Prevalence of depression and associated factors among heart failure patients at cardiac follow-up clinics in government teaching hospital at Addis Ababa, Ethiopia; A cross sectional study

Objective This study aimed to assess prevalence of depression and associated factors among heart failure patients at cardiac follow-up clinics. Methods Health care institution based cross-sectional study design was employed to assess the prevalence of depression and associated factors among 424 heart failure patients who were selected by using a systematic random sampling method from January 1 to 30, 2021 at four public hospitals


Introduction
According to Global Burdon of disease study report, 62 million people suffered from problem related to heart failure and more than half of the patients were in sever stages.Depression is one of the most comorbid disorders in patients with cardiovascular disease and it is one of the main public health problems worldwide 1,2 .Depression is a common psychiatric disorder clearly seen by the presence of low mood or loss of interests associated with several other features that are present almost daily for at least two weeks.Moreover, depression ultimately impairs function and indicate a pathological mental change 2 .
A study indicates that depression has strong association with heart failure (HF).Depressed patients have less functionality with increased physiological activity of the heart, heart failure symptoms and impaired health-related quality of life.Moreover, HF patients with depression are at risk for re-hospitalization 3. Therefore, HF with depression, highly impact the overall quality of life and they had 2-fold increased risk of death or cardiac events.After ve years diagnose 50% of HF patients will die 4 .Among heart failure patients with depressive symptoms there will be an increased risk of mortality 2-3 times higher than in patients without symptoms of depression 5. Furthermore, hospitalized heart failure patients with depression are at particularly at high risk for mortality.Median survival is 1.7 years for men and 3.2 years for women, with only 25% of men and 38% of women surviving for the last 5 years.This mortality rate is 4-8 times greater than that of the general population with similar age 6,7 A study done in New York hospitalized heart failure (HF) patients with depression the rate from 13-77.5% and out-patient is from 13-42% and depression is ve times more prevalent in HF patients compared to the whole population 8,9 .
Another study conducted in west Amhara region in Ethiopia, the prevalence of depression among hear failure patients is 49%, and Dessie were 50% 1,10 .
A study done in Pakistan shows that depression is higher among single HF patients with low family care and support also the frequency of depression was higher among young unmarried HF patients 11 .The presence of social support has been associated with lower incidence of depression and faster remission of depressive symptoms, were as lack of social support, con ict relation-ship have been linked to the presence of depression.A systematic and meta-analysis conducted in Ethiopia indicates that depression is a common co-morbid illness among patients with diabetes 12 .And another meta-data analysis done in Greece, Patients classi ed in New York Heart Association (NYHA) in class "I to IV" of them class III and IV were more likely to be depressed than class I and II Patients 13 .
According to the study done in Nigeria, the New York Heart Association (NYHA) functional status is correlated with the prevalence of depression according to the study done in Nigeria, which increased steadily from 11% in patients with NYHA class I (mild), 20% class II, 38%, class III, and 42% of them categorized in class IV (severe) heart failure 14 .Depression is associated with poor health care behaviors and additional risks factors, such as smoking, sedentary life, unhealthy dietary habits, lack of regular exercise, uncontrolled weight gain may lead to worsening of depression 15.Another study done in Brazil indicates that selfcare behaviour was signi cantly associated with depression of the heart failure participants 16.A cross sectional study in west Amhara region in 2019 shows that poor knowledge of HF patient has strong association with depression. 1,17But factor associated with depression in heart failure are not assessed adequately in developing countries including Ethiopia.More importantly, no single study found in public hospital of at Addis Ababa.Therefore, this study aimed to assess the prevalence of depression and associated factors among heart failure patients at cardiac follow up-clinic at government teaching hospital in Addis Ababa, Ethiopia.This study nding may support for health care professionals to focuses their interventional strategies on the management of depression in heart failure patients, policy makers and responsible o ces at various level of health care interventions to take appropriate measures and also serve as a base line information for researchers who are interested to conduct similar studies.

Conceptual frame work
Conceptual framework for this study was established after reviewing and adapted from different literatures related to similar sociodemographic characteristics of the study population and identi ed variables as illustrated in the gure 1 below, the socio-demographic factors (marital status, age, gender of the participants, educational level and occupation), self-care behavior such as smoking habit and alcohol use, psycho-social factor like cognitive, perception and social support and co-morbidity like heart failure patient with diabetic, hypertension and chronic kidney disease and stage of heart failure and associated factors of depression.The direction of the relationship between outcome variable (Depression) and explanatory variables are illustrated. 3,12,18 Methods And Materials

Study setting
The study was conducted at selected public hospitals of Addis Ababa city administration, Ethiopia.Addis Ababa is the largest and the most populated capital city of Ethiopia.It is a metropolitan area with a population of estimated to be around 5,00,6000 people in 2021.The capital city holds 527 square kilometers of area in Ethiopia.The population density is estimated to be near

Study design and period
An institution-based cross-sectional study design was conducted from January 1 to 30, 2021.

