Depression, Anxiety and Stress Levels among Chronic Disease Patients During COVID-19 Pandemic in Dessie Town Hospitals, Ethiopia

The overall anxiety, depression, and stress level were 19.9%, 21.5%, and 17.7%, respectively. In multivariate analysis, older age, female gender, urban residency, duration of living with chronic diseases, and presence of comorbidities were associated with depression of chronic disease patients during the pandemic at p-value <0.05. Age, female gender, presence of comorbidities, and no social support were associated with anxiety. Urban residency, use of hand sanitizer, those who had respiratory manifestations, and travel history in the last two weeks were significantly associated with stress levels.


INTRODUCTION
Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the etiology of COVID-19. This virus was first reported in China in December 2019, and it has been spreading globally. On March 11, 2020, WHO announced COVID-19 as a universal pandemic [1]. septic shock. Novel coronavirus infection is more severe in older age populations who have chronic diseases like diabetes mellitus, kidney disease, chronic lung diseases, and liver diseases. In addition, patients with high body mass index and those taking immunosuppressant medications are at higher risk of COVID-19 morbidity and mortality [5,6]. Furthermore, another study revealed that people with hypertension, diabetes mellitus, diseases of the heart and lung were highly affected by COVID-19 [7].
COVID-19 is a highly contagious disease that can be transmitted mainly through close contacts [8 -11]. This pandemic affected many people throughout the world. At the time of writing this manuscript (as of September 3, 2020), about 25.6 million people have been affected by COVID-19, and 852,752 deaths were recorded. At the same time, in Ethiopia, a total of 53,304 people were infected, and 828 deaths were reported [12]. COVID-19 is not only an infectious disease but also a shock to the major economies of the world [13].
Until the present date, there was no confirmed medication reported from anywhere to treat COVID-19. However, WHO recommended different prevention strategies which focused on rapid case finding and management, follow-up of cases and awareness creation, prevention, and control of infection, quarantine of travelers, and other public health interventions [14,15].
COVID-19 is not only a disease, but it has also affected the financial sector and caused political and social issues [13, 16 -20]. In addition, the disease has affected the health care system of Africa, including Ethiopia [21 -23]. During the current pandemic, various studies were done to assess depression, stress, and anxiety level in the general population [24 -32]. As per our knowledge, until data collection of this study, there were no published studies in Ethiopia on depression, anxiety and stress levels of patients with the chronic disease during the pandemic. Thus, the objective of this study was to assess depression, anxiety, and stress levels of chronic disease patients in Dessie town government and private hospitals. The result of the study may help policymakers and health care workers in formulating comprehensive interventions to improve the mental health of chronic disease patients. Furthermore, this study provides valuable information to Dessie town and South Wollo zone health office, health professionals, and policymakers to plan their resources and implement accordingly.

Study Area
This study was carried out in the Dessie town government and private hospitals. Dessie town is situated 401 km North of Addis Ababa in a mountainous landscape, and it is about 480 km from Bahirdar (capital city of Amhara regional sate). Dessie town has two government and three private hospitals. These government and private hospitals serve South Wollo zone, North Wollo Zone, and some parts of the Afar region population.

Study Design and Period
A facility-based cross-sectional study was done from July 20 to August 5, 2020.

Source Population
All chronic disease clients who attended inpatient departments and outpatient clinics in Dessie town government and private hospitals were the source population.

Study Population
All chronic disease patients who attended selected Dessie town government and private hospitals during the study period were the study population.

Inclusion Criteria
All patients with chronic disease aged 18 years and above who visited government and private hospitals in Dessie town during the study period were included.

Exclusion Criteria
Critical ill and hearing impairment patients were excluded.

Sample Size Determination
It is calculated by using single proportion formula [n = (Z a/2) 2 P(1-P)/d 2 ]. A proportion of 50% was used because there were no published data on chronic diseases patients' depression, anxiety, and stress level during the pandemic in our country up to the date of data collection of this study, 95% confidence level (Z=1.96), 5% margin of error, and 10% nonresponse rate. Thus, the final sample size was 422.

Sampling Technique and Procedure
In Dessie town, there are five hospitals. Of those, the Dessie referral hospital and two private hospitals, namely Selam and Ethio general hospitals, were selected by using a simple random sampling technique. To determine the clients load in selected hospitals, the daily average flow of chronic disease patients at in-patient and out-patient clinics were estimated. Proportional allocation was made based on clients' load on the selected facilities (295: Dessie referral hospital; 67: Ethio general hospital; 60: Selam general hospital). Finally, a systematic random sampling method was employed to select study participants

Data Collection Tool
Structured interviewer-administered questionnaires were used for data collection, which consists of three sections.
(1) Socio-demographic characteristics: Age, educational level, sex, occupation, residency, family size, marital status, and number of house room.
(2) Clinical characteristics: Type of chronic diseases, duration of chronic disease, presence of co-morbidities, respiratory manifestations in the last two weeks, travel history to other areas, having social support, member of community health insurance, use of face mask and hand sanitizer.

Data Collection Procedure and Quality Control
The data collection tool was translated from English to Amharic (the local language of the study area) and then back to English to check its consistency. Pre-test was conducted by taking 10% of the sample size in the non-selected hospital (Baty hospital). Training was given to data collectors and supervisors. The data were collected under regular supervision after giving training for data collectors. Data collection was done by wearing a face mask and by maintaining the physical distance of two meters.

