RESEARCH ARTICLE
Community and individual sense of trust and
psychological distress among the urban poor
in Accra, Ghana
Mawuli K. Kushitor1, Maame B. Peterson1, Paapa Yaw Asante2, Naa Dodua Dodoo1,
Sandra Boatemaa1, Raphael Baffour Awuah1, Francis Agyei2, Lionel Sakyi3, F. Nii-
Amoo Dodoo1, Ama de-Graft Aikins1*
1 Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana, 2 Department of
Psychology, University of Ghana, Accra, Ghana, 3 Centre for Migration Studies, University of Ghana, Accra,
a1111111111
Ghana
a1111111111
a1111111111 * adaikins@ug.edu.gh
a1111111111
a1111111111
Abstract
OPENACCESS Background
Citation: Kushitor MK, Peterson MB, Asante PY, Mental health disorders present significant health challenges in populations in sub Saharan
Dodoo ND, Boatemaa S, Awuah RB, et al. (2018) Africa especially in deprived urban poor contexts. Some studies have suggested that in col-
Community and individual sense of trust and lectivistic societies such as most African societies people can draw on social capital to atten-
psychological distress among the urban poor in
uate the effect of community stressors on their mental health. Global studies suggest the
Accra, Ghana. PLoS ONE 13(9): e0202818. https://
doi.org/10.1371/journal.pone.0202818 effect of social capital on mental disorders such as psychological distress is mixed, and
emerging studies on the psychosocial characteristics of collectivistic societies suggest that
Editor: Benedict Weobong, London School of
Hygiene & Tropical Medicine, UNITED KINGDOM mistrust and suspicion sometimes deprive people of the benefit of social capital. In this
study, we argue that trust which is often measured as a component of social capital has a
Received: November 6, 2017
more direct effect on reducing community stressors in such deprived communities.
Accepted: August 9, 2018
Published: September 27, 2018 Methods
Copyright: © 2018 Kushitor et al. This is an open Data from the Urban Health and Poverty Survey (EDULINK Wave III) survey were used.
access article distributed under the terms of the
The survey was conducted in 2013 in three urban poor communities in Accra: Agbogbloshie,
Creative Commons Attribution License, which
permits unrestricted use, distribution, and James Town and Ussher Town. Psychological distress was measured with a symptomatic
reproduction in any medium, provided the original wellbeing scale. Participants’ perceptions of their neighbours’ willingness to trust, protect
author and source are credited. and assist others was used to measure community sense of trust. Participants’ willingness
Data Availability Statement: All relevant data are to ask for and receive help from neighbours was used to measure personal sense of trust.
within the paper and its Supporting Information Demographic factors were controlled for. The data were analyzed using descriptive and
files.
multivariate regressions.
Funding: Funding sources were jointly from
Secretariat of the African Caribbean and Pacific
Results
Group of States (ACP) - ACP-EU Cooperation
Programme in Higher Education (EDULINK), The mean level of psychological distress among the residents was 25.5 (SD 5.5). Personal
International Development Research Centre
sense of trust was 8.2 (SD 2.0), and that of community sense of trust was 7.5 (SD 2.8).
(IDRC), Research on Obesity and Diabetes among
African Migrants (RODAM) and the William and While community level trust was not significant, personal sense of trust significantly reduced
Flora Hewlett Foundation. The funders had no role psychological distress (B = -.2016728, t = -2.59, p < 0.010). The other factors associated
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 1 / 13
Community and individual sense of trust and psychological distress
in study design, data collection and analysis, with psychological distress in this model were perceived economic standing, education and
decision to publish, or preparation of the locality of residence.
manuscript.
Competing interests: We declare no potential real Conclusion
or perceived conflict of interest.
This study presents evidence that more trusting individuals are significantly less likely to be
psychologically distressed within deprived urban communities in Accra. Positive intra and
inter individual level variables such as personal level trust and perceived relative economic
standing significantly attenuated the effect of psychological distress in communities with
high level neighbourhood disorder in Accra.
Introduction
Sub-Saharan Africa (SSA) is fast urbanizing, and Ghana is no exception [1,2]. The high influx
of migrants from rural to urban areas has resulted in the growth of urban poor and slum com-
munities in the capital, Accra [3]. Within these urban poor and slum communities there is the
rising burden of mental health disorders. Mental health disorders such as depression are
known to seriously affect the quality of life and increase the risk of premature mortality [4–6].
In addition, mental health problems are strongly associated with chronic conditions and recur-
rent infectious conditions [7,8]. The double burden of infectious and chronic diseases in SSA
is reported to affect urban poor communities disproportionately, and a rising burden of men-
tal health disorders will only worsen the low quality of life of urban poor communities. Com-
munity based stressors such as a high crime rate, lack of employment, poor sanitation,
mistrust and suspicion have been implicated in the high burden of mental disorders in urban
poor communities [9–12]. Some studies have suggested that social cohesion may hold the key
to reducing the burden of mental health challenges amongst deprived urban residents.
