Depressive Symptoms Among People with Direct Exposure to Natural Disasters in Ethiopia: Focused on the Moderating Effects of Health Insurance

Abstract

Background: Disasters are categorized as either natural or manmade and the cause of disaster defines the type of disaster. Natural disasters are caused by natural phenomena and, recently, the occurrence of natural disaster has been on the rise due to climate change and the damage is substantial. Exposure to natural disasters not only jeopardizes the physical health but also the mental health of the affected population. Globally, psychological distress has been reported following natural disasters, irrespective of the magnitude of disasters or countries' income levels. Nevertheless, the impact of natural disasters disproportionately affects low-and-middle income countries (LMICs), and particularly vulnerable populations who lack the necessary resources to alleviate the psychological distress caused by the shocks. This disparity often results in untreated mental health conditions and can have a disproportionate impact on the mental health of directly affected individuals. Ethiopia is particularly vulnerable to various natural disasters with frequent occurrences of droughts and floods. When exposed to these various natural disasters, people suffer from various psychological disorders and of all the disorders, depression is widely reported as a common mental disorder. In fact, the prevalence of depression in Ethiopia is 9.1%, which is the highest prevalence among the psychological disorders within the country. This study primarily focuses on depressive symptoms of adult population in the aftermath of natural disasters in Ethiopia. Cognizant of such serious national health issue, the government of Ethiopia has responded actively to mental health problems by integrating mental health care services into primary care since 2012, making these services accessible and affordable. In order to improve accessibility to mental health services, it is critical that more Ethiopians have health insurance, yet only one-third of the population has health insurance. Despite the significant prevalence of mental health problems in Ethiopia, empirical evidence on the relationship between mental health, health insurance, and natural disasters is scarce. Furthermore, the topic of mental health remains largely unfamiliar within the country, and stigma and discrimination towards people with psychological disorders continue to persist. As a result, there is an urgent need to generate empirical evidence on whether health insurance protects the mental health of the population directly affected by natural disasters in Ethiopia with the aim of eliciting policy implications for Ethiopia and other developing countries. Therefore, this study aims to estimate the effects of natural disasters on mental health and moderating effects of health insurance on depressive symptoms among Ethiopians directly exposed to natural disasters.

Methodology: The present study used the Disaster Poverty Household Survey (DPHS) data collected in Addis Ababa and Dire Dawa by the World Bank in May and June 2017 to examine the impact of natural disasters on mental health and the potential moderating effects of health insurance. The DPHS data captured critical information on household characteristics, living conditions, coping strategies, and disaster experiences, which provided a comprehensive assessment of poverty-related disaster risks. In the analysis, the study conducted OLS regression to estimate depressive symptoms as a continuous variable and multiple regression model using both probit and linear probability model to estimate depressive symptoms as a binary variable. Also, the analysis was carried out using three models: model 1 for exposure to natural disasters, model 2 for possession of health insurance and model 3 for the interaction term between exposure to natural disasters and health insurance. For control variables, age, sex, education attainment, marital status, religion, asset ownership, labor participation, social (financial) support, illness, and access to health facility were selected. To ensure a rigorous comparison of disaster exposure, propensity score matching (PSM) methodology was performed. The study first estimated the effects of direct exposure to natural disasters on depressive symptoms measured using the 10-item Center for the Epidemiological Studies of Depression Short Form (CES-D-10). Second, the effects of health insurance on depressive symptoms among those directly exposed to natural disasters were explored.

Result: The findings of this study demonstrated a positive association between direct exposure to natural disasters and depressive symptoms and statistically significant at 1% level, while the negative association between health insurance and depressive symptoms among the affected population was not statistically significant. Furthermore, the results demonstrated that being married or in a consensual union, owning a refrigerator as an asset, and social (financial) support were negatively associated with depressive symptoms and the effects were statistically significant (p<0.1, p<0.1 and p<0.01, respectively).

Conclusion: Direct exposure to natural disasters in Ethiopia poses a significant risk to the depressive symptoms of affected individuals. Additionally, several sociodemographic factors such as marital status, asset ownership, and social (financial) support had a significant association with reduced depressive symptoms. However, health insurance was not found to have a statistically significant effect on reducing depressive symptoms among those who experienced natural disasters. Such results are likely due to various factors such as small number of insured populations, stigma towards mental illness, and inadequate resources for mental health services. Further, the results demonstrate that in order for health insurance to properly work simultaneous efforts to raise awareness of mental health issues and treatment are required. This study underscores the importance of emotional and social (financial) support in the aftermath of a natural disaster, and emphasizes the access to mental health services as a part of disaster management strategies in developing countries. The evidence derived from this study will support the development of policies and interventions aimed at improving mental health outcomes for disaster-affected populations in Ethiopia and other LMICs, ultimately contributing to the progress of achieving the SDGs 11.5 and 3.8.