Social determinants of comorbid depression among patients living with diabetes and/or HIV at primary healthcare settings in Western Cape Province of South Africa

Tintinger, Susanet

Social determinants of comorbid depression among patients living with diabetes and/or HIV at primary healthcare settings in Western Cape Province of South Africa

Thesis / Dissertation

2025

Publisher

University of Cape Town

Department

Department of Medicine

Faculty

Faculty of Health Sciences

Abstract

The co-occurrence of physical and mental health conditions poses a significant public health challenge globally especially in low- and middle-income countries (LMICs). In South Africa, diabetes, HIV, and depression frequently co-occur in an intricate manner, and the illness experience is largely shaped by the differences between individuals, communities, and provinces. Previous research highlights the influence of socioeconomic factors on the relationship between diabetes, HIV, and depression, although the focus has mainly been on the variability in health outcomes explained by individual-level factors. There is a need for evidence on the mental health outcome variations attributable to distinct contextual levels amongst patients living with HIV and/or diabetes. This dissertation assesses the socioeconomic determinants of depressive symptoms among patients living with HIV and/or diabetes accessing healthcare at the primary health care (PHC) level in the Western Cape province. Furthermore, it examines the variation in depressive symptoms attributable to individual, household, and community levels among this sub-population. Baseline data collected from participants in a cluster randomised controlled trial, named Project MIND conducted in the Western Cape, was used in this analysis. This study applied a three-level multi-level logistic regression analysis. Random intercepts were added at the household and community levels using grouping variables for household socioeconomic status and PHC catchment areas to account for the heterogeneity across the data hierarchy levels. Four random intercept multi-level models were fitted sequentially. The estimated intraclass correlation coefficients (ICCs) were used to determine the proportion of the outcome variance attributable to the grouping- and individual-level variables for each model. Overall, the findings indicate that the variance in depressive symptoms among patients with HIV and/or diabetes can be explained by differences at the household- and community-levels when controlling for individual-level factors. Higher odds of moderate to severe depressive symptoms were significantly associated with being female, secondary level education, and food insecurity. Lower odds of moderate to severe depressive symptoms were associated with harmful/hazardous alcohol use, increased social support, and increased self-efficacy. This study highlights the importance of policies that simultaneously consider individual, household- and community-levels to address co-occurring mental and physical health conditions in the Western Cape. The findings support interventions at the PHC level and in the community to bolster social support systems and self-efficacy, promote mental health from early educational years, prioritise gender-sensitive health programs, and address household food insecurity among patients living with HIV and/or diabetes with depressive symptoms.