Anxiety and depression are common mental illnesses. The total number of people living with anxiety and depression in the world is estimated to 322 million and 264 million, respectively [
A systematic review and meta-analysis study reported that anxiety and depression were common among patients with chronic illness in both developed and developing countries [
Anxiety and depression have a bidirectional relation with chronic illnesses [
Having a chronic illness puts a person at greater risk of developing anxiety or depression. A study which is conducted in USA and China stated that both anxiety and depression are the major comorbidities in patients with chronic illnesses [
Anxiety and depression have numerous negative health outcomes in patients with chronic illnesses. Medication nonadherence, rapid disease progression, and poor health outcomes were effects of untreated and unrecognized anxiety and depression [
There are different factors that affect the prevalence of anxiety and depression among patients with chronic illness. A systematic review and meta-analysis conducted in Ethiopia revealed that age, sex, and duration of disease were factors associated with depression [
Identifying factors associated with anxiety and depression is helpful for early screening and management. Nevertheless, factors associated with depression and anxiety in patients with diabetes, hypertension, and heart failure are not assessed adequately in developing countries including Ethiopia. Thus, this study was initiated to examine factors associated with anxiety and depression among patients with diabetes, hypertension, and heart failure in Dessie Referral Hospital, Northeast Ethiopia.
The study was conducted at Dessie Referral Hospital which is found in Dessie town. Dessie town, which is an administrative town of South Wollo Zone, is 401 km far from Addis Ababa in the northeast direction. Dessie Referral Hospital, which is one of the frontline hospitals in Ethiopia, serves more than 3.5 million people as a referral hospital. It has about 749 workers. From this, 548 are health professionals and 201 are administrative staffs serving in the hospital. Out of those health professionals, 332 are nurses and 61 of them are diploma nurses. The study was conducted from February 22, 2019 to April 6, 2019.
An institutional-based cross-sectional study design was employed.
All patients with diabetes, hypertension, and heart failure who are on follow-up in Dessie Referral Hospital were sources of population.
All patients with diabetes, hypertension, and heart failure who are on follow-up in Dessie Referral Hospital during the data collection period were the study populations.
On follow-up patients who are diagnosed either with hypertension or diabetes or heart failure and who are 18 years and above were included
Patients unable to communicate were excluded
The sample size for the first objective was calculated by using the single-population proportion formula with 95% confidence level, 5% margin of error, and proportion of depression among patients with heart failure. Proportion, which is 51.1% %, was taken from a study conducted on depression among heart failure patients in three public hospitals of Northwest Ethiopia [
Therefore, by adding a 5% nonresponse rate of 385, the total sample size was 404.
The study utilized a stratified random sampling technique. Initially, patients with a chronic illness were stratified into diabetes mellitus (DM), hypertension, and heart failure based on their diagnosis. After that, the total sample size was allocated for each stratum based on their proportion. Then, study participants were selected by systematic sampling in every
Dependent variables were anxiety and depression, and independent variables were sociodemographic variables (sex, age, educational level, marital status, resident, occupation, monthly income, family size, weight, height, and BMI), disease characteristics (duration of disease since diagnosis, number of medication), perception towards prognosis of illness, substance and alcohol use (coffee and tea use, smoking, chat chewing, uses of hashish and shisha, and alcohol drinking), and physical activity.
The data were collected by using a structured questionnaire which is adapted from previous research. It has 3 parts. The first part asked about the sociodemographic status of the study participants. The second part measured the level of anxiety and depression with generalized anxiety disorder and patient health questionnaire, respectively. In this study, internal reliability for GAD-7 questionnaires and PHQ-2 questionnaires were 0.76 and 0.8, respectively. The third part focused on factors such as physical activity, substance use, alcohol use, and support from anyone. Physical activity was screened by the International Physical Activity Questionnaire (IPAQ-7) which is a standardized tool for measurement of physical activity for patients with chronic illnesses. All parts of the questionnaire were prepared in English version initially and translated into Amharic then back to English to check their consistency. Additionally, weight (in kilogram) and height (in meter) for nonpregnant and edematous patient were measured by data collectors during data collection.