The relationship between social cohesion and mental health disorders is complex. While
several studies have found a positive relationship between constructs of social cohesion such as
the sense of trust and belonging, and psychological distress [13–18], other studies have
observed a negative relationship [11,13,14]. Social cohesion is a broad concept spanning com-
munity sense of belonging, trust in the community, reciprocity (which is a sense of obligation
to help others and confidence in return of assistance), equality with community members and
community networks. Studies on the urban poor study context usually select ‘sense of trust in
the community’, as a dominant variable. Researchers, such as Korayi and Rothermund (2012)
demonstrate how trust acts as a resource that is activated in times of need. Others have sug-
gested that the construct of cohesion can infer negative effects on people including, but not
limited to, their psychological well-being [19–21]. For instance, we can infer that, while rela-
tionships with community members could potentially be beneficial in terms of receiving help,
they could at the same time impose a burden on community members who are expected to
provide continuous help.
The evidence from the literature highlights implications of factors including poverty, edu-
cation, age, marital status, employment status, urban/rural residence, household living
arrangements, social capital among other factors, on mental health [22–29]. Evidence of com-
munity level factors and their impact on mental health remains scarce. A set of extensive
reviews of the literature shows that trust is the material from which community safety nets are
woven [9,10,30–34]. Our study focused on three urban poor communities in Accra, where
community level factors such as crime, insecurity, and poor environmental conditions
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 2 / 13
Community and individual sense of trust and psychological distress
predispose people to poor individual level psychological outcomes such as anxiety and depres-
sion [11]. Using data available from the Urban Health and Poverty Project (EDULINK)–situ-
ated in these three communities—we investigate the relationships between community and
personal trust and psychological wellbeing, allowing us to test for associations and pathways
through which these associations operate.
This study addresses three questions: (1) do community level of trust and individual level
sense of trust have an influence on the mental well-being of the urban poor? (2) how do com-
munity level sense of trust and individual level sense of trust independently and together influ-
ence psychological distress of residents in urban poor localities in Accra? (3) do urban poor
residents’ perceptions of relative economic status in society mitigate the relationship between
their sense of trust and mental health?
1.1 Sense of trust, mental health in the context of urban poverty
Researchers observe that neighbourhood disorder is a function of both mistrust and power-
lessness [32,33,35]. Powerlessness results from an inability to control negative community
conditions such as a high crime rate and danger. Powerlessness is associated with anxiety,
depression and other negative mental health outcomes [11,30–32,36,37]. Mistrust, on the
other hand, focuses on the relationship between place and people. Mistrust develops amongst
people who have limited social and economic resources and live in contexts where resources
are scarce. Places with very high levels of neighbourhood disorder are also associated with high
levels of threat. The perceived threat in the community undermines the health [21,38] of com-
munity members. Individuals in disadvantaged neighbourhoods are challenged by material
deprivation which influences their mental health status. Ross (2011) thus argues that people
who live in disadvantaged communities lose their sense of control to neighbourhood disorder
which makes them more vulnerable to adverse mental health problems such as psychological
distress. There is evidence that community disorder, anxiety and disadvantage are associated
with powerlessness and mental health outcomes [26–28].
Positive social cohesion has been associated with positive community outcomes such as
care, reciprocity and affection from community members [10]. The effect of mistrust and pow-
erlessness therefore is that people isolate themselves from the broader community and there-
fore do not receive the benefits of positive social cohesion. Besides isolation from the broader
community, mistrust has also been associated with suspicion within the community [39–41].
Communities with high neighbourhood disorder have also been associated with a high sense
of suspicion. Suspicion makes people believe that their neighbours will harm them if they had
the opportunity. The tendency to be suspicious in neighbourhoods with high levels of per-
ceived social threat makes people protect their vulnerabilities from their neighbours. For
instance, people may not disclose their disease status, fearing that in a moment of crises disclo-
sure might be used against them. Psychological distress may be compounded in a situation
where people do not talk about important personal issues that concern them. In addition,
when people live in a constant state of suspicion it has the potential to affect their mental health
in the long term.
Trust enables people to build positive relationships with each other and amongst commu-
nity members. Trust enables people to share and receive from each other within a given com-
munity [42]. Trust may therefore have the potential to mitigate the effect of psychological
distress in disadvantaged or urban poor communities. However, very few studies have been
conducted to assess the influence sense of trust has on psychological distress in an urban poor
context in SSA. Community trust as applied in this study relates to the extent to which people
can rely on each in the community. It measures a community level attribute of reciprocity and
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 3 / 13
Community and individual sense of trust and psychological distress
dependability. Individual trust on the other hand, specifically measures resources available to
individuals when they need emotional support from within the community and/or outside of
the community.
Materials and methods
2.1 Study setting
The sites for this study were three indigenous communities in central Accra. James Town and
Ussher Town are a twin community commonly known as Ga-Mashie, dominated by an indig-
enous Ga ethnic group. The third site, Agbobloshie, is a heterogeneous migrant slum settle-
ment adjoining Ga Mashie. The prevailing language spoken in the three communities is Ga.
However, due to the high influx of internal migrants from other ethnic representations, other
languages including Twi, Hausa and Ewe, are spoken in the communities.
