The association between household food insecurity and mental health

among adolescent girls and young women (AGYW) during the COVID-19

epidemic in South Africa

Stanley Carries1, Lovemore Sigwadhi2, Audrey Moyo2, Colleen Wagner3, Catherine Mathews1,

Darshini Govindasamy1

1
Health Systems Research Unit, South African Medical Research Council, South Africa
2
Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and

Health Sciences, Stellenbosch University, Cape Town, South Africa

3
Networking HIV and AIDS Community of Southern Africa (NACOSA), South Africa

Corresponding author: Stanley Carries, Email: stanley.carries@mrc.ac.za, Tel: +27795908363

pg. 1
Abstract

This study investigated the relationship between household food insecurity (HFI) and depressive

symptoms among adolescent girls and young women (AGYW) during the COVID-19 pandemic.

We conducted a secondary data analysis of survey data collected from December 2020 - February

2021 with N=515 AGYW (15-24 years) from six South African districts. Study data were drawn

from a cross-sectional study, HERStory, which was conducted from 01 December 2020 to 28

February 2021 during COVID-19 lockdown in South Africa. Those with a CES-D-10 total score

of ≥12 were deemed to have depressive symptoms. AGYW, who reported being worried about

food shortages, were classified as being exposed to HFI. We fitted the data using a multi-variable

robust Poisson regression model and controlled for sociodemographic and health factors. Most

AGYW were 20 years old, with 74% exposed to HFI and 30.29% with depressive symptoms.

AGYW exposed to HFI had 1.80 times the risk of depressive symptoms compared to those from

food secure households [adjusted risk ratio (aRR): 1.80; 95% CI: 1.35-2.42, p<0.0001)]. Targeting

AGYW exposed to HFI is a viable pandemic relief strategy to identify and link AGYW at risk for

developing depression.

Key words: Mental health, Household food insecurity, Adolescent girls and young women,

COVID-19, CES-D-10, depression

pg. 2
 Introduction

1 Globally, mental health disorders affect one in seven adolescents, yet remain largely undetected

2 and untreated despite the availability of effective treatments [1-3]. Depression is a major

3 contributor to the overall burden of disease and a leading cause of disability worldwide [4, 5]. The

4 global prevalence of clinical depression among young people (≤18 years) during COVID-19

5 (25.2%) [6] almost doubled the pre-COVID-19 estimate of 12.9% [2]. COVID-19-related

6 lockdowns disrupted daily routines, restricted social interactions and limited access to health and

7 social services [7]. The early stages of lockdown were associated with languishing mental health

8 [8], with women and younger people experiencing higher levels of depression, anxiety and stress

9 [9]. Adolescents and younger people generally felt more worried and helpless, and experienced

10 increased relationship problems and suicidal ideation compared to pre-COVID-19 levels [10].

11 Moreover, adolescents were reported to have increased engagement in risk behaviors (e.g.,

12 substance abuse) as negative coping mechanisms [10, 11]. Left untreated during early adolescence,

13 depression can have long term negative health, economic and social consequences in adulthood

14 [2]. Economic consequences include health system costs to treat depression and related

15 comorbidities, and reduced contribution to national economic output due to decreased productivity

16 [12].

17

18 Studies in South Africa have shown that AGYW are more vulnerable to depressive symptoms than

19 their male counterparts [3, 5]. More importantly, depression may be a precursor to the high

20 prevalence of HIV infection among South African AGYW [13] because of its association with

21 increased alcohol abuse and risky sexual behaviors [14], which are both risk factors for HIV

22 acquisition [13].

pg. 3
23

24 High income losses (30%) during the COVID-19 lockdown in South Africa amplified household

25 food insecurity (HFI) [15, 16]. Research indicates that HFI during the COVID-19 pandemic is

26 associated with mental health conditions [17-19]. In the United States, for instance, adults exposed

27 to HFI had 3.53 greater odds of being depressed (95% CI: 2.99-4.17) [18]. This was more

28 pronounced in sub-Saharan Africa (SSA) given the region’s pre-existing structural inequalities. A

29 study in Tanzania, for example, found that adolescents living in food-insecure households were

30 1.8 times at higher risk (95% CI: 1·3–2·5) of experiencing suicidal ideation and at a 2.4 times

31 higher risk (95% CI: 1·7–3·3) of attempting suicide [20]. In addition, a Kenyan study showed that

32 adolescents who skipped meals because of COVID-19-related household income losses, had 2.5

33 higher odds (95% CI: 2.0-3.1) of having depressive symptoms [19]. Against this backdrop, AGYW

34 have been neglected in COVID-19 recovery efforts [21].

35

36 AGYW are at a stage of life in which they build human and social capital essential for their

37 wellbeing in adulthood [22]. Failure to detect depression early in AGYW could impair their mental

38 health in adulthood. In South Africa, there are no existing measures to readily detect depressive

39 symptoms among AGYW in an already overburdened public health system.

40

41 Reports of increased depression levels among adolescents and women due to COVID-19 income

42 losses and HFI, inter alia, have increased the urgency for technologies to readily detect AGYW at

43 high risk of depression and by proxy, households possibly in urgent need of economic support.