After preparing the questionnaire, 4 BSc nurses for data collection and 1 BSc nurse as a supervisor were recruited. A two-day training was given for each of them on the meaning of every items of the questionnaire and the techniques of data collection such as ways of greeting, ways of taking consent, ways of data quality monitoring during height and weight measurement, and ways of addressing ambiguous items. Data were collected by face-to-face interview after patients finish their visit.
Patients were interviewed with 7 questions to assess their level of physical activity. The total score of questions was categorized into three levels: inactive, those individuals who do not meet the criteria for minimally active or health-enhancing physical activity (HEPA); minimally active, 3 or more days of vigorous activity of at least 20 minutes per day or 5 or more days of moderate-intensity activity or walking of at least 30 minutes per day or 5 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities achieving a minimum of at least 600 metabolic equivalent (MET) (min/week); and health-enhancing physical activity, vigorous-intensity activity on at least 3 days achieving a minimum of at least 1500 metabolic equivalent (MET) (minutes/week) or 7 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities achieving a minimum of at least 3000 MET (minutes/week).
Height and weight were measured for nonpregnant and edematous patients during the data collection period by data collectors. To avoid a repeated interview for patients with repeated visit, data collectors asked and verified whether the patient is interviewed or not before data collection. The supervisor and principal investigator monitored closely the data collection process.
The quality of data was assured by training the data collectors and supervisor, carefully designing the questionnaire, monitoring the data collection process, and checking the completeness of data during data collection time. In addition to these, all questionnaires were pretested on 10% of the sample size (40 respondents) at Hidar 11 Primary Hospital to address confusing items and to increase the quality of data. During the pretest, some respondents were confused on the duration of anxiety questions and physical activity questions. To address this confusing issue, data collectors tried to remind the duration in each section of the questionnaire at the time of data collection.
After data collection, completely collected data were entered in to EpiData version 3.1 and exported to Statistical Package and Service Product (SPSS) version 25 for analysis. During analysis, the study participants who scored 9 and above in the Generalized Anxiety Disorder item 7 (GAD-7) questionnaire were categorized as having anxiety, and study participants who scored 3 and above in the Patient Health Questionnaire item 2 (PHQ-2) questionnaire were categorized as positive for depression disorder. The results of the study was presented by using texts, tables, and figures, and the binary logistic regression model was enrolled by considering 95% confidence level and a
From a total of 405 respondents, 384 respondents participated with a 94.8% response rate. Among these, 179 (46.6%) were female, 152 (39.6%) were illiterate (unable to read and write), 241 (62.8%) were married, and 138 (35.9%) were farmers. The median age of respondents was 45 (
Sociodemographic status of patients with diabetes, hypertension, and heart failure at Dessie Referral Hospital, 2019 (
Variable | Category | Frequency | Percentage |
---|---|---|---|
Sex | Female | 179 | 46.6 |
Male | 205 | 53.4 | |
Age | 18-24 | 52 | 13.6 |
25-29 | 38 | 9.9 | |
30-34 | 30 | 7.8 | |
35-44 | 65 | 16.9 | |
45-64 | 146 | 38.0 | |
≥65 | 53 | 13.8 | |
Educational level | Unable to read and write | 152 | 39.6 |
Able to read and write (informal school) | 32 | 8.3 | |
Grade 1-8 | 53 | 13.8 | |
Grade 9-12 | 54 | 14.1 | |
Certificate | 12 | 3.1 | |
Diploma and above | 81 | 21.1 | |
Marital status | Single | 68 | 17.7 |
Married | 241 | 62.8 | |
Widow | 53 | 13.8 | |
Divorced | 22 | 5.7 | |
Residence | Urban | 233 | 60.7 |
Rural | 151 | 39.3 | |
Occupation | Farmer | 138 | 35.9 |
Merchant | 125 | 32.5 | |
Student | 26 | 6.8 | |
Gov’t or non gov’t employee | 84 | 21.9 | |
Others (retired, no permanent job) | 11 | 2.9 | |
Monthly income (ETB) | ≤1000 | 113 | 29.4 |
1001-2000 | 84 | 21.9 | |
2001-3500 | 96 | 25 | |
>3500 | 91 | 23.7 | |
Family size | ≤4 | 235 | 61.2 |
>4 | 149 | 38.8 | |
Any support | Yes | 300 | 78.1 |
No | 84 | 21.9 | |
BMI | Underweight | 38 | 10.3 |
Normal | 255 | 68.7 | |
Overweight | 78 | 21 |
Note: monthly income was categorized based on quartile range; family size was based on mean; BMI was based on WHO weight classification for Ethiopia.