The urban poor study area is populated largely by traders and fishermen. This densely pop-
ulated area is characterized by restricted access to public amenities. For example, the commu-
nities have shared public facilities, such as toilets and baths. Characteristic of urban poverty,
unemployment and underemployment rates are high in these communities and educational
attainment is low [43]. Many community members are engaged in the informal sector sales
and services (trading), and manual labour. Other urban poor community dynamics include
poor sanitation, a double burden of infectious and chronic diseases and high levels of crime,
sex work and drug peddling. These characteristics of urban poverty, as has been shown in sev-
eral studies in the sub-region have negative implications on security, sense of community and
consequently, the health of inhabitants.
2.2 Data
This study was carried out with secondary data from the Urban Health and Poverty survey
(Edulink Wave III) in Accra. This population-based cross-sectional survey, carried out from
September to November 2013, was set in the three urban poor communities -Agbogbloshie,
James Town and Ussher Town -as part of the Population Training and Research Capacity for
Development (PopTRCD) project that aimed to improve training in the population sciences,
as well as study the demography of urban poor communities in Accra, Ghana. Data were col-
lected from women and men aged 15–49 years and 15–59 years respectively, based on a sam-
pling frame designed by the Ghana Statistical Service for the Ghana Demographic and Health
Surveys. The sample was drawn from 29 enumeration areas (EAs), each with 40 households
systematically chosen to make up a total of 1160 households distributed over the three locali-
ties. The number of EAs and, therefore, households in each locality was proportionate to the
population size of that locality. There were five EAs from Agbogbloshie, eight from James
Town and sixteen from Ussher Town. Six hundred and seventy-five (675) households were
selected for the EDULINK survey, yielding a sample size of 782 respondents who were eligible
for the individual questionnaire. This sample was used for the analyses of the relationship
between respondents’ community sense of trust, personal trust and psychological distress
within the context of urban poverty.
The survey instrument addressed a variety of issues, including neighbourhood contexts and
psychosocial/mental health. The data were collected using an interviewer-administered ques-
tionnaire in English and mostly Ga and Twi, these being languages indigenous to the study
area. Forward and backward translation of the questionnaire was done to validate for appro-
priateness of wording and potential misinterpretation. Interviewers were trained, and the
questionnaire was pre-tested prior to the survey.
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 4 / 13
Community and individual sense of trust and psychological distress
2.3 Ethics statement
Written informed consent was obtained from all respondents prior to conducting the inter-
view. Respondents who could not append their signatures were provided ink pads to thumb
print in the relevant sections of the informed consent forms. For participants below the age of
eighteen, written consent was signed by parents/guardian. In addition to parental consent,
they were required to provide written consent before interviews were conducted. Further,
study participants had the option of withdrawing from the study at any point without conse-
quences. Ethical clearance for this study was obtained from the Noguchi Memorial Institute
for Medical Research’s Institutional Review Board (NMIMR-IRB) in September, 2013, with
the most recent renewal in September, 2017. The protocol number is 105/12-13.
2.4 Measures
Evidence on community as well as individual level factors in the extant literature suggests how
community sense of trust and individual level background characteristics influence mental
health [44]. Incorporating variables from this perspective, the study operationalizes both com-
munity and interpersonal level predictors. For the dependent variable, the survey incorporated
the Kessler Psychological Distress Scale. This is a symptomatic psychological distress/ wellbe-
ing item scale [45], where respondents were asked about how they had been feeling during the
past four weeks. For each question (Table 1), they were asked to give the one answer that came
closest to the way they had been feeling, on a 5-point scale ranging from 1 (none of the time)
to 5 (all of the time). The scale was scored using the weighted sum of respondents’ answers. On
the five-point scale, respondents’ scores ranged from a minimum of 9 to a maximum of 45 for
psychological distress.
The conceptualisation of sense of trust is measured from a multilevel perspective; at the
community, interpersonal and intrapersonal levels. According to Ross (2011), loss in commu-
nity sense of trust develops in places where resources are scarce. Alluding to the urban poor
context of the study, people may likely develop mistrust in community safety nets in adverse
situations, that may result in poor mental well-being. Thus, to explore this relationship to men-
tal well-being, community sense of trust was operationalised as a scale incorporating respon-
dents’ summed answers to three following questions on a Likert scale (1 = strongly disagree;
2 = disagree; 3 = agree 4 = strongly agree): (1) People in this community are willing to help
each other; (2) People in this community can be trusted; (3) People in this community watch
out for each other. A Cronbach’s alpha of 0.71 indicating a reliable scale was noted. A high
score indicates a higher level of trust [13].
Table 1. Psychological distress item scale.
a. Have you been a very nervous person?
b. Have you felt so unhappy and not yourself that nothing could cheer you up?
c. Have you felt downhearted and let down?
d. Did you feel worn out?
e. Have you felt worthless or hopeless?
f. Did you feel full of life and bounce?
g. Have you felt calm and peaceful?
h. Did you have a lot of energy?
i. Have you been a happy person?