Study population
All heart failure patients those who had follow-up at selected four government hospitals of cardiac centre in Addis Ababa during the study period.

Sampling procedure and technique
The total number of heart failure patient in the four study hospitals were 2,867.Hence, after the sample size was determined by using simple population proportion formula (n-424).The study sample was proportionally allocated to each study hospitals in line with proportional allocation formula.Tikur Anbesa specialized hospital (X 1 ): the total number of heart failure patients in this hospital was = 1667, proportional allocation of sample was calculated n=1667×424/2867=246.St Paulo's specialized hospital (X 2 ): the total number of heart failure patients in this hospital was=833 proportional allocation of sample was calculated n=,833×424/2867=123.Armed force specialized hospital (X 3 ): the total number of heart failure patients in this hospital was=200 proportional allocation of sample was calculated n=200×424/2867 =30.Yekatit 12 hospital (X 4 ): the total number of heart failure patients in this hospital was=167 proportional allocation of sample was calculated n=167×424/2867=25.
The study population taken from four randomly selected government hospitals.As shown in gure 2 below the sample size was proportionally allocated for each hospital.Study participants were selected from proportionally allocated study subject in each hospital using a random sampling technique from eligible patients visiting the cardiac clinic during the data collection period was interviewed.

Procedure of Data Collection and tool used
Data was collected by four trained BSc nurses using 5% pretested interviewer administered questionnaire and supervised by two MSc nurses.The data collection instrument includes the following components.PHQ-9: by using a check-list that was developed on the basis of prior similar studies, the data was collected by using the Patient Health Questionnaire (PHQ-9), the questionnaire has nine items, the total score ranges from 0 to27 a score 5,10,15,20 represent cut point for mild, moderate, moderate-sever and severe depression respectively.In PHQ-9 tool there are four options (0= none at all, 1=several days, 2=more than half of the days, and3=nearly every day).Which have been used to screen depression symptoms from the study participants 21. and it has 88% speci city and sensitivity.HF patients score between 1-4 categorized as having no depression.HF patient score between 5-9 was Mild depression, HF patient score between 10-14 was Moderate depression, between 15-19 categorized as having severe depression and score >20 was categorized as having severe depression severe depression.PHQ-9 tool Cronbach alpha value was 0.904.21. 21,22ropean HF Self-care behaviours scale-9 (EHFScBC-9): The EHFScBS-9 had supportive psychometric properties of validity, reliability and precision, and it's used to measure self-care behaviours in clinical practice and research.The EHFScBS-9 has nine items of questions each item uses a 5-point Likert scale from 1 ("completely agree") to 5 ("completely disagree")..Alpha Cronbach was 0.806 Oslo social support scale (OSSS-3) Evidence supports reliability and validity of the OSSS-3 as a measure of social determinants of health in the general population.The OSSS-3 consists of three items assessing the level of social support the sum score ranges from 3 to 14, with high values (>8) representing strong levels and low values (3-8)   representing poor levels of social support 14 .Alpha Cronbach in this study was 0.869.
The Dutch HF knowledge scale has 15 multiple choices for each item patient can choose from the three options, with one of the options being the correct answer.When a person gives the correct answer, 1 point is given whereas the answer is wrong the person receive 0 point for that question.The possible total score for knowledge of heart failure ranges from 0 to 15 and interpreted as Study subject's knowledge on HF was found to be a score of DHFKS above Median was used as a cut off for good knowledge and poor knowledge as the score is below Median 24 .

Data Quality Assurance
Structured and pre-tested questionnaire was used and also training were given for data collectors and supervisors on the objective of the study, method, contents and also how to maintain con dentiality and privacy of the study subject was strictly conducted.Data was collected by four experienced staff nurses with BSc degree and above.Pre-test was conducted on 5% of HF patients at Zewditu hospital before the actual data collection period and based on the nding the necessary correction made on the method and materials.

Data Processing and Analysis
The collected data was entered in to epi data processed and analysed by using SPSS version 25.Descriptive statistics was employed to describe the percentages and frequency distributions of the variables in the study.Adjusted odd ratio with 95% con dence interval was estimated to measure the strength of association a P-Value of ≤ 0.05 was used for statistical signi cance.The results were presented using tables and gures.