44 HFI is a known predictor of depressive symptoms in adult populations globally [23, 24]. However,

45 few studies have quantitatively examined the association between HFI and depressive symptoms

pg. 4
46 among AGYW. Identifying AGYW at risk of developing depressive symptoms could help identify

47 factors to prevent and/or manage anxiety and depression among younger people and answer

48 international calls to examine the structural drivers of anxiety and depression among youth [25,

49 26]. This study aimed to determine the relationship between HFI and depressive symptoms among

50 AGYW during the COVID-19 epidemic in South Africa.

51

Materials and Method

52 Study setting and population

53 The data used for this secondary data analysis were drawn from a cross-sectional study, HERStory

54 [https://www.samrc.ac.za/intramural-research-units/healthsystems-herstory (SAMRC HREC

55 identifier: EC036- 9/2020)], which was conducted from 01 December 2020 to 28 February 2021

56 during COVID-19 lockdown in South Africa. The HERStory study evaluated a combination HIV-

57 prevention intervention for AGYW aged 15 – 24 years, the My Journey program

58 (https://www.myjourney.org.za), in six districts covering six South African provinces: Bonjanala

59 District (Northwest Province), Klipfontein (Western Cape Province), King Cetshwayo (KwaZulu-

60 Natal Province), Ehlanzeni District (Mpumalanga Province), Nelson Mandela Bay (Eastern Cape

61 Province), and Thabo Mofutsanyana District (Free State Province). The survey population was

62 AGYW aged 15-24 years enrolled in the My Journey program for at least one year.

63

64 In the survey, a team of female interviewers (aged 20-35 years), fluent in all languages spoken in

65 the sampled districts, were employed by the SAMRC. AGYW, whose contact details were in the

66 My Journey program database and who previously agreed to be contacted, were invited

67 telephonically to participate. All interviews were conducted once the AGYW self-reported being

pg. 5
68 in a safe and comfortable place to be administered the survey. The survey took approximately an

69 hour to complete. A reimbursement amount of ZAR 100 was sent to each AGYW participant

70 through electronic banking services. Further details of the survey methods can be found at

71 https://www.samrc.ac.za/intramural-research-units/healthsystems-herstory. For this secondary

72 data analysis, we used the entire study population in the dataset and did not restrict age or region.

73

74 Measures

75 Outcome:
76 The study outcome measure, depressive symptoms, was assessed using the Center for

77 Epidemiological Studies Depression Scale (CES-D-10). This scale is a brief depressive symptoms

78 screener consisting of ten items assessing an individual’s feelings over the past week. Eight items

79 cover negative feelings (i.e., feeling bothered, lack of focus, feeling depressed, feeling that

80 everything was an effort, feeling fearful, restless sleep, loneliness, and inability to get going), and

81 two items (questions 5 and 8) cover positive feelings (i.e., feeling happy and hopeful about the

82 future). The CES-D-10 scale has been psychometrically evaluated in a South African sample, and

83 showed good validity and reliability [27]. A cutoff point of 12 was deemed optimal for detecting

84 the presence of significant depressive symptoms in this sample [27].

85

86 Potential correlates
87 We evaluated the demographic, clinical, and socioeconomic factors potentially associated with

88 current probable depressive symptoms (see Appendix 1 for the description of variables).

89 Demographic variables included AGYW: age at recruitment, highest school grade completed,

90 enrolled in fulltime study before lockdown, disengaged in secondary or tertiary education in 2020,

91 and length of stay in community; clinical variables included: self-reported HIV status, lacked

pg. 6
 92 access to essential medication, and lacked access to family planning services; socio-economic

93 variables included: lacked access to social support services, violence at home, HFI (defined as

94 households where AGYW were worried about food running out because of lack of money during

95 COVID-19 lockdown), and household asset index score. We also used no meals for the whole day

96 as a proxy for HFI in the sensitivity analysis.

97

98 The following potential factor variables were dichotomized: highest school grade completed (≥

99 grade 9=1 vs. <grade 9=0), length of stay in community (< 5 years vs. ≥ 5 years), HIV status

100 (positive=1 or negative=0), lacked access to social support services (yes=1, no=0), disengaged in

101 secondary or tertiary education in 2020 (yes=1 vs. no=0); each of lacked access to essential

102 medication, lacked access to family planning services, violence at home, no meal for a whole day,

103 and HFI as (often/sometimes=1 vs. never=0). The age at recruitment was treated as a continuous

104 variable.

105

106 Statistical analysis

107 Continuous variables were expressed as medians with interquartile ranges because they were not

108 normally distributed. Categorical variables were expressed as frequencies and percentages. Chi-

109 squared and Fisher’s exact tests were used to assess the association between depressive symptoms

110 and categorical variables. The Mann–Whitney U test was used to assess median differences.