Source: Edulink Wave III, 2013
https://doi.org/10.1371/journal.pone.0202818.t001
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 5 / 13
Community and individual sense of trust and psychological distress
Likewise, personal trust was operationalised as a scale incorporating respondents’ summed
answers to three following questions on a Likert scale (1 = very likely; 2 = likely; 3 = not very
likely 4 = never): (1) How likely are you to ask for help from a neighbour if you needed to talk
about something worrying you? (2) How likely do you think you would be able to receive help
from a neighbour if you asked to talk about something worrying you? (3) How likely do you
think you would be able to receive help from a neighbor outside the community if you asked
to talk about something worrying you? Personal trust response was reverse coded. A Cron-
bach’s alpha of 0.72 was noted. A high score indicates a higher level of personal sense of trust.
Demographic variables controlled for included age, sex, level of educational attainment
(primary, JHS, SHS, higher), religiosity operationalised as the number of times a person
attended religious services in the past month, locality of residence (James Town, Ussher Town,
Agbogbloshie), marital status (in union or not), employment status (employed or not), ethnic-
ity (Ga, Akan, other).
2.5 Analytical procedure
The data are analyzed using descriptive statistics (frequency distributions, means and standard
deviation), bivariate tests of associations (cross-tabulations, oneway ANOVA), and multivari-
ate regressions. The background characteristics of respondents, including age, sex, marital sta-
tus, ethnicity, highest level of educational attainment, religious affiliation, locality of residence,
type of occupation engaged in, are described using frequency distributions. Bivariate tests of
associations between community sense of trust and the other variables, are carried out, using
one-way ANOVA. Multilevel regression analysis explores community level and personal sense
of trust effects on psychological distress outcomes. Here, multiple linear regression is
employed due to the continuous nature of the dependent variable.
Results
3.1 Characteristics of the participants
The demographic and socio-economic characteristics of the participants are presented in
Table 2. Females constituted a little more than half of the participants (56%). Majority (45%)
of the participants had attained junior high school education. Approximately 6% of the partici-
pants had tertiary education. About two thirds (65%) of the participants were employed. With
regard to marital status, more than half (55%) of the participants were single. The mean score
for psychological distress was 25.4. Overall, the mean score for individual-level sense of trust
was 8.2, while that of community-level sense of trust was 7.5 (see Table 2).
3.2 Relationship between demographic characteristics and psychological
trust
Table 3 describes the bivariate relationship between demographic characteristics and psycho-
logical distress. Oneway ANOVA was used because the dependent variable was continuous.
The bivariate table shows that among the demographic characteristics, sex, education and per-
ceived relative economic standing were significantly associated with psychological distress at
the bivariate level. The mean psychological distress score was lower for males than for females.
In terms of education, as the level of education attainment increased, psychological distress
decreased. A similar negative relationship was observed for perceived relative economic stand-
ing. Locality, marital status, employment status, religiosity and ethnicity were not significantly
associated with psychological distress.
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 6 / 13
Community and individual sense of trust and psychological distress
Table 2. Demographic characteristics of respondents.
Demographic Characteristics Frequency (%)
Gender
Male 344 (44.0%)
Female 438 (56.0%)
Education
Primary school 137 (18.7%)
Junior high school 332 (45.2%)
Senior high school 223 (30.4%)
Tertiary 42 (5.7%)
Locality
James Town 218 (27.9%)
Ussher Town 457 (58.4%)
Agbogbloshie 107 (13.7%)
Employment Status
Employed 510 (65.2%)
Unemployed 272 (34.8%)
Marital Status
Married 156 (19.9%)
Cohabiting 182 (23.3%)
Single 434 (55.5%)
Psychological Distress 25.35 (±5.5)
Individual-level sense of trust 4.93 (±1.9)
Community-level sense of trust 7.47 (±2.1)
Perceived economic standing 2.64 (±1.9)
Age 30.32 (±10.6)
https://doi.org/10.1371/journal.pone.0202818.t002
Table 4 features results from the multivariate regression model. In all, 3 models were used
in assessing the relationship between psychological distress and both community and personal
levels of trust, controlling for other explanatory factors. The first model expressed the relation-
ship between only community level trust and psychological distress. The second model focused
on the relationship between community level trust only and psychological distress. The third
model expressed the relationship between the psychological distress and both community and
personal trust while controlling for demographic factors. The results of the multivariate analy-
sis showed that although community level trust was inversely related to psychological distress,
the relationship was not significant (B = -0.1565, t = -1.59, p< 0.105). In model 1 (see
Table 4), the results show that personal trust had a significant association with psychological
distress. Personal trust was inversely related to psychological distress, meaning an increase in
personal trust was associated with a significant decrease in psychological distress. Specifically,
every unit increase in personal sense of trust, a 0.22 unit decrease in psychological distress was
predicted (B = -.2151196, t = -2.88, p< 0.004).
In model 3, other factors associated with psychological distress in this model were perceived
economic standing, sex, education and locality of residence. A higher level of educational
attainment was found to be negatively related to psychological distress. Higher educational
attainment was significantly associated with lower levels of psychological distress. For example,
respondents with the highest level of education attainment recorded the least psychological
distress (B = -3.006885, t = -2.94, p< 0.003). Likewise, those with the least level of education
recorded the highest psychological distress score (B = -1.165499, t = -2.07, p< 0.038). In terms
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 7 / 13
Community and individual sense of trust and psychological distress
Table 3. Relationship between demographic characteristics and psychological distress.