Operational De nitions
Depressive symptom-The individual participant had depressive symptoms when he/she has at least four positive symptoms in the PHQ-9 including Q1(Little interest or pleasure in doing things) and Q2 (Feeling down, depressed or hopeless) 25 .
Poor self-care -The individual participant had poor self-care when scored with from 9 to 45 with a higher score above >18 indicating poor, and lower <18 is good self-care of European Heart Failure Self-Care Behaviour Score-9 17 .
Poor social support-The individual participant had poor social support when she/he scored between the 3-8 out of 14 23 Knowledge A score of DHFKS above Median was used as a cut off for good knowledge and poor knowledge as the score is < Median 26 Knowledge of HF patient de nes as ability to recognize and interpreted HF symptoms 27 .
Low knowledge-A score of DHFKS "≥10" was used as a cut off for good knowledge and poor knowledge as the score is "<10". 26lf -care behaviour is de ned as the activity of HF patient performs to take care of their health in terms of exercise habit, abstain from cigarette smoking and alcohol intake 17 .
Psycho-social support de nes as help maintain a continuum of social support during or after a problem and prevent from long term mental disorder and make him to developed good perception 23 Co-morbidity-The individual heart failure patient has additional chronic disease like DM, HTN, CKD 17 .
Diabetes mellitus -a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrate and elevated level of glucose in the blood 28 .Hypertension -abnormal high blood pressure which is systolic blood pressure >130 and diastolic blood pressure >85mmHg 25 .Chronic kidney disease is abnormality of kidney structure or function, present for >3 month, with implications for health 28 .

Socio-demographic characteristics
A total of 424 study participants were included with 100% response rate and about 238 (55.2%) of the study participants were female.The mean and standard deviation of age of the respondents were 52.68 and17.471yearsrespectively.A high proportion of 134 (31.6%) of the respondents were within the age group of 37-54 years and about 166 (39.1%) the study reveals participants were married.The study found that one out of four participants did not attend formal education which is not able to read and write and two-third of participants were employed in government and non-governmental institutions.As shown in Table 1 below.About 36.3% participants are having a monthly income in the range of 601-1650 Ethiopian birr.

Prevalence of depression
The study indicates that depression is common problem in the study area as shown gure 3 below, the prevalence of depression was 59% (95% CI 54.

Factor associated with depression among heart failure patients attending cardiac follow-up clinic
The bi-variate logistic regression analysis indicates that, age of respondent, marital status, educational status, profession, NYHA classi cation, self-care behaviour, high alcohol intake, social support, knowledge level of the disease prognosis and co-morbidity were associated with depression among heart failure patients as shown in Table 2 below.
The multivariate logistic regression analysis also shows that, NYHA class, self-care behavior, high alcohol intake, social support, knowledge level and marital status were found to be associated with depression and statistical signi cance with a P-value of less than 0.05.

Discussions
The aim of this study was to assess the prevalence and associated factor of depression among heart failure patients at cardiac follow-up clinic in selected government teaching specialized hospital of Addis Ababa.The prevalence of depression in this study reveals that 59% (95% CI,54.5-63.7),this indicates that depression is highly associated with heart failure.It is obviously clear that depression is highly affecting the quality of life and e cacy of care.
A study conducted in Australia shows the prevalence of depression was 52% and South Africa in Johannesburg indicates 50% 8,21.This similarity might be due to problem of depression in heart failure patient spreading across in different nations globally.The current study is higher when compared to the study done in Greece (20-40%), Japanese (5.8%),United states of America (42.1%) 20, 27, 28.The difference might be due to difference in screening strategy, study design and sociodemographic characteristics of the study population.The prevalence of depression observed in the present study was higher than a study conducted in west Amhara region and Dessie city administration were 50% 1 , this variation might be different educational background, their life style and sociodemographic characters.
This study indicated that those heart failure patients with NYHA class III and IV are more likely at risk of depressive disorders compare to those who had NYHA class I and II.The possible explanation could be individual heart failure patients with advanced stage might be worry about their worsening symptom, illness-related complication, dietary restriction and un able to do any activity and they are always dependent on others.This might be directly or indirectly lead to depression.This nding supported by a study done in Greece 2020, and study done in Ethiopia 1,15.This indicate that advanced heart failure patients need to be early evaluation of depression and cardiac clinic work in collaboration with psychiatry department to screen and therapeutic interventions.This study found that heart failure patients who had poor self-care behaviour is positively associated with depression when compared to good self-care behaviour, this might be due to poor self-care behaviour and prone to depression and potential to develop bad habit, like cigarette smoking, the use of shisha, chat chewing and lack of regular exercise.The other co-relation between psychological factors and disease outcomes, such as poor quality of life, effect of poor practice of self-care behaviour as the result heart failure patients may be potential to develop depression.This nding was in line with the study conducted in New-York, Brazil and Gondar 10,16, 17.This similarity might be due to prevention strategy of the country and pathological nature of disease process.
In this study, those heart failure patients who experienced high alcohol intake shows strongly positive association with depressive disorder than those who have not experienced alcohol use [(AOR: 17.7(4.14-35.65),95%CI, P=0.001)] this might be due to the fact that alcohol use exposes to depression.Most alcohol users might be affected by physiological, psychological, social and economic behaviour that can alters metabolic condition of an individual life and as the result of con ict to family and society at large.This nding supported by a research done in Australia and England 21,24 and this nding contradict to a research done in united kingdom showed that there is no signi cant association alcohol intake and depression31 The difference might be due to difference in socio-demographic characteristics of the study population.And also, this study indicates that heart failure patients who had poor social support is more likely to be depressed when compare to good social support [(AOR: 4.6(1.2-16.7),95%CI,P=0.020)].The reason might be patients who have poor social support may not share their own stressor.and also plays great role in the coping strategies, so that this situation might be directly or indirectly expose to depression.This nding supported by research done in Pakistan, USA and Greece [25][26] .This reveals that and contact with support group for those HF patients who had poor social support.In this study heart failure patients who had poor knowledge about their disease were having positive associated with depression [(AOR:5.1 (1.3-20.6),95%CI,P=0.020)].This nding supported by research done in Ethiopia 1,30 .
This indicate that health care institution should be focused on health education specially for heart failure patients who had poor knowledge.In general health care professionals should focus on education about their disease process and associated factors.
This study reveal that unmarried patients have positively associated with depression compared to married ones.[(AOR:0.108(0.03-0.47),95%CI,P=0.001)]This might be heart failure patients who were unmarried did not share their own stressor to life partner.This nding was in line with the study conducted in Pakistan and Ethiopia 11,27 .