111 Owing to the high prevalence of depressive symptoms (30%), logistic regression overestimated

112 the effect measure with large standard errors, resulting in wide confidence intervals, and log-

113 binomial regression faced convergence problems. Robust Poisson regression was used as an

114 alternative to assess the associations between demographic and socioeconomic variables with

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115 depressive symptoms. Known factors linked to depressive symptoms, such as socioeconomic [28],

116 education, social inclusivity [29], age, and gender [29] were regarded as a prior confounders in

117 the model. Three different models were fitted and adjusted risk ratios with 95% CIs were used as

118 a measure of association. In the first model (Model 1) we adjusted for age at recruitment, length

119 of stay in community, highest school grade completed, and household asset index score. In Model

120 2, we added lacked access to social support services. In Model 3, we added lacked access to

121 essential medication. Multicollinearity was assessed using variance inflation factors (VIF), with a

122 VIF of less than five considered adequate for suggesting no multicollinearity [30]. All statistical

123 analyses were performed using STATA software (version 16, Stata Corp, College Station, Texas,

124 USA).

125

Results

126 Only 515 of the 2160 AGYW sampled were contactable by telephone and participated in the study,

127 giving an overall sample realization of 23.8%. The median age of the participants at recruitment

128 was 20 years (IQR:18-22). The self-reported HIV prevalence was 3.7%, and nearly 80% resided

129 in their community for more than 5 years (Table 1). Almost 97% of the participants had completed

130 their primary school education (i.e., grade 9), 77.3% were either attending high school (47.2%) or

131 college/university (30.1%) before the COVID-19 lockdowns were imposed. Nearly 23% were not

132 attending formal education when COVID-19-lockdowns were implemented, while 34% dropped

133 out of enrolled education in 2020. Slightly over 10% did not use social support services from social

134 workers within a year of the survey, 79.7% had access to family planning services, and 27.2%

135 indicated that they were unable to obtain essential medication because of COVID-19 or lockdown.

136 The majority (73,8%) resided in HFI, almost 70% experienced household financial problems,

pg. 8
137 while 22,5% went without a meal for a whole day at least once because of COVID-19. Thirteen

138 percent reported experiencing higher levels of violence at home during the lockdown. Overall,

139 30.29% of the AGYW had depressive symptoms.

140

141 Table 1: Explorations of participant characteristics (n=515)

Characteristic Total N (%) Characteristic Total N (%)
Age at recruitment in years (median, IQR) 20 (18-22)
Depressive symptoms score
< 12 359 (69.7)
≥ 12 156 (30.3)
HIV status (self-reported) Lacked access to essential
medication
HIV positive 17 (3.7) Never 367 (72.8)
HIV negative 444 (96.3) Often/Sometimes 137 (27.2)
Length of stay in community Lacked access to family planning
services
< 5 years 104 (20.2) Never 401 (79.7)
≥ 5 years 410 (79.8) Often/Sometimes 102 (20.3)
Enrolled in fulltime study before lockdown Household financial problems
Not enrolled 117 (22.7) Never 154 (30.6)
High school 243 (47.2) Often/Sometimes 349 (69.4)
College/University 155 (30.1) HFI (worry about food) (main
explanatory variable)
Disengaged in secondary or tertiary education in Never 132 (26.2)
2020
No 481 (93.4) Often/Sometimes 371 (73.8)
Yes 34 (6.6) HFI (no meals for the whole day)
Highest school grade completed Never 390 (77.5)
< grade 9 17 (3.3) Often/Sometimes 113 (22.5)
≥ grade 9 498 (96.7) Violence at home
Lacked access to social support services Never 438 (86.9)
Yes 452 (89.7) Often/Sometimes 66 (13.1)
No 52 (10.3) Household asset index score* 4.37 (3.5-5.6)
142 * Based on Booysen, van der Berg [31]
143
144 Significant differences between those with and those without depressive symptoms were observed

145 for the following variables: age at recruitment (p=0.016), enrolled in fulltime study before

146 lockdown (p=0.009), lacked access to essential medication (p=0.005), HFI (p=0.043), no meal for

147 a whole day (p<0.001), and violence at home (p=0.003) (Table 2).

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148 Table 2: Comparison between AGYW with versus without depressive symptoms (n=515)

No Depressive Depressive No Depressive Depressive

Characteristic symptoms symptoms p-value Characteristic symptoms symptoms p-value
N (%) N (%) N (%) N (%)
Total participants 359 (69.71) 156 (30.29) Lacked access to social support services
Median (IQR) Median (IQR) Yes 321 (89.4) 131 (90.3)

Age at recruitment (years) 20 (18-22) 20 (19-22) 0.016 No 38 (10.6) 14 (9.7)