Variables Mean SD F stats Prob > F
Locality 2.61 0.0746
Usshertown 25.71 5.34
Jamestown 24.67 5.90
Agbogbloshie 25.54 5.39
Sex
Male 24.69 5.62 9.48 0.0021
Female 25.92 5.38
Education 5.83 0.0006
Primary 26.74 5.36
Middle/JSS 25.39 5.72
Secondary 24.78 5.72
Higher 23.26 5.20
Marital Status
Not in Union 25.55 5.72 0.95 0.3000
In Union 25.16 5.22
Religiousity
Low 25.6 5.45 0.9 0.4073
Medium 25.08 5.42
High 25.64 5.68
Ethnicity
Ga 25.12 5.44 1.48 0.2276
Akan 25.67 5.74
Others 25.98 5.47
Perceived relative Economic standing 7.86 0.0000
First Quintile 28.03 6.22
Second Quintile 25.51 4.86
Third Quintile 24.87 5.49
Fourth Quintile 25.08 5.42
Fifth Quintile 23.17 5.32
Employment
No 25.77 5.53 1.61 0.2047
Yes 25.19 5.50
https://doi.org/10.1371/journal.pone.0202818.t003
of location, Usshertown recorded a higher level of psychological distress compared to Agbog-
bloshie and James Town. Perceived relative economic standing was significantly related with
psychological distress. Respondents who rated themselves higher economically in the commu-
nities recorded significantly lower levels of psychological distress. Perceived relative economic
standing was closely related to a higher sense of self efficacy.
Discussion
This study examined the influence of community and individual sense of trust on psychologi-
cal distress in three urban poor communities in Accra. Community sense of trust did not pre-
dict psychological distress. However, individual trust significantly predicted psychological
distress. In addition to the main independent variables, sex, education, locality and relative
perceived economic also significantly predicted psychological distress.
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 8 / 13
Community and individual sense of trust and psychological distress
Table 4. Multivariate model expressing the relationship between psychological distress and explanatory factors.
Variables Model 1 P>[t] Model 2 P>[t] Model 3 P>[t]
Individual Trust -0.21574 0.004 -0.202 0.010
Community Trust -0.1565 0.105 0.002 0.982
Locality
Usshertown
Jamestown -1.161 0.016
Agbogbloshie -1.278 0.072
Sex
Male
Female 0.644 0.123
Education
Primary
Middle/JSS -1.165 0.038
Secondary -1.608 0.009
Higher -3.006 0.003
Marital Status
In Union -0.305 0.486
Not in Union
Religiosity
Low
Medium 0.612 0.340
High 0.291 0.639
Ethnicity
Ga
Akan 0.885 0.098
Others 1.010 0.118
Economic
Perceived relative Economic standing -0.841 0.000
Employment
No
Yes -0.455 0.314
Variables included in the model: individual sense of trust, perceived economic standing, sex, age, marital status, religiosity, education, employment status and locality of
residence. Model: R2 = 0.0804; Adjusted R2 = 0.0599; F (15, 673) = 545; p < .001
https://doi.org/10.1371/journal.pone.0202818.t004
4.1 Sense of trust on psychological distress
The findings from this study showed that only personal sense of trust predicted psychological
distress among urban poor residents in Accra. That is, a higher sense of personal trust was sig-
nificantly associated with lower psychological distress. This finding is contrary to suggestions
that communal living is the fundamental pathway to ensuring psychological well-being in col-
lectivistic communities [40,46,47]. This study demonstrates that even in collectivistic urban
poor communities, positive interpersonal attributes such as the ability to trust people attenu-
ates the effect of psychological distress. There is evidence to show that in collectivistic contexts,
people still maintain their sense of individuality and draw on their inter-personal psychological
resources to buffer the stress of the collective [40]. In collectivistic and individualistic societies
alike, individuals express individual, relational and collective selves, with each aspect of self
becoming salient depending on specific personal and social circumstances[48]. Consistent
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 9 / 13
Community and individual sense of trust and psychological distress
with these arguments, the findings from the current study suggests that while mental health in
urban poor communities is shaped by multi-level dynamics, personal and interpersonal level
factors play more important buffer roles for psychological wellbeing than community level
factors.
4.2 Demographic and socio-economic factors on psychological distress
Four of the demographic factors, namely sex, level of education, perceived relative economic
standing and locality, predicted psychological distress. Formal education is generally associ-
ated with better health outcomes. Some researchers consider education to be a ‘social vaccine’
[49–51]. The educational effect on psychological distress can operate through access to social
and labour-market resources [52]. In Ghana, individuals with higher education have access to
better paid formal jobs and healthcare compared to those with no education [53]. These privi-
leges may buffer individuals against the adverse effects of psychological distress in urban poor
communities[54].
