbering of households was done in the selected kebeles. Population proportion allocation was done to identify representative study participants from each district and town administration.
Finally, systematic sampling technique with an interval (K) was used to select study participants. The first study participant was selected using lottery method, and every three (3) households was interviewed for Dilla town, every four (4) household was interviewed for Gedeb district, every four (4) household was interviewed for Bule district and every six (6) household was interviewed for Yirgacheffe town. In situations where households had two or more eligible study participants, only one was selected by lottery method.

Data collection tools and procedures
The structured questionnaire was used to collect data regarding information about the study participants' socio-demographic characteristics such as age, sex, marital status, ethnicity, religion, educational level and duration of unemployment.
Patient health questionnaire-9(PHQ-9) based on the DSM-IV criteria was used to assess the presence of depression with recall period of two weeks [47]. The scale consists of 9-items representing symptoms of depression and each symptom will be rated on a 4-point scale indicating the occurrence and the severity of symptoms: 0(not at all), 1(several days), 2(more than half the days) and 3(nearly every day). The PHQ-9 items showed good internal reliability with Cronbach's alpha of 0.84 for primary health care setting and general population [48]. A cutoff score of 10 was established for the PHQ-9 (sensitivity 86.49%, specificity 89.36%), correctly classifying 86.4% of patients with current depression in primary health care setting [48].
The presence of substance use was measured by using WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) tool [49]. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) was developed for the World Health Organization (WHO) by an international group of researchers and clinicians as a technical tool to assist with early identification of substance use related health risks and substance use disorders in primary health care, general medical care and other settings [49].
The self-esteem was measured with Rosenberg Self-esteem Scale (RSES). The scale is a 10-item self-report scale designed to measure global self-esteem with a Cronbach alpha reliability range of 0.79 to 0.86 [50]. Some items in the scale are "I feel that I have a number of good qualities," "I feel I do not have much to be proud of," and "At times I think I am no good at all." Responses are provided on a 4-point Likert scale ranging from "Strongly Agree" (with 4 marks), "Agree" (3 marks),"Disagree" (2 marks) and "Strongly Disagree" (1). Items 3, 5, 8, 9 and 10 are reverse scored in which a "Strongly Agree" response attracts 1 mark, "Agree" with 2 marks,"Disagree" with 3 marks and "Strongly Disagree" with 4 marks. The scale ranges from 0 to 30: a score greater than 15 suggest high self-esteem and scores less than 15 suggest low self-esteem [50].
Social support was measured by using three items Oslo social support scale (OSS-3) [51].
Social Support-Oslo three items social support scale (OSS-3) provides a brief measure of social support and functioning and it is considered to be one of the best predictors of mental health. It covers different fields of social support by measuring the number of people the respondent feels close to, the interest and concern shown by others, and the ease of obtaining practical help from others. In order to score OSS-3, total scores are calculated by adding up the raw scores for each item. The sum of the raw scores has a range from 3-14.The Cronbach's alpha level of OSS-3 is relatively low (.50). In this case, however, the low Cronbachs's alpha does not necessarily reflect a low reliability, but rather the multidimensional structure of the index [51].
The questionnaire was first prepared in English and translated to Amharic (local working language) by language experts and was translated back to English by another person to ensure consistency and accuracy. The data collectors and supervisors were recruited based on previous experience on data collection and supervision. Training was given for three consecutive days for data collectors and supervisors on how to interview, handle ethical issues, supervise and maintain confidentiality and privacy of study subjects. The data collection instrument was pre-tested on 5% of the actual sample size in similar setting, and amendments were made accordingly. Data was collected by trained eight BSc Psychiatry Nurses and supervised by four MSc Mental health professionals and the principal investigator. Finally, after checked completeness of the required type of data by principal investigator and supervisors the completed data was coded.

Data analysis
The data was checked for completeness, coded and entered into Epi-Data version 3.1 and exported to statistical package for social sciences (SPSS) version 20 for analysis. Means, frequencies, and percentages were used to summarize data and figures, tables and text to present data. Bivariate analysis was done to see the associations of each independent variable with depression among unemployed young adults. Variables which had p-value less than 0.2 were considered for the multivariable logistic regression to control the effects of confounding variables. The Hosmer-Lemeshow goodness of fit test was checked for the model. Finally, Variables which had P-values less than 0.05 on multivariable logistic regression were considered as statistically significant and were identified on the basis of OR with 95% C.I.