From the total study participants, 39 (10.2%) had poor perception towards the prognosis of their illness. For 64 (16.7%) study participants, the duration of disease since diagnosis was above 6 years. From the total study participants, 26 (6.8%) took 5 and above drugs daily in the past one month (Table
Disease characteristics and individual factors among patients with diabetes, hypertension, and heart failure at Dessie Referral Hospital, 2019 (
Variable | Category | Frequency | Percent (%) |
---|---|---|---|
Perception towards prognosis of illness | Good | 240 | 62.5% |
Fair | 105 | 27.3% | |
Poor | 39 | 10.2% | |
Duration of disease after diagnosis | Below 3 years | 163 | 42.4% |
3 to 6 years | 157 | 40.9% | |
Above 6 years | 64 | 16.7% | |
Number of drugs taken daily | Below 5 drugs | 358 | 93.2% |
5 and above drugs | 26 | 6.8% |
From the total study participants, majority 311 (81%) of them drank coffee and/or tea in the past one month. Only 4 (1%) respondents smoke cigarettes in the past month, and twenty-eight (7.3%) drank any type of alcohol in the past one month. From the sum score of alcohol drinking, smoking cigarette, chat chewing, and using shisha, and others, 32 (8.3%) of them took at least one substance in the past month (Table
Substance and alcohol use among patients with diabetes, hypertension, and heart failure at Dessie Referral Hospital, 2019 (
Variable | Category | Frequency | Percent (%) |
---|---|---|---|
Coffee and/or tea | Yes | 311 | 81 |
No | 73 | 19 | |
Cigarette smoking | Yes | 4 | 1 |
No | 380 | 99 | |
Alcohol drinking | Yes | 28 | 7.3 |
No | 356 | 92.7 | |
Chat chewing | Yes | 1 | 0.3 |
No | 383 | 99.7 | |
Using shisha and other substances | Yes | 0 | 0 |
No | 384 | 100 | |
Sum of substance uses (alcohol drinking, chat chewing, cigarette smoking, shisha, etc.) | Yes | 32 | 8.3 |
No | 352 | 91.7 |
Physical activity was assessed for only 332 study participants since others were excluded from the analysis during data cleaning because of incomplete data. Among these respondents, the level of physical activity for one-third 110 (33.1%) of them was inactive and minimally active (Figure
Level of physical activity among patients with diabetes, hypertension and heart failure at Dessie Referral Hospital, 2019.
From the total study participants, 123 (32%) had anxiety. Among the total hypertensive patients, 34.8% had anxiety. The prevalence of anxiety based on disease condition is presented in Figure
Prevalence of anxiety among patients with diabetes, hypertension and heart failure in Dessie Referral Hospital, Northeast Ethiopia, 2019.
In this study, among the total of 384 study participants, only 5.73% had depression. From the total heart failure patients, 11.1% had depression. The prevalence of depression based on the disease condition is presented in Figure
Prevalence of depression among patients with diabetes, hypertension, and heart failure at Dessie Referral Hospital, 2019.