Perceived relative economic status was negatively associated with mental health in this
study. Our finding are similar to those in Japan [55,56], and US [57], Perceived relative eco-
nomic standing to some extent relates to the self-efficacy of community members. Respon-
dents with a higher perceived relative economic standing had lower scores on the
psychological distress scale. This implies that both inter (individual sense of trust) and intra
personal attributes (perceived relative economic standing) were better predictors of psycholog-
ical distress than community related variables. The model shows that perceived economic
standing was the most significant predictor of psychological distress, while community sense
of trust was the least significant predictor of psychological distress amongst the three main
independent variables.
4.3 Limitations of the study
The study has a number of limitations. First, we cannot infer causality because the data we ana-
lysed was cross sectional. Also, the findings of the study cannot be generalized to the entire
Ghanaian population. These findings are, however, relevant for rapidly expanding populations
in major urban centres across the country. Additionally, other factors that measure sense of
trust were not included in this study. For instance, the study did not directly measure the miti-
gating role of social institutions such as religious institutions on psychological distress.
4.3 Conclusion
This study presents evidence that more trusting individuals are significantly less likely to be
psychologically distressed within deprived urban communities in Accra. Positive intra and
inter individual level variables such as personal level trust and perceived relative economic
standing significantly attenuated the effect of psychological distress in communities with high
level neighbourhood disorder in Accra. Belonging to social groups where people can develop
positive interpersonal relationships with each other may provide an avenue to buffer the effect
of psychological distress in urban African contexts with rapidly growing populations and
neighbourhoods with high levels of neighbourhood disorder.
Supporting information
S1 Data. The data for this analysis is contained in a stata file.
(DTA)
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 10 / 13
Community and individual sense of trust and psychological distress
Acknowledgments
Funding sources were jointly from Secretariat of the African Caribbean and Pacific Group of
States (ACP)—ACP-EU Cooperation Programme in Higher Education (EDULINK), Interna-
tional Development Research Centre (IDRC), Research on Obesity and Diabetes among Afri-
can Migrants (RODAM) and the William and Flora Hewlett Foundation. The funders had no
role in study design, data collection and analysis, decision to publish, or preparation of the
manuscript.
Author Contributions
Conceptualization: Mawuli K. Kushitor, Maame B. Peterson, Naa Dodua Dodoo, Lionel
Sakyi, Ama de-Graft Aikins.
Data curation: Naa Dodua Dodoo, F. Nii-Amoo Dodoo.
Formal analysis: Mawuli K. Kushitor, Maame B. Peterson, Paapa Yaw Asante, Sandra Boate-
maa, Raphael Baffour Awuah, Francis Agyei.
Funding acquisition: F. Nii-Amoo Dodoo.
Investigation: F. Nii-Amoo Dodoo, Ama de-Graft Aikins.
Methodology: Maame B. Peterson, F. Nii-Amoo Dodoo, Ama de-Graft Aikins.
Project administration: F. Nii-Amoo Dodoo.
Supervision: Ama de-Graft Aikins.
Visualization: Francis Agyei.
Writing – original draft: Mawuli K. Kushitor, Maame B. Peterson, Paapa Yaw Asante, Sandra
Boatemaa, Raphael Baffour Awuah.
Writing – review & editing: Mawuli K. Kushitor, Maame B. Peterson, Naa Dodua Dodoo,
Ama de-Graft Aikins.
References
1. Cobbinah PB, Erdiaw-Kwasie M.O. Amoateng P. Africa’s urbanisation: Implications for sustainable
development. Cities. 2015; 47: 62–72.
2. UNDESA/PD. World urbanisation prospects: The 2011 revision. New York: United Nations; 2012.
3. Agyei-Mensah S, de-Graft Aikins A. Epidemiological transition and the double burden of disease in
Accra, Ghana. J Urban Heal Bull New York Acad Med. 2010; 87: 879–897. https://doi.org/10.1007/
s11524-010-9492-y PMID: 20803094
4. Prince M, Patel V, Saxena S, Maj M, Maselko J, Philllips M, et al. No health without mental health. Lan-
cet. 2007; 370: 859–877. https://doi.org/10.1016/S0140-6736(07)61238-0 PMID: 17804063
5. Cuijpers P, Smit F. Excess mortality in depression: a meta-analysis of community studies. J Affect Dis-
ord. 2002; 72: 227–36. PMID: 12450639
6. Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, et al. The global burden of mental
disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiol Psychiatr Sci.
2009; 18: 23–33.
7. Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the
epidemiology, risk and treatment evidence. Med J Aust. 2009; 190: 54–60.
8. Kiecolt-Glaser JK, Glaser R. Depression and immune function: central pathways to morbidity and mor-
tality. J Psychosom Res. 2002; 53: 873–876. PMID: 12377296
9. Ross CE, Mirowsky J. Neighborhood Disorder, Subjective Alienation, and Distress. J Health Soc
Behav. 2009; 50: 49–64. https://doi.org/10.1177/002214650905000104 PMID: 19413134
10. Ross CE. Collective threat, trust, and the sense of personal control. J Health Soc Behav. 2011; 52:
287–296. https://doi.org/10.1177/0022146511404558 PMID: 21799185
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 11 / 13
Community and individual sense of trust and psychological distress
11. Greif MJ, Dodoo FNA. How community physical, structural, and social stressors relate to mental health
in the urban slums of Accra, Ghana. Health Place. 2015; 33: 57–66. https://doi.org/10.1016/j.
healthplace.2015.02.002 PMID: 25754264
12. de-Graft Aikins A, Ofori-Atta AL. Homelessness and mental health in Ghana: Everyday experiences of
Accra’s migrant squatters. J Health Psychol. 2007; 12: 761–78. https://doi.org/10.1177/
1359105307080609 PMID: 17855461
13. Erdem Ö, Van Lenthe FJ, Prins RG, Voorham TA, Burdorf A. Socioeconomic inequalities in psychologi-
cal distress among urban adults: the moderating role of neighborhood social cohesion. PLoS One.