N (%) N (%) Lacked access to essential medication 0.005

HIV status 0.530 Never 274 (76.3) 93 (64.1)
HIV positive 13 (4.0) 4 (2.9) Often/Sometimes 85 (23.7) 52 (35.9)
Lacked access to family planning
HIV negative 308 (96.0) 136 (97.1) 0.095
services
Length of stay in community 0.180 Never 293 (81.6) 108 (75.0)
< 5 years 78 (21.8) 26 (16.7) Often/Sometimes 66 (18.4) 36 (25.0)
≥ 5 years 280 (78.2) 130 (83.3) Household financial problems <0.001
Enrolled in fulltime study before
0.009 Never 126 (35.2) 28 (19.3)
lockdown
Not enrolled 69 (19.2) 48 (30.8) Often/Sometimes 232 (64.8) 117 (80.7)
Household food insecurity (worry about
High school 182 (50.7) 61 (39.1) 0.043
food) (main explanatory variable)
College/University 108 (30.1) 47 (30.1) Never 103 (28.8) 29 (20.0)
Disengaged in secondary or tertiary
0.510 Often/Sometimes 255 (71.2) 116 (80.0)
education in 2020
Household food insecurity (no meals
No 337 (93.9) 144 (92.3) <0.001
for the whole day)
Yes 22 (6.1) 12 (7.7) Never 296 (82.7) 94 (64.8)
Highest school grade completed 0.650 Often/Sometimes 62 (17.3) 51 (35.2)
< grade 9 11 (3.1) 6 (3.8) Violence at home 0.003
≥ grade 9 348 (96.9) 150 (96.2) Never 322 (89.7) 116 (80.0)
0.870 Often/Sometimes 37 (10.3) 29 (20.0)
Household asset index score 4.37 (3.46-5.62) 4.37 (3.86-5.62) 0.93

149

pg. 10
150 In the unadjusted model, we examined the association between HFI and depressive symptoms and

151 found that AGYW living in HFI were at an 87% higher risk of experiencing depressive symptoms

152 [risk ratio (RR): 1.87; 95% CI:1.47-2.38, p<0.001)] compared to those from food secure

153 households (Table 3). In the first model, adjusting for demographic characteristics increased the

154 risk of depressive symptoms among AGYW in HFI by 1% (aRR1:1.88; 95% CI: 1.43-2.48,

155 p<0.001). Adjusting for lacked access to social support services in Model 2 increased the risk to

156 89% (aRR2: 1.89; 95% CI: 1.43-2.51, p<0.001). In Model 3, adjusting for access to essential

157 medicine reduced the risk to 80% (aRR3: 1.80; 95% CI: 1.35-2.42, p<0.001). AGYW who lacked

158 access to essential medication were 1.4 times (RR: 1.40: 95% CI: 1.20-1.64), p<0.001) more likely

159 to experience depressive symptoms than those who were able to access essential medication. There

160 was also a significant association between age at recruitment of AGYW and depressive symptoms,

161 with younger women (based on median age [i.e., 20 (IQR:19-22)]) at 7% higher risk of

162 experiencing depressive symptoms (RR:1.07; 95% CI: 1.01-1.14, p<0.020). Sensitivity analysis

163 (using no meals for a whole day as an alternate proxy for HFI) did not produce significant

164 associations between HFI and depressive symptoms in univariable and multi-variable analyses

165 (see Table 3).

166

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167 Table 3: Regression modeling to identify associations between food insecurity and depressive symptoms with unadjusted risk
168 ratio (RR) and adjusted risk ratio (aRR)
Variable Risk Ratio Model 1 Model 2 Model 3
RR (95% CI) p-value aRR1 (95% CI) p-value aRR2 (95% CI) p-value aRR3 (95%CI) p-value
Age at recruitment (years) 1.07 (1.01-1.14)0.020 1.07 (1.01-1.14)0.024 1.07 (1.01-1.14)0.023
Length of stay in community
< 5 years ref ref ref
≥ 5 years 1.24 (0.86-1.79) 0.255
1.23 (0.84-1.79) 0.294
1.20 (0.81-1.77)0.363
Highest school grade
completed
< grade 9 ref ref ref
≥ grade 9 0.83 (0.38-1.80)0.641 0.83 (0.39-1.81)0.650 0.82 (0.39-1.75)0.616
Household asset index score 1.04 (0.98-1.10)0.172 1.04 (0.98-1.10)0.217 1.05 (0.99-1.10)0.089
Lacked access to social
support services
No ref ref
Yes 0.90 (0.71-1.14) 0.391
0.86 (0.64-1.15)0.320
Lacked access to essential
medication
Never ref
Often/Sometimes 1.40 (1.20 -1.64) <0.001
Household food insecurity
(worry about food)
Never ref ref ref ref
Often/Sometimes 1.87 (1.47-2.38) < 0.001 1.88 (1.43-2.48) < 0.001 1.89 (1.43-2.51) <0.001 1.80 (1.35-2.42) <0.001
169
170
171

pg. 12
 Discussion

172 The COVID-19 pandemic has amplified structural inequalities and HFI, increasing psychological

173 distress among vulnerable populations. Globally, there have been calls to identify groups severely

174 impacted by the pandemic to better direct recovery efforts towards high-risk groups and inform

175 economic protection strategies during future pandemics [21, 32]. AGYW in SSA are vulnerable to

176 mental health problems, given the physiological, psychosocial, and cognitive changes experienced

177 during this phase [5]. This vulnerable group has been neglected in COVID-19 recovery efforts

178 [21]. The present study investigated the relationship between HFI and depressive symptoms among

179 AGYW during COVID-19, using cross-sectional survey data from South Africa. The vast majority

180 of AGYW (73,8%) resided in food insecure households. After adjusting for key socio-economic

181 and demographic variables, we found that AGYW living HFI were at 80% (95% CI) higher risk

182 of experiencing depressive symptoms compared to those from food secure households. This

183 highlights the need for stronger COVID-19 recovery investment towards multi-sectoral policies

184 and programmes that can promote the economic and psychological wellbeing of AGYW residing

185 in HFI.