Variables which have an association with anxiety at
Bivariable and multivariable logistic regression output on the association between anxiety and factors, 2019 (
Variable | Category | Anxiety | COR | AOR | ||
---|---|---|---|---|---|---|
No | Yes | |||||
Educational level | Unable to read and write | 86 | 66 | 1 | 1 | 0.001 |
Able to read and write | 23 | 9 | 0.51 (0.22-1.17) | 7.91 (3.08-20.26) | ||
Grade 1-8 | 41 | 12 | 0.38 (0.18-0.78) | 3.81 (1.18-12.32) | ||
Grade 9-12 | 36 | 18 | 0.65 (0.34-1.24) | 1.18 (0.39-3.54) | ||
Certificate | 7 | 5 | 0.93 (0.28-3.06) | 3.53 (1.30-9.57) | ||
Diploma and above | 68 | 13 | 0.24 (0.12-0.48) | 3.83 (0.82-17.93) | ||
Marital status | Single | 41 | 27 | 1.67 (0.95-2.93) | 2.82 (1.35-5.91) | 0.032 |
Married | 173 | 68 | 1 | 1 | ||
Widowed | 33 | 20 | 1.54 (0.82-2.87) | 0.80 (0.35-1.85) | ||
Divorced | 14 | 8 | 1.45 (0.58-3.62) | 0.74 (0.23-2.40) | ||
Residence | Urban | 173 | 60 | 0.48 (0.31-0.75) | ||
Rural | 88 | 63 | 1 | |||
Occupation | Farmer | 83 | 55 | 1 | ||
Merchant | 85 | 40 | 0.71 (0.42-1.17) | |||
Student | 16 | 10 | 0.94 (0.39-2.23) | |||
Employee | 69 | 15 | 0.32 (0.17-0.63) | |||
Others | 8 | 3 | 0.56 (0.14-2.22) | |||
Monthly income | ≤1000 | 65 | 48 | 1 | 1 | 0.001 |
1001-2000 | 54 | 30 | 0.75 (0.42-1.34) | 0.57 (0.28-1.17) | ||
2001- 3500 | 76 | 20 | 0.35 (0.19-0.66) | 0.25 (0.12-0.54) | ||
>3500 | 66 | 25 | 0.51(0.28-0.92) | 1.25 (0.53-2.93) | ||
Perception to prognosis of illness | Good | 176 | 64 | 1 | 1 | 0.022 |
Fair | 63 | 42 | 1.83 (1.13-2.97) | 2.28 (1.27-4.10) | ||
Poor | 22 | 17 | 2.12 (1.06-4.25) | 1.41 (0.61-3.23) | ||
Substance use | Yes | 17 | 14 | 1.99 (0.96-4.13) | 2.56 (1.05-6.23) | 0.038 |
No | 244 | 108 | 1 | 1 | ||
Physical activity | Inactive | 12 | 11 | 1.72 (0.72-4.09) | ||
Minimally active | 62 | 25 | 0.75 (0.44-1.30) | |||
HEPA | 145 | 77 | 1 | |||
BMI | Undernutrition | 23 | 25 | 1.30 (0.64-2.62) | ||
Normal | 170 | 85 | 1 | |||
Overweight | 59 | 19 | 0.64 (0.36-1.14) |
Notes: Hosmer and Lemeshow
Variables which have an association with depression at
Bivariable and multivariable logistic regression output on the association between depression and factors, 2019 (
Variable | Category | Depression | COR | AOR | ||
---|---|---|---|---|---|---|
No | Yes | |||||
Sex | Female | 165 | 14 | 2.08 (0.85-5.10) | ||
Male | 197 | 8 | 1 | |||
Marital status | Single | 62 | 6 | 3.23 (1.04-9.97) | 4.02 (1.05-15.41) | |
Married | 234 | 7 | 1 | 1 | 0.001 | |
Widowed | 45 | 8 | 5.94 (2.05-17.21) | 4.75 (1.25-18.05) | ||
Divorced | 21 | 1 | 1.59 (0.18-13.56) | |||
Residence | Urban | 225 | 8 | 0.34 (0.14-0.85) | ||
Rural | 137 | 14 | 1 | |||
Occupation | Farmer | 128 | 10 | 1 | ||
Merchant | 116 | 9 | 0.99 (0.39-2.52) | |||
Student | 24 | 2 | 1.06 (0.22-5.17) | |||
Employee | 84 | 0 | ||||
Others (retired, no job) | 10 | 1 | 1.28 (0.14-11.03) | |||
Monthly income | ≤1000 | 101 | 12 | 1 | ||
1001-2000 | 78 | 6 | 0.64(0.23-1.80) | |||
2001–3500 | 94 | 2 | 0.18(0.03-0.82) | |||
>3500 | 89 | 2 | 0.18(0.04-0.87) | |||
Perception to prognosis of illness | Good | 232 | 8 | 1 | ||
Fair | 96 | 9 | 2.71 (1.01-7.25) | |||
Poor | 34 | 5 | 4.26 (1.31-13.79) | |||
Substance use | Yes | 331 | 21 | 0.5 (0.06-3.90) | ||
No | 31 | 1 | 1 | |||
Physical activity | Inactive | 16 | 7 | 18.98 (5.41-66.6) | 2.13 (0.58-7.83) | |
Minimally active | 81 | 6 | 3.21 (0.95-10.82) | 24.03 (6.01-96.0) | ||
HEPA | 217 | 5 | 1 | 1 | 0.001 | |
BMI | Undernutrition | 33 | 5 | 2.82 (0.94-8.42) | ||
Normal | 242 | 13 | 1 | |||
Overweight | 75 | 3 | 0.74 (0.20-2.68) | |||
Number of drugs | <5 drugs | 339 | 19 | 1 | ||
≥5 drugs | 23 | 3 | 2.32 (0.64-8.44) |
Notes: Hosmer and Lemeshow
Anxiety and depression are common in patients with diabetes, hypertension, and heart failure. Despite this fact, there is lack of attention to screening and early treatment. Identifying risk factors is helpful for early screening and treatment. Thus, this study was carried out to assess factors associated with anxiety and depression among patients with diabetes, hypertension, and heart failure in Dessie Referral Hospital.
