Adverse childhood experiences (ACEs), including abuse, neglect, and household dysfunction, are linked to negative mental health outcomes. This is especially true for adolescents and young adults in informal urban settlements, where poverty, unemployment, and violence worsen the effects of early life adversity.
Mental health challenges are a significant burden for youth in Africa. Specifically, 40.8% experience emotional and behavioral problems, 29.8% suffer from anxiety disorders, 26.9% face depression, 24% exhibit post-traumatic stress disorder (PTSD), and 20.8% report suicidal ideation. This burden is even higher among adolescents living in informal urban settlements in Kenya because of poverty, overcrowding, violence, breakdown of social networks, and limited access to services.
ACEs are traumatic events occurring before the age of 18 years, including abuse, neglect, and household challenges. Psychological stress resulting from ACEs significantly changes how children develop, leading to lasting effects on their health, behaviors, and life potential in adulthood.
Research in Africa has consistently linked ACEs to chronic physical and mental health problems like PTSD, substance use disorders, depression, injuries, and adverse outcomes for mothers and children. ACEs are also associated with lower educational attainment, unemployment, and reduced earning potential.
Nevertheless, mental health research focusing on this group remains sparse, especially for youth residing in Nairobi’s urban informal settings, where structural inequities and limited access to supportive services exacerbate the burden of ACEs and mental health distress in this population. Guided by the life course perspective, this study fills the knowledge gap by examining the association between ACEs and symptoms of depression, anxiety, and stress among youth aged 15 - 24 years living in Nairobi’s informal settlements.
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This article aims to explore the impact of ACEs on the mental health of youth in informal urban settlements in Nairobi, Kenya, highlighting the need for targeted interventions.
Kibera, one of the informal settlements in Nairobi, Kenya. Source: Dennis Ocholla via Panoramio.
Study Design and Methodology
This study utilized baseline data from a pilot cluster-randomized mixed-methods sequential study conducted in two informal settlements in Nairobi, Kenya. Data were collected from a community sample between September and December 2024. A snowball sampling method was employed to recruit 94 youth aged 15 - 24 years.
Five research assistants (RAs) were recruited through a competitive hiring process after a public call for applications. Participant recruitment was conducted in collaboration with two local youth-serving organizations in Mukuru Kwa Reuben and Kibera, Nairobi, Kenya. RAs and community health promoters distributed flyers outlining the study details, including the location and timing.
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Written informed consent or assent was obtained from all participants and parental or caregiver consent for those under 18 years, with separate procedures to avoid coercion. Eligibility screening was conducted in person, and interviews were conducted by trained RAs fluent in English and Swahili. The surveys were interviewer-administered in the participant’s preferred language and lasted approximately 30 minutes. To protect privacy, all the interviews were conducted in private settings.
Data Collection
Data were collected using tablet-based surveys administered in English or Swahili on mental health outcomes of depression (using PHQ - 9), anxiety (assessed by GAD - 7), stress (assessed by stress scale), and ACEs (evaluated by the ACEs scale). We conducted generalized linear models to examine the relationship between ACEs (0 - 2 vs. 3+ experiences) and mental health outcomes.
Independent variable: Adverse Childhood Experiences was assessed using the 10-item Adverse Childhood Experiences-International Questionnaire. The questionnaire included items on emotional and/or physical neglect; emotional, sexual, and/or physical abuse; bullying; cohabitation with someone with a substance use disorder and/or a mental disorder; having an incarcerated household member; witnessing domestic violence; experiencing parental loss and/or divorce/separation; witnessing community violence; and exposure to collective violence (e.g., war, terrorism, and political violence). Each item was treated as a binary variable (1 = experienced, 0 = not experienced).
Outcome variables: The study examined three dependent variables: depressive symptoms, anxiety symptoms, and stress.
- Depressive symptom severity in this study was evaluated using the 9-item Patient Health Questionnaire (PHQ).
- Anxiety symptoms were evaluated using the 7-item Generalized Anxiety Disorder Scale (GAD - 7) to measure anxiety symptoms.
- Stress was measured using a 10-item Perceived Stress Scale (PSS).
Control variables: We controlled for participants’ sociodemographic factors of age (continuous), gender (categorical: male and female), employment status (categorical: working vs. not working), education (categorical: secondary or less vs. higher than secondary), and living situation (categorical: living with a caregiver vs.
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Statistical Analysis
We performed descriptive statistics and bivariate tests of association appropriate for each variable’s level of measurement. We estimated generalized linear models, which are not subject to ordinary least squares regression assumptions. To inform model specification, we assessed the distribution of each outcome using histograms and descriptive statistics.
Stress was approximately normally distributed, whereas depression and anxiety were positively skewed. Based on these assessments, we specified a Gaussian distribution for the stress outcome and gamma distributions for depression and anxiety. Because Gamma models require positive outcomes and some depression and anxiety scores were zero, we added a 0.01 constant to all depression and anxiety scores. All models used log links, and the coefficients were exponentiated to aid interpretability.
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Key Findings
The median age of the 94 participants was 21 years. Most participants were male (n=51; 54%), had secondary education or less (n=76; 81%), were not working (n=60; 64%), and lived with a parent or guardian (n=66; 70%). Youth with 3+ ACEs had significantly higher depression and anxiety scores than those with fewer ACEs, but no significant association with stress symptoms was observed.
Participants with higher education reported significantly greater stress symptoms than those with secondary or less education (exp(β)=1.30, 95% CI: 1.06, 1.60, p<.05).
Our findings indicate that youth in informal urban settlements who reported three or more adverse childhood experiences (ACEs) had significantly greater symptoms of depression and anxiety than those with fewer ACEs. While ACEs were not significantly linked to stress symptoms in this study, the strong associations with both depression and anxiety underscore the critical need for trauma-informed mental health services that consider early life experiences.
The median depression and anxiety scores in our sample fell below the established clinical cut-offs for probable major depression (≥10 on the PHQ - 9) and generalized anxiety disorder (≥10 on the GAD - 7). This suggests that our participants may represent a non-clinical population.
| Variable | Description | Assessment Tool |
|---|---|---|
| Adverse Childhood Experiences (ACEs) | Traumatic events occurring before age 18 | Adverse Childhood Experiences-International Questionnaire (10 items) |
| Depressive Symptoms | Severity of depressive symptoms | Patient Health Questionnaire (PHQ-9) |
| Anxiety Symptoms | Severity of anxiety symptoms | Generalized Anxiety Disorder Scale (GAD-7) |
| Stress | Level of perceived stress | Perceived Stress Scale (PSS) |
Discussion
Although ACEs impact everyone, their effects on youth in informal settlements are amplified by the structural and social conditions that shape their health trajectories. For instance, in Kenya, intersecting structural issues of unemployment, violence, unstable housing, poverty, and inadequate sanitation facilities converge in informal urban settlements and exacerbate the impact of ACEs on overall youth well-being, negatively impacting mental and physical health outcomes.
Additionally, the high prevalence of ACEs may reflect the cumulative psychosocial stressors that youths face in informal urban settlements, including violence, caregiving responsibilities, lack of educational opportunities, and limited mobility. In the context of informal urban settlements, where educational attainment is often hard-won amidst adversity, increased academic and economic pressures among more educated youth may increase mental symptom severity.
Youth in informal urban settlements may also encounter heightened expectations or uncertainty regarding future opportunities, contributing to elevated symptoms of depression, anxiety and stress. Therefore, we argue that while education is often protective, it can also serve as a source of psychological burden in structurally disadvantaged environments.
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