186

187 In our sample, the prevalence of depressive symptoms during the COVID-19 pandemic was high

188 (30.3%). While few studies have reported depression outcomes among AGYW in SSA during

189 COVID-19, our estimate is comparable with global estimates [19, 33, 34]. For example, the

190 prevalence of depressive symptoms among AGYW in Kenya was estimated to be 34.5% [19], 32%

191 in Peru [33] and 33% in the United States [34]. The Organization for Economic Cooperation and

192 Development [35] (OECD) reported a 31% prevalence of depression in the United Kingdom and

pg. 13
193 29% in both Japan and Belgium. The OECD (2021) also reported a global increase in depression

194 among younger people during the COVID-19 pandemic ranging from 30-80%.

195

196 Comparing the prevalence of depressive symptoms among AGYW from this cohort to previous

197 South African studies proved challenging. This was in part due to the dearth of literature on the

198 topic in SSA [36]. However, an earlier study among young South African people (aged 15-26

199 years) estimated the prevalence of depressive symptoms among young women at 20.5% [36]. A

200 more recent estimate among 16–24-year-olds by Jesson, Dietrich [37] was much higher (48%).

201 This high estimate is possibly due to the study’s focus on a select group of young people residing

202 in known high-risk areas of South Africa. Another study by Goin, Pearson [13] among AGYW

203 (aged 13–21 years) examined the association between depressive symptoms and HIV incidence

204 and estimated a prevalence of depressive symptoms of 18.2% among this group. Given the strong

205 link between depressive symptoms and HIV acquisition, and HIV/AIDS being the leading cause

206 of mortality and morbidity among AGYW in this region, policymakers should direct resources

207 towards reducing depression among AGYW. Depression has also been linked to poor sexual

208 reproductive health outcomes (e.g., unplanned pregnancy and STIs). Programmes targeting

209 depression could assist in preventing unplanned pregnancies in AGYW. Healthcare policies should

210 ensure that appropriate measures are in place to secure continued access to medication among

211 vulnerable populations during times of disaster, as lack of access to needed medication was linked

212 to an increased risk of depressive symptoms among AGYW during the COVID-19 lockdown.

213

214 Our study also found that AGYW living in HFI were at higher risk of depressive symptoms

215 compared to those living in food secure households (RR: 1.87; 95% CI: 1.47-2.38, p<0.001). After

pg. 14
216 adjusting for confounders, this risk decreased slightly (aRR3,1.80; 95% CI:1.35-2.42, p<0.001).

217 This is consistent with previous studies from SSA, which indicated that AGYW living in HFI were

218 at higher risk of developing depressive symptoms compared to their male counterparts [18, 19,

219 38]. Gibbs, Govender [38], for instance, found that food insecure AGYW from South African

220 informal settlements were 5.57 times more likely to have depressive symptoms (aOR

221 5.57, p =0.039). Similarly, a study on Kenyan parent-adolescent dyads found that adolescents had

222 2.5 higher odds of depressive symptoms (OR 2.5, 95% CI: 2.0-3.1)[19]. Although several studies

223 have highlighted the association between HFI and depression, it is worth noting that depression

224 itself may be the cause of food insecurity. For example, Jesson, Dietrich [37] found that younger

225 people with probable depression had higher odds of being food insecure (2.79, 95% CI: 1.57–

226 4.94).

227

228 In this setting, formal and informal job losses during the COVID-19 pandemic may have directly

229 contributed towards HFI [39]. Fang, Thomsen [18] found that job losses during the pandemic were

230 associated with a 27% increase in the risk of depression (OR:1.27; 95% CI: 1.05 to 1.55). Job

231 losses in this setting possibly meant that households lacked income to purchase essential food

232 items [40], which may have caused AGYW to become distressed [16] and to develop depressive

233 symptoms. HFI caused by job losses has been shown to be associated with caregiver anxiety,

234 depression and parenting stress [41]. Poor HFI-induced parent/caregiver mental health can also

235 cause psychological distress in younger people [42]. Younger people also felt embarrassed by their

236 household’s food situation [42]. Feeling powerless, desperate, and guilty about their household’s

237 food situation could have directly contributed to their anxiety and depressive symptoms [43]. Such

238 a state could lower adolescents’ self-esteem and happiness and negatively affect their perceptions

pg. 15
239 of their parental role model(s) [44]. If these socioeconomic conditions persist without any coping

240 strategies, this could have a negative effect on the health of young people. It is thus important to

241 implement interventions that allow young people to easily access mental health services to prevent

242 and/or manage depression.