2016; 11.
14. Lang R, Homburg S. What is social capital and why is it so important to public policy? Hous Policy
Debte. 2010; 9: 1–19.
15. Ahern J, Galea S. Collective efficacy and major depression in urban neighborhoods. Am J Epidemiol.
2011; 173: 1453–62. https://doi.org/10.1093/aje/kwr030 PMID: 21527512
16. Echeverria S, Diez-Roux AV, Shea S, Borrell LN, Jackson S. Associations of neighborhood problems
and neighborhood social cohesion with mental health and health behaviors: the Multi-Ethnic Study of
Atherosclerosis. Health Place. 2008; 14: 853–65. https://doi.org/10.1016/j.healthplace.2008.01.004
PMID: 18328772
17. Rios R, Aiken LS, Zautra AJ. Neighborhood contexts and the mediating role of neighborhood social
cohesion on health and psychological distress among Hispanic and non-Hispanic residents. Ann Behav
Med a Publ Soc Behav Med. 2012; 43: 50–61.
18. Fone D, Dunstan F, Lloyd K, Williams F., Watkins J, Palmer S. Does social cohesion modify the associ-
ation between area income deprivation and mental health? A multilevel analysis. Int J Epidemiol. 2007;
36: 338–45. https://doi.org/10.1093/ije/dym004 PMID: 17329315
19. Curley A. Draining or gaining? The social networks of public housing movers in Boston. J Soc Pers
Relationsh. 2009; 26: 227–247.
20. Durden E, Hill T, Angel R. Social demands, social supports, and psychological distress among low
income women. J Soc Pers Relationsh. 2007; 24: 343–361.
21. Kawachi I, Berkman L. Social ties and mental health. J Urban Heal. 2001; http://link.springer.com/
article/10.1093/jurban/78.3.458
22. Tutu RA, Boateng JK, Busingye JD, Ameyaw E. Asymmetry in an uneven place: migrants’ lifestyles,
social capital, and self-rated health status in James Town, Accra. GeoJournal. 2016; 1–15.
23. Ajrouch KJ, Reisine S, Lim S, Sohn W, Ismail A. Perceived everyday discrimination and psychological
distress: does social support matter? Ethn Health. 2010; 15: 417–434. https://doi.org/10.1080/
13557858.2010.484050 PMID: 20582775
24. Sipsma H, Ofori- Atta A, Canavan M, Osei- Akoto I, Udry C, Bradley E. Poor mental health in Ghana:
who is at risk? BMC Public Health. 2013; 13: 2–9.
25. Ovuga E, Boardman J, Wasserman D. The prevalence of depression in two districts of Uganda. Soc
psychiatry Psychiatr . . .. 2005; http://link.springer.com/article/10.1007/s00127-005-0915-0
26. Aidoo M, Harpham T. The explanatory models of mental health amongst low-income women and health
care practitioners in Lusaka, Zambia. Health Policy Plan. 2001; http://heapol.oxfordjournals.org/
content/16/2/206.short
27. Hamad R, Fernald L, Karlan D, Zinman J. Social and economic correlates of depressive symptoms and
perceived stress in South African adults. J Epidemiol Community Heal. 2008; 62: 538–544.
28. Abiodun O. A study of mental morbidity among primary care patients in Nigeria. Comp Psychiatry.
1993; 34: 10–13.
29. Abiodun O, Ogunremi O. Psychiatric morbidity in medical and surgical wards of a Nigerian general hos-
pital. J Psychosom Res. 1990; 34: 409–414. PMID: 2376841
30. Hill TD, Ross CE, Angel RJ. Neighborhood Disorder, Psychophysiological Distress, and Health. J
Health Soc Behav. 2005; 46: 170–86. https://doi.org/10.1177/002214650504600204 PMID: 16028456
31. Ross CE. Neighborhood Disadvantage and Adult Depression. J Health Soc Behav. 2000; 41: 177–87.
32. Ross CE, Mirowsky J. Normlessness, Powerlessness, and Trouble with the Law. Criminology. 1987;
25: 257–7.
33. Ross CE, Mirowsky J, Pribesh S. Disadvantage, Disorder, and Urban Mistrust. City Community. 2002;
1: 59–82.