Data Processing and Analysis
Epidata 3.1 was used for data entry, and SPSS version 23.0 was utilized for analysis. Descriptive statistics of continuous variables were presented by using mean and discrete variables by using percentages and tables. Binary logistic regression analysis was tested along with 95% CI to assess the degree of association between outcome and independent variables. Variables that had a p-value of <0.2 in bivariate analysis were entered into a multivariate model to control confounding variables. A significant association was declared at the p-value of <0.05 in multivariate analysis.

Depression, Anxiety and Stress Level among Chronic Disease Patients
The Open Psychology Journal, 2021, Volume 14 253

DISCUSSION
Currently, COVID-19 is a major global health problem, including in Ethiopia. The current study investigated the depression, anxiety, and stress level of chronic disease patients. This finding could help inform policymakers, health professionals, and non-governmental organizations to alleviate the mental problems of chronic disease patients during the period of COVID-19.
In our study, 21.5% (95% CI: 17.5-25.6) of chronic disease patients had depression during the COVID-19 pandemic from mild to extremely severe cases. This finding was supported by studies conducted in China (20.1%) [29] and Italy (32.8%) [32]. The finding is higher than that found in another study in China (17.17%) [40]. These discrepancies might be due to the difference in COVID-19 burden in different settings, a time gap of studies in various settings and countries, and the presence of differences in perceived susceptibility towards the pandemic in various study areas.
In our study, the overall stress from mild to extremely severe stress was 72 (17.7%) (95% CI: 14.1-21.1). This finding was similar with a study carried out in Iraq (17.5%) [29], but it is lower than studies conducted in Spain (37%) [41], India (35.7%) [31], China (32.1%) [24] and Italy (27.2%) [32]. This discrepancy could be related to the difference in the burden of the pandemic in different study areas, the time gap between studies, and the difference in socio-demographic profile.
Overall, our study revealed that depression, anxiety, and stress were common in chronic disease patients during the COVID-19 pandemic, which needs interventions by the government, local administrations, health care workers, and researchers as well as non-governmental organizations.
In our study, associated factors of depression, anxiety, and stress were also identified. Age ≥55 years were associated with depression symptoms as compared to age from 18-34 years. Age ≥55 years and 35-54 years were also significantly associated with the anxiety level of chronic disease patients as compared to age 18-34 years. This finding contradicts a study done in Japan where depressive symptoms and anxiety symptoms were higher for young and middle-aged respondents compared to older respondents [38]. A study done in China also revealed that young aged individuals (21-40 years) were more vulnerable to mental illnesses [27]. This discrepancy could be explained by the fact that older aged people in this study may have more economic problems as compared to Japan and China, that end up with higher depression and anxiety during COVID-19.
Female gender was significantly associated with anxiety and depression of chronic diseases patients during COVID-19, which was similar to studies conducted in China,Iraq,Italy,and Nepal [24,29,32,39]. This might be related to genderbased violence and the economical influence on females which made them develop depression and anxiety over the COVID-19 burden. The finding was also supported by other studies in which females were more vulnerable to experiencing and developing post-traumatic symptoms than males [42].
Urban residency and the presence of comorbidities were significantly associated with depression of chronic disease patients. A study carried out in Turkey also revealed that the pandemic had a greater effect on urban dwellers and on those who had comorbidities [43]. Duration of living with chronic diseases 5-10 years and > 10 years were also significantly associated with depression of chronic disease patients during the current pandemic as compared to less than 5 years. This implies that as the duration of the disease becomes longer, the burden on mental health becomes high.
People having no social support were more likely to have anxiety compared to those with social support. This is similar to a study carried out in China where social support and anxiety were negatively correlated. This suggested that the anxiety level of patients having chronic diseases should be monitored during the pandemic [44].
The presence of respiratory manifestations in the past two weeks was significantly associated with the stress level of chronic disease patients during the current pandemic. This is in line with a study conducted on populations of Spain where significant positive associations were found between stress level and COVID-19 symptoms [41]. Travel history in the last 2 weeks and hand sanitizer use also had an association with stress levels. The possible reason might be that as people travel to other areas during the pandemic, they may over think about the transmission of the diseases during their journey, which might lead to stress. More stressed individuals might use hand sanitizer more frequently as they might think about the COVID-19 pandemic over and over again.
This study had limitations. Due to the cross-sectional nature of the study, it is difficult to conclude the prolonged effect of COVID-19. In addition, we tried to compare our findings with general population studies due to the availability of limited researches on patients with chronic diseases, depression, anxiety, and stress levels during the COVD-19 pandemic.

CONCLUSION
A noteworthy number of chronic disease patients had depression, anxiety, and stress during the COVID-19 pandemic. Age ≥55 years, being female, urban residency, living with chronic diseases for a longer duration, and presence of additional comorbidities were significantly associated with depression of patients during COVID-19. During the pandemic, older age, female gender, presence of comorbidities, and no social support were independently associated with anxiety of chronic disease patients. Furthermore, urban residency, hand sanitizer use, presence of respiratory manifestations, and travel history to other areas in the last two weeks were factors associated with stress of chronic disease patients during the pandemic. Therefore, governmental and non-governmental organizations, health professionals, media, and hospital administrators should be involved in decreasing the depression, anxiety, and stress of chronic disease patients during the pandemic. Since COVID-19 is still an ongoing public health problem, the need for mental health interventions throughout the remainder of the pandemic is crucial. Moreover, we encourage researchers to conduct comparative longitudinal studies to assess depression, anxiety, and stress level of chronic disease patients before and after the onset of the COVID-19 pandemic.

HUMAN AND ANIMAL RIGHTS
No animals were used in this research. All human research procedures were followed in accordance with the ethical standards of the research review committee and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION
Informed consent has been obtained from all participants.