243

244 The advent of COVID-19 and lockdowns has worsened the economic situation of many

245 households. Policies should prioritize identifying such households and provide them with relief

246 (e.g., cash and food packages) to reduce HFI, thereby reducing the risk of depressive symptoms in

247 these households. AGYW should also be given psychosocial support through building fortitude,

248 defined by Pretorius and Padmanabhanunni [45] as a person’s ability to manage stress and remain

249 well. Fortitude is rooted in positive and/or adaptive appraisals of the self, family, and significant

250 others. Online and digital platforms could be offered to AGYW for mental health education and

251 psychological counseling services, delivered through low-cost mobile phone applications [45, 46].

252 These applications can be used by trained community healthcare workers to disseminate

253 knowledge about future pandemics, address uncertainties, and provide support [45]. Moreover, a

254 strong focus should be placed on the early detection and management of depressive symptoms in

255 AGYW. Family strengthening interventions focused on enhancing parenting, communication, and

256 social connectedness should be prioritized, with an emphasis on building resilience among AGYW

257 [47]. There is, therefore, a need for more intersectionality research to look at findings by

258 geography, ethnicity, and demography to ensure nuanced policy decision-making [48]. We also

259 argue that scaling-up food programs during future pandemics could be effective in protecting the

260 mental health of vulnerable AGYW in South Africa.

261

pg. 16
262 The strengths of the study include:1) the survey was conducted in multiple South African districts;

263 2) we used a robust depressive symptoms measure (CES-D-10) that was previously validated in

264 South Africa [27]; 3) data collectors conducted interviews in participants’ preferred languages and

265 built a good rapport with AGYW to make them feel safe over the phone.

266

267 Our study had the following limitations:1) our main explanatory variable, HFI, was based on one

268 item, namely, worry about food running out because of a lack of money. To account for this

269 shortcoming, we performed a sensitivity analysis using no meals for the whole day as a proxy for

270 HFI and found no significant associations with depressive symptoms. Future studies should

271 consider using validated measures, such as the Food Insecurity Experience Scale, to measure HFI

272 in population surveys [49]; 2) this analysis was based on a cross-sectional dataset. It remains

273 unclear whether depressive symptoms in AGYW were caused by HFI or vice versa. There is thus

274 a need for a longitudinal study to examine the temporality of HFI-depression causation [50]; 3)

275 the study sample is not a national sample; as such, the results might not be generalizable over the

276 entire AGYW population of South Africa; 4) selection bias, the AGYW in this study were selected

277 specifically because they were enrolled in a program for AGYW (viz. My Journey program).

278

279 In conclusion, our study highlighted the impact of HFI on the mental health of AGYW living in

280 these households. As part of COVID-19 recovery efforts, there is a need for scaling-up intensive

281 AGYW mental health screening programs, given the burden of depressive symptoms in this

282 population. Our findings suggest that using HFI would be an effective indicator in community-

283 based screening programs for identifying AGYW at risk of depressive symptoms and linking them

284 to mental health services. Our results highlight that multi-sectorial approaches and programs are

pg. 17
285 critical for reducing the mental health burden among AGYW. Social policies should include food

286 hampers, cash transfers, support groups, and social protection interventions that target younger

287 people. Economic policies should also focus on mobilizing youth economic development by

288 investing in entrepreneurship development.

289

pg. 18
Author contributions
SC and DG prepared and wrote the manuscript. CM and CW critically reviewed and edited the
manuscript. DG formulated the ideas and overarching goals and aims and led the compilation of
the manuscript. LS and AM conducted all statistical analyses and data syntheses.

Financial Support
The AGYW intervention was funded by the Global Fund to Fight AIDS, TB and Malaria. The
combination HIV prevention interventions were implemented by civil society organizations
appointed by organizations responsible for the management of the AGYW programme: the
Networking HIV and AIDS Community of Southern Africa (NACOSA), the AIDS Foundation of
South Africa (AFSA), and Beyond Zero. The programme was aligned with the She Conquers
campaign and implemented with support from the South African National AIDS Council
(SANAC) through the Country Coordinating Mechanism (CCM) and the CCM Secretariat. This
study was supported by NACOSA.

Institutional review board statement

Research ethics approval for this study was granted by the South African Medical Research
Council Ethics Committee (EC036-9/2020).

Informed consent statement

Informed consent was obtained from all participants involved in the study. Parental/caregiver
consent was obtained for participants younger than 18-years-old prior to conducting the assent
procedures.

Data Availability Statement

The raw data were generated by the South African Medical Research Council. The derived data
supporting the findings of this study are available from the corresponding author [SC] on request.

Acknowledgements
We would like to thank the AGYW who participated in this research and shared their views and
experiences with us. We acknowledge the implementers of the AGYW program for their support

pg. 19
in the evaluation study and for providing support and counselling to the participants that we
referred to them. We also thank our excellent team of data collectors and monitors, and individuals
who provided administrative and logistical support for the study.

