Mental Health and Injury Outcomes in Liberia, 1990–2017: An Ecological Systems Analysis

Abstract

Bronfenbrenner’s bioecological model of human development is widely used to explain health outcomes, but most research focuses on the more immediate microsystem influences. Over the last 30 years, Liberia has experienced two civil wars, government regime changes, and an Ebola outbreak. We considered associations between those macrosystem and chronosystem shifts in Liberia on four public health outcomes from 1990 to 2017: suicide, depression, sexual violence, and substance use disorders. We conducted separate analyses for women and men. The results indicated substantial changes in health that coincided with macrosystem and chronosystem changes in Liberia. Men’s suicide rates increased during wartime and decreased afterwards, especially during the stable Sirleaf presidency. Both men and women experienced decreasing depression rates during the First Civil War. Depression rates for both men and women flattened during the stable Sirleaf presidency and increased during the Ebola outbreak. The rate of sexual violence was high for both genders during wartime and economic turmoil but declined markedly, especially among women, during the Sirleaf presidency, when government policies were enacted to reduce sexual violence. Substance use disorders were highest during times of economic stability and growth. Men experienced higher rates of suicide and substance use and lower rates of depression and sexual violence compared to women at all times. Consistent with Bronfenbrenner’s model, the results indicate how macrosystem and chronosystem shifts coincided with changes in individual-level mental health and injury outcome trends. We recommend macrosystem-level changes to prevent violence and increase mental health services, both in Liberia and globally.