Conclusion
This study reveals that depressive disorder and associated factors in heart failure patients at selected government specialized teaching hospitals found to be very high and advanced stage of heart failure patients was more depressive, poor self-care behavior, alcohol users and poor social support were more potentially at risk of depressive disorder.And also, heart failure patient who had good knowledge are at lower risk of depressive disorder and having single or unmarried patients are at more risk of depressive disorder and those variables were associated with the odds of depression among heart failure patient in Addis Ababa.

Recommendations:
All health of cardiac units should work on screening of heart failure patients for depression and consult psychiatrist and Psychologist for early detection and possible measure.In addition to this health care workers should focus to teach heart failure patients about disease prognosis and associated risk factors and patient education should be a part of heart failure patient management guideline.

Figures
Figures

5,165 individuals per square kilometer available. Based on the 2020 population enumeration annual growth rate is 4.42%. The city has 15 public hospitals from this four of them randomly selected to conduct this research study namely
19,20tal: it is under the governance of Addis Ababa city administrative health bureau.The hospital provides service for population approximately 4 million people.It has 9 departments and 6 units with 265 beds, it is main referral hospital for treatment of burn.and the burn unit has 19 beds, 12 for adult and 7 for pediatrics.D) Armed Force Specialized Hospital: formerly known as prince Tsehay Memorial Hospital.It changes the name after 1974 revolution.It has 350 beds, 150 doctors 300 nurses 100 administrative staffs19,20

Table 1
Majority of participants 257(60.6%)were having poor knowledge and more than half 230 (54.2%) of study participants had poor social support.The mean of heart failure patients with self-care behaviour score was 19.29, with SD of 4.918.From the total study participants,235(55.4%) had poor self-care behaviour with cigarette smoking 120 (28.3%).More than half 235(54.4%) of them were alcohol users.

Table 2
Factor associated with Depression in bi-variate logistic regression among heart failure patients attending cardiac follow-up clinic at selected government hospitals (n=424) Those heart failure patients who had NYHA Class category of III and IV were more likely to be depressed than class I and II[(AOR:12.8(2.2--71.6),95%CI,P= 0.004, (AOR:19.2(1.9-189.9),95%CI,P= 0.011)] respectively.Those heart failure patients who had poor self-care behavior are 9-fold at risk of depressive disorder as compared to those who had good self-care behavior [(AOR: 9.1(2.4-34.6),95%CI,P=0.001)].Those heart failure patients they were alcohol users are 18 times more likely to be depressed than those who have not taken alcohol [(AOR: 17.7(4.14-35.65),95%CI,P=0.001)].Those heart failure patients who were poor social support are 5 times more likely to be depressed when compared to good social support [(AOR: 4.6(1.2-16.7),95%CI,P=0.020)] as depicted in Table3below.In this study those heart failure patients who had poor knowledge were more likely 5 times to be depressed as