Conflicts of interest
None to declare

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References

1. WHO. Adolescent mental health. 2021 [cited 2022 22 August]; Available from:
https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-
health#:~:text=Depression%20is%20estimated%20to%20occur%20among%201.1%25%20of,dis
orders%20can%20profoundly%20affect%20school%20attendance%20and%20schoolwork.
2. Lu, W., Adolescent depression: national trends, risk factors, and healthcare disparities. American
journal of health behavior, 2019. 43(1): p. 181-194.
3. Donenberg, G., et al., Mental health outcomes of a pilot 2-arm randomized controlled trial of a
HIV-prevention program for South African adolescent girls and young women and their female
caregivers. BMC Public Health, 2021. 21(1): p. 2189.
4. WHO. Depression. 2021 [cited 2022 22 August ]; Available from: https://www.who.int/news-
room/fact-sheets/detail/depression.
5. Shorey, S., E.D. Ng, and C.H. Wong, Global prevalence of depression and elevated depressive
symptoms among adolescents: A systematic review and meta‐analysis. British Journal of Clinical
Psychology, 2022. 61(2): p. 287-305.
6. Racine, N., et al., Global Prevalence of Depressive and Anxiety Symptoms in Children and
Adolescents During COVID-19: A Meta-analysis. JAMA Pediatr, 2021. 175(11): p. 1142-1150.
7. Magson, N.R., et al., Risk and Protective Factors for Prospective Changes in Adolescent Mental
Health during the COVID-19 Pandemic. J Youth Adolesc, 2021. 50(1): p. 44-57.
8. Gloster, A.T., et al., Impact of COVID-19 pandemic on mental health: An international study. PLoS
One, 2020. 15(12): p. e0244809.
9. Loades, M.E., et al., Rapid Systematic Review: The Impact of Social Isolation and Loneliness on
the Mental Health of Children and Adolescents in the Context of COVID-19. J Am Acad Child
Adolesc Psychiatry, 2020. 59(11): p. 1218-1239.e3.
10. Meherali, S., et al., Mental Health of Children and Adolescents Amidst COVID-19 and Past
Pandemics: A Rapid Systematic Review. Int J Environ Res Public Health, 2021. 18(7).
11. Jones, E.A.K., A.K. Mitra, and A.R. Bhuiyan, Impact of COVID-19 on Mental Health in
Adolescents: A Systematic Review. Int J Environ Res Public Health, 2021. 18(5).
12. McDaid, D., A.-L. Park, and K. Wahlbeck, The economic case for the prevention of mental illness.
Annual review of public health, 2019. 40: p. 373-389.
13. Goin, D.E., et al., Depression and incident HIV in adolescent girls and young women in HIV
prevention trials network 068: targets for prevention and mediating factors. American journal of
epidemiology, 2020. 189(5): p. 422-432.
14. Parry, C.D., et al., Fresh perspectives on the alcohol and HIV Nexus: a call for action in an era of
increased opportunities and challenges. AIDS and Behavior, 2017. 21(2): p. 121-125.
15. van Staden, Q., C.A. Laurenzi, and E. Toska, Two years after lockdown: reviewing the effects of
COVID‐19 on health services and support for adolescents living with HIV in South Africa. Journal
of the International AIDS Society, 2022. 25(4): p. e25904.
16. Posel, D., A. Oyenubi, and U. Kollamparambil, Job loss and mental health during the COVID-19
lockdown: Evidence from South Africa. PloS one, 2021. 16(3): p. e0249352.
17. Shepherd, D.L., Food insecurity, depressive symptoms, and the salience of gendered family roles
during the COVID-19 pandemic in South Africa. Social Science & Medicine, 2022. 301.
18. Fang, D., M.R. Thomsen, and R.M. Nayga, The association between food insecurity and mental
health during the COVID-19 pandemic. BMC public health, 2021. 21(1): p. 1-8.
19. Pinchoff, J., et al., How Has COVID-19-Related Income Loss and Household Stress Affected
Adolescent Mental Health in Kenya? J Adolesc Health, 2021. 69(5): p. 713-720.
20. Shayo, F.K. and P.S. Lawala, Does food insecurity link to suicidal behaviors among in-school
adolescents? Findings from the low-income country of sub-Saharan Africa. BMC psychiatry, 2019.
19(1): p. 1-8.

