Study setting and period
The study was conducted among health facilities found in the Eastern Hararghe Zone, Oromia regional states found in eastern part of Ethiopia. The East Hararge Zone is bordered on the southwest by Bale, on the west by West East Shewa Zone, on the north by Dire Dawa and on the north and east by the Somali Region. The Harari regional state is an enclave inside this zone. The Administrative center of this zone is Harar city. The East Hararghe zone contains four hospitals, and 67 health centers according to the East Hararghe health bureau report [24]. The study was conducted from October 25 to November 15, 2020.
Study design and source population
Health facilities based cross-sectional study design was used. All health care workers from randomly selected health facilities found in the Eastern Hararghe zone were the study population. Health care workers who unable to communicate due to illness were excluded.
Sample size determination
The sample size was calculated using the formula for estimation of a single population proportion (n=[(Zα/2)2 *P(1-P)]/d2 ) with the assumptions of 95% confidence level, marginal error (d) of 0.05, and 50.4% the prevalence of depression among health care workers [25]. Thus, after applying the finite population correction formula and adding 10% of the non-response rate, the final sample size obtained was 297.
Sampling procedure and sampling technique
Two hospitals and eight health centers were selected by simple random sampling method (lottery method) from four hospitals and 39 health centers. The study participants from each selected health facilities were selected by simple random sampling technique by considering proportional to the institutions health professionals’ size.
Variables
Dependent variable was depression.
Independent variables were socio-demographic characteristics such as age, marital status, and level of education, work experience, Perceived susceptibility, perceived severity, and perceived benefit.
Data collection and questionnaire
An interview questionnaire was developed to assess socio-demographic characteristics include; age sex, marital status, educational level, type of profession, types of health facility, and worker experiences. The 9-item Patient Health Questionnaire (PHQ-9) tool was used to assess depression symptoms. The questionnaire was validated in the Ethiopian context and it recommended for use [26].
The data was collected by ten nurses. Four MSC health professionals were assigned to supervise the data collection process. Both the data collectors and supervisors were taken 2-day intensive training before the actual work about the aim of the study, procedures, data collection techniques, the art of interviewing, ways of collecting the data, and clarification. The intensive supervision was done by the principal investigator, co-investigators and supervisors. Completeness, accuracy, and consistency of data were checked at the site of data collection throughout the data collection period. Finally, double data entry was done by two data clerks, and consistency of the entered data was cross-checked by comparing the two separately entered data.
Measurements
The PHQ-9 is the depression module, which scores each of the nine DSM-IV criteria as 0 to 3 for every nine symptoms of depression, “0” not at all, “1” several days “2” more than half the days “3” nearly every day. Scoring was done by