Results
Socio-demographic characteristics of unemployed young adults A total number of 1419 unemployed young adults were participated in the present study with the response rate of 97.7%. The mean age of the study participants was 23.7 (SD ± 3.35) years, and 837 (59%) of the participants were in the age range of 18-24 years.
Among unemployed young adults participated in the current study, 820 (57.8%) were males and 599(42.2%) were females. Of the 1419 respondents, 991(69.8) were single, 1066 (75.1%) were Gedeo in ethnicity, and 607 (42.8%) were Orthodox in religion. Six hundred seventy four (47.5%) of participants had diploma educational level, and 688(48.5%) of participants had poor social support. Regarding duration of unemployment, 951 (67%) of study participants had duration of unemployment less than one year and followed by those who had ≥ 1 year duration of unemployment, 468(33%). Of the total unemployed young adults participated in the study, 788(55.5%) had high self-esteem, and followed by those who had low self-esteem, 631 (44.5%) as measured by Rosenberg Selfesteem Scale (Table 1).   (Fig. 2).

Substance use among unemployed young adults
Both lifetime and current substance use was measured in our study by using ASSIST WHO tool. The overall rate of lifetime substance in our study was 44.7% (95%CL: 41.8%-47.4%).
On the other hand, the overall prevalence of current substance use in the present study was 38.8% (95%CL: 36.2%-41.3%). Of the total current substance users, 26.3% were alcohol users, 30.6% were khat users, 20% were cigarette smokers, and 12.3% were illicit drug users (e.g. marijuana, cannabis) (Fig. 4) reported the higher prevalence of depression (34.4%) among long-term unemployed people measured by using Patient Health Questionnaire-9 (PHQ-9) as compared to the result of our study (30.9%). Also the results of studies conducted in Spain (51.5%) [23], Korea (39.5%) [24] and Bangladesh (49.3%) [25] were higher than the findings of our study.
The reason for variation might be due to difference in sample size, as it was 365 in Germany, 244 in Spain, 901 in Greece, and 301 in Bangladesh, whereas it was 1419 in this study. The assessment instrument might also be the possible reason for the differences in the prevalence of depression among unemployed people. For instance, the previous studies conducted in Germany, Greece, and Bangladesh used Depression Anxiety Stress Scale (DASS-21) to assess depression, whereas our study used the Patient Health Questionnaire-9 (PHQ-9). The other explanation for the difference might be due to the type of data collection procedure that researchers used (interviewer administered versus self-administered) and the study settings (community based versus institutional based).
The present study identified factors associated with depression among unemployed young adults. Sex was identified as a significant variable, as men were 1.40 times more likely to experience depression relative to women. Our study finding is consistent with findings of previous studies that found unemployed men were more likely to be affected by depression [26,27], but the finding of our study is inconsistent with those of previous studies that reported unemployed women exhibited higher rate of depression [28, 46, 52].
The reasons why unemployed men are more affected by depression than women might be due to unemployed man should experience stronger distress due to his failure to fulfill his central duty of his life-the role of family provider. In addition, masculine identity is intricately linked to having a job in most developing countries including Ethiopia and is severely threatened by unemployment related distress like depression. Furthermore, for women, on the other hand, work is seen as only one of several roles (e.g. the role of being wife and mother are assumed to be as important as work in women's lives). For example, Dew and Bromet [26] found that unemployment has a lesser impact on women which might be due to different gender roles with women valuing their jobs less and gaining more selfesteem from their family. Additionally, two main arguments based on the study conducted by Shamir[53] to explain the reason why depression is more common among unemployed men than women were; First, men are assumed to have a higher commitment to the work role than women, resulting in stronger distress when deprived of this role. Second, women are assumed to have an alternative role that can serve as a substitute to employment.
In our study, we found that the likelihood of depression among unemployed young adults with long duration of unemployment (≥ 1 year) was found to be 1. their right not to participate or stop the interview at any time. Hence, informed verbal consent was obtained from the unemployed young adults who were involved in the study and participant involvement was on voluntary basis. Moreover, confidentiality of study participants was maintained by using codes rather than names.

Consent for publication
Not applicable Availability of data and materials Due to ethical issues and protection of confidentiality of the study participants, raw data cannot be provided. But, the summary data are available in the main document. When needed they are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
Dilla University funds the research project for data collection and analysis but not for publication.
Authors' contributions HM wrote the proposal, involved in study design, participated in data collection process, analyzed the data, and drafted the manuscript. KY and GA were involved in designing of the study and drafted the manuscript. All authors read and approved the final manuscript.    Prevalence of current substance by type of substance among unemployed young adults living in Gedeo zone, Southern Ethiopia, 2019.