pg. 21
21. Ahinkorah, B.O., et al., COVID-19 pandemic worsening gender inequalities for women and girls
in Sub-Saharan Africa. Frontiers in Global Women's Health, 2021. 2.
22. Govindasamy, D., et al., A qualitative enquiry into the meaning and experiences of wellbeing
among young people living with and without HIV in KwaZulu-Natal, South Africa. Social Science
& Medicine, 2020. 258: p. 113103.
23. Shafiee, M., et al., Household food insecurity is associated with depressive symptoms in the
Canadian adult population. Journal of Affective Disorders, 2021. 279: p. 563-571.
24. Lauren, B.N., et al., Predictors of households at risk for food insecurity in the United States during
the COVID-19 pandemic. Public health nutrition, 2021. 24(12): p. 3929-3936.
25. Wellcome Trust. Anxiety and depression in young people: finding the next generation of treatments
and approaches. 2022; Available from: https://wellcome.org/what-we-do/mental-
health/projects/anxiety-depression-young-people-finding-next-generation-treatments.
26. Kola, L., et al., COVID-19 mental health impact and responses in low-income and middle-income
countries: reimagining global mental health. The Lancet Psychiatry, 2021. 8(6): p. 535-550.
27. Baron, E.C., T. Davies, and C. Lund, Validation of the 10-item centre for epidemiological studies
depression scale (CES-D-10) in Zulu, Xhosa and Afrikaans populations in South Africa. BMC
psychiatry, 2017. 17(1): p. 1-14.
28. Zhou, Q., L. Fan, and Z. Yin, Association between family socioeconomic status and depressive
symptoms among Chinese adolescents: Evidence from a national household survey. Psychiatry
Research, 2018. 259: p. 81-88.
29. Peng, M., et al., Prevalence, risk factors and clinical correlates of depression in quarantined
population during the COVID-19 outbreak. Journal of Affective Disorders, 2020. 275: p. 119-124.
30. Belsley, D., Conditioning Diagnostics: Collinearity and Weak Data in Regression. 1991, New
York: John Wiley & Sons.
31. Booysen, F., et al., Using an Asset Index to Assess Trends in Poverty in Seven Sub-Saharan African
Countries. World Development, 2008. 36(6): p. 1113-1130.
32. UN, UN Research Roadmap for the COVID-19 Recovery: Leveraging the Power of Science for a
More Equitable, Resilient and Sustainable Future. 2020, United Nations: New York.
33. Porter, C., et al., Impact of the COVID-19 pandemic on anxiety and depression symptoms of young
people in the global south: evidence from a four-country cohort study. BMJ Open, 2021. 11(4): p.
e049653.
34. Liu, C.H., et al., Factors associated with depression, anxiety, and PTSD symptomatology during
the COVID-19 pandemic: Clinical implications for U.S. young adult mental health. Psychiatry Res,
2020. 290: p. 113172.
35. Organization for Economic Cooperation and Development, Supporting young people’s mental
health through the COVID-19 crisis. 2021: p. 14.
36. Nduna, M., et al., Prevalence and factors associated with depressive symptoms among young
women and men in the Eastern Cape Province, South Africa. Journal of Child & Adolescent Mental
Health, 2013. 25(1): p. 43-54.
37. Jesson, J., et al., Food insecurity and depression: a cross‐sectional study of a multi‐site urban youth
cohort in Durban and Soweto, South Africa. Tropical Medicine & International Health, 2021. 26(6):
p. 687-700.
38. Gibbs, A., K. Govender, and R. Jewkes, An exploratory analysis of factors associated with
depression in a vulnerable group of young people living in informal settlements in South Africa.
Global Public Health, 2018. 13(7): p. 788-803.
39. Ingle, K., T. Brophy, and R. Daniels. National Income Dynamics Study–Coronavirus Rapid Mobile
Survey (NIDS-CRAM) panel user manual. Technical Note Version 2020 [cited 1; Available from:
https://cramsurvey.org/reports/.
40. Maina, M. and S. Pillay Gonzalez, The emotional toll of the ‘hard’lockdown: an analysis of diary
entries from Gauteng, South Africa. South African Geographical Journal, 2022: p. 1-20.

pg. 22
41. Ward, K.P. and S.J. Lee, Associations of food insecurity and material social support with parent
and child mental health during COVID-19. Children and Youth Services Review, 2022. 140: p.
106562.
42. Leung, C.W., et al., Understanding the Psychological Distress of Food Insecurity: A Qualitative
Study of Children’s Experiences and Related Coping Strategies. Journal of the Academy of
Nutrition and Dietetics, 2020. 120(3): p. 395-403.
43. Nagata, J.M., et al., Food insecurity is associated with poorer mental health and sleep outcomes in
young adults. Journal of Adolescent Health, 2019. 65(6): p. 805-811.
44. Powdthavee, N. and J. Vernoit, The transferable scars: a longitudinal evidence of psychological
impact of past parental unemployment on adolescents in the United Kingdom. 2012.
45. Pretorius, T. and A. Padmanabhanunni, A looming mental health pandemic in the time of COVID-
19? Role of fortitude in the interrelationship between loneliness, anxiety, and life satisfaction
among young adults. South African Journal of Psychology, 2021. 51(2): p. 256-268.
46. Connolly, S.L., et al., Digital clinics and mobile technology implementation for mental health care.
Current Psychiatry Reports, 2021. 23(7): p. 1-7.
47. Bhana, A., et al., Mental health interventions for adolescents living with HIV or affected by HIV in
low- and middle-income countries: systematic review. BJPsych Open, 2020. 6(5): p. e104.
48. Mazzeo, J., et al., A Tale of Two Cities During the COVID-19 Pandemic: Evaluating Food
Insecurity in Chicago and New York City. Journal of Racial and Ethnic Health Disparities, 2022:
p. 1-18.
49. Food and Agriculture Organisation (FAO). The Food Insecurity Experience Scale. 2022 [cited
2022 05 September]; Available from: https://www.fao.org/in-action/voices-of-the-hungry/fies/en/.
50. Tomita, A., et al., Major depression and household food insecurity among individuals with
multidrug-resistant tuberculosis (MDR-TB) in South Africa. Social psychiatry and psychiatric
epidemiology, 2019. 54(3): p. 387-393.

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