In this study, the prevalence of anxiety among patients with diabetes, hypertension, and heart failure was 32% (95% CI: 27.3%-36.7%). This finding is consistent with the finding of studies conducted in Korea (30%) [
This study revealed that the prevalence of depression among patients with diabetes, hypertension, and heart failure was 5.73% (95% CI: 3.4%-8.3%). This finding is in line with the magnitude of depression among pregnant women in a study conducted at Malaysia (6.9%) [
In this study, anxiety had a significant association with low educational level. Patients who do not read and write develop anxiety 7.89 times more likely compared with those whose educational status is diploma and above (AOR: 7.89; 95% CI: 3.08-20.26;
This study revealed that patients whose level of physical activity is inactive develop depression 24 times more likely than patients who did a health-enhancing physical activity (AOR: 24.03; 95% CI: 6.01–96.08;
Marital status was statistically associated with depression. According to the finding, patients who were single reported depression 4 times more likely compared with married patients (AOR: 4.02; 95% CI: 1.05–15.41,
The association between substance use and depression was not seen. This is consistent with the report of a study conducted in Addis Ababa [
This study has limitations although it has different methodological strengths. However, having a cross-sectional study design is the limitation of this study. This study assessed anxiety and depression for only diabetes, hypertension, and heart failure patients. It cannot be generalized for other chronic illnesses.
Lower educational level, being single, higher monthly income, and poor perception to prognosis of illness were factors associated with anxiety among patients with diabetes, hypertension, and heart failure. On the other hand, being single and inactive to physical activity were factors associated with depression among patients with diabetes, hypertension, and heart failure. Any patient with diabetes, hypertension, and heart failure should be screened, recognized, and treated for anxiety and depression. Patients with low educational level and monthly income should be screened early for anxiety. Health care providers provide advice to patients with diabetes, hypertension, and heart failure about physical activity to prevent depression. Researchers should investigate more regarding the factors affecting depression and anxiety among patients with other chronic illnesses. Policy makers should develop a guideline for the screening and treatment of anxiety and depression.
The data used to support the findings of this study are available from the corresponding author upon request.
Before data collection period, ethical clearance and approval was obtained from Wollo University College of Health Science Research and Ethical Committee (Com/Nurs/135/11). A supportive letter was given to the Dessie Referral Hospital and permission was obtained from hospital manager to implement the study.
Prior to interviewing the respondents, the aim and objectives of the study were clearly explained to the participants and oral informed consent was obtained. Additionally, participants were informed about the right to ask questions and stop response in anywhere. Confidentiality and anonymity were ensured throughout the execution of the study.
The authors declared that they have no conflict of interest.
Afework Edmealem conceived and designed the study and performed analysis and interpretation of data. Dr. Caridad Sanchez Olis advised and supervised the design conception, analysis and interpretation of data, and made critical comments at each step of research. All authors read and approved the final Manuscript. Confidentiality and anonymity were ensured throughout the execution of the study.
We want to forward our heartfelt thanks to the study participants and data collectors for their commitment and cooperation during data collection period. We would also like to thank Dessie Referral Hospital and Wollo University for their support.