This study aimed to determine factors which influence depression in children and adolescents with SCA in a low-resource setting. Among the determined factors, age and educational level had positive relationships while gender, socioeconomic status and disease severity had no relationship with depression in children and adolescents with SCA.
The absence of an association between gender and depression among children and adolescents in this study interestingly added to the inconsistency noted in previous researches. Thus while Friedberg and Sinderman  argued that females are expected to score higher on CDI and Hasan et al  believed that female sex is an important predictor of depression in SCA, other workers [7–9, 12, 28] documented lack of association between sex and depression in SCA. The controversy surrounding the effect of gender on depression may be due to differences in the age groups of recruited SCA patients as adolescent girls are noted to have higher rates of depression than boys while pre-adolescence attenuate the gender differences . Thus, similar to our study, studies with children and adolescents as their subjects consistently found gender as non-predictive of depression [7, 8].
Furthermore, recruitment of children and adolescents may also allow the effect of age to be determined compared to recruitment of homogenous groups like young adults or adults. Researchers had reported that older children endorsed more symptoms on the CDI and total CDI scores significantly correlated with children’s age . Our study found a significant positive correlation between age and CDI scores. The age range in this study was 7–17 years while previous studies on effect of age recruited much older children and documented lack of relationship between age and depression in individuals with SCA [9–11]. This finding can be explained by the fact that aside more depressive symptoms in adolescents because of the peculiar stressors they face from physical, emotional, and psychological challenges [4, 5], those with SCA experience additional disease related challenges such as delayed puberty, short stature, fatigue and leg ulcers which can lead to depression .
Interestingly, there was a significant positive linear relationship between educational level and depression scores of the SCA children and adolescents. This is expected since their educational level naturally increase with increasing age. This is inconsistent with the observation of Hasan et al  who noted that less than high school education significantly predicted the likelihood of depression compared to above high school. Alhamoud et al  and Altaitoon et al  also found a significant association between lower education and depression. The difference between our finding and that of previous studies may be paradoxical considering that the lower age category in these studies (adolescents) corresponds with the higher age category in our study. Hence since educational level is usually affected by age, the adolescents will likely be in lower educational level in the previous studies while in higher educational level in this study but still report their typical higher depressive symptoms in both settings. Thus, as has been suggested, psychological evaluation may be incorporated into the protocol for management of children with SCA as they progress academically .
The results demonstrated lack of association between depression and socio-economic status of the subjects. This finding disagrees with long held belief that there is an association between depression and socioeconomic status . It also contrasted with previous observations that depression was generally more common among people in low socioeconomic group . Unlike other parents belonging to low socioeconomic classes, parents of children with SCA may be providing them with extra care which may allay depressive tendencies. Hence, Sehlo and Kamfar  found that higher level of parental support is a significant predictor of low depression state in children with SCA.
It is noteworthy that despite the perceived effect of SCA disease severity on psychosocial function , and the proportion of SCA people with depression increasing with increasing disease severity in this study, there was lack of association between depression and disease severity. This finding is in keeping with the observation by previous researchers that, using CDI, disease severity is not a predictor of depression . In contrast, Hasan and colleagues  assessed measures of severity and found each a significant predictors of depression. The lack of relationship in this study may not be unrelated to the recruitment done in the clinic when they are stable and may not fully recount previous experiences. Again, the result may have been affected by the period considered in CDI tool used for assessment of depression. As feelings and thoughts in the preceding 2 weeks are reported, some of the children with severe disease may not fully recall them while others may feel restricted from expressing the thoughts and feelings beyond preceding 2 weeks.
A limitation of this study is the use of a single setting. Although UNTH serves a large geographic region, which encompasses rural and urban centers, statements about generalizability may be conservative. A multi-site study would have improved generalization of the study.