34. Daoud N, O’Campo P, Urquia ML, Heaman M. Neighbourhood context and abuse among immigrant
and non-immigrant women in Canada: findings from the Maternity Experiences Survey. Int J Public
Health. 2012; 57: 679–689. https://doi.org/10.1007/s00038-012-0367-8 PMID: 22588309
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 12 / 13
Community and individual sense of trust and psychological distress
35. Ross CE, Mirowsky J. Neighborhood Disadvantage, Disorder, and Health. J Health Soc Behav. 2001;
42: 258–76. PMID: 11668773
36. Aneshensel CS, Sucoff CA. The Neighborhood Context of Adolescent Mental Health. J Health Soc
Behav. 1996; 37: 293–310. PMID: 8997886
37. Latkin C, Curry A. Stressful Neighborhoods and Depression: A Prospective Study of the Impact of
Neighborhood Disorder. J Heal Soc Behav. 2003; 44: 34–44.
38. Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality, and mortality.
Am J Public Health. 1997; 87: 1491–1498. PMID: 9314802
39. Kramer RM. Trust and Distrust in organization: Emerging perspectives, enduring questions. Annu Rev
Psychol. 1999; 50: 569–98. https://doi.org/10.1146/annurev.psych.50.1.569 PMID: 15012464
40. Adams G, Dzokoto VA. Self and identity in African studies. Self Identity. 2003; 2: 345–359.
41. Adams G. The cultural grounding of personal relationship: enemyship in North American and West Afri-
can worlds. J Pers Soc Psychol. 2005; 88: 948. https://doi.org/10.1037/0022-3514.88.6.948 PMID:
15982115
42. Rotter JB. Interpersonal trust, trust worthiness, and Gullibility. Am Psychol. 1980; 35: 1–7.
43. de-Graft Aikins A, Kushitor M, Koram K, Gyamfi S, Ogedegbe G. Chronic non-communicable diseases
and the challenge of universal health coverage: Insights from community-based cardiovascular disease
research in urban poor communities in Accra, Ghana. BMC Public Health. BioMed Central Ltd; 2014;
14 Suppl 2: S3. https://doi.org/10.1186/1471-2458-14-S2-S3 PMID: 25082497
44. Sampson R, Raudenbush S, Earls F. Neighborhoods and violent crime: a multilevel study of collective
efficacy. Science (80-). 1997; 277: 918–924.
45. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al. Short screening scales to
monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;
32: 959–976. PMID: 12214795
46. Markus HR, Kitayama S. Culture and the self: Implications for cognition, emotion, and motivation. Psy-
chol Rev. 1991; 98: 224.
47. Markus HR, Kitayama S. Cultures and selves: A cycle of mutual constitution. Perspect Psychol Sci.
2010; 5: 420–430. https://doi.org/10.1177/1745691610375557 PMID: 26162188
48. Sedikides C, Gaertner L, Luke MA, O’Mara EM, Gebauer JE. A three-tier hierarchy of self-potency: Indi-
vidual self, relational self, collective self. Adv Exp Soc Psychol. 2013; 48: 235–295.
49. Baker DP, Collins JM, Leon J. Risk factor or social vaccine? The historical progression of the role of
education in HIV and AIDS infection in Sub-Saharan Africa. Prospect Q Rev Comp Educ. 2009; 38:
467–486.
50. Peters E, Baker DP, Dieckmann NF, Leon J, Collins J. Explaining the effect of education on health: a
field study in Ghana. Psychol Sci. 2010; 21: 1369–1376. https://doi.org/10.1177/0956797610381506
PMID: 20739672
51. de Walque D, Nakiyingi-Miiro JS, Busingye J, Whitworth JA. Changing association between schooling
levels and HIV-1 infection over 11 years in a rural population cohort in south-west Uganda. Trop Med Int
Heal. 2009; 10: 993–1001.
52. Brannlund A, Hammarstrom A. Higher education and psychological distress: a 27-year prospective
cohort study in Sweden. Scand J Public Health. 2014; 42: 155–162. https://doi.org/10.1177/
1403494813511559 PMID: 24265167
53. Brännlund A, Hammarström A. Higher education and psychological distress: a 27-year prospective
cohort study in Sweden. Scand J Soc Med. 2014; 42: 155–162.
54. Tutu RA. Self-rated resilience among young migrants in old Fadama, Accra, Ghana. GeoJournal. 2013;
78: 709–725.
55. Sakurai K, Kawakami N, Yamaoka K, Ishikawa H, Hashimoto H. The impact of subjective and objective
social status on psychological distress among men and women in Japan. Soc Sci Med. 2010; 70: 1832–
1829. https://doi.org/10.1016/j.socscimed.2010.01.019 PMID: 20303205
56. Kobayashi T, Suzuki E, Noguchi M, Kawachi I, Takao S. Community-level social capital and psychologi-
cal distress among the elderly in Japan: A population-based study. PLoS One. 2015; 10: p.e0142629.
57. Adler N, Singh-Manoux A, Schwartz J, Stewart J, Matthews K., Marmot M. Social status and health: a
comparison of British civil servants in Whitehall-II with European- and African-Americans in CARDIA.
Soc Sci Med. 2008; 66: 1034–45. https://doi.org/10.1016/j.socscimed.2007.11.031 PMID: 18180089
PLOS ONE | https://doi.org/10.1371/journal.pone.0202818 September 27, 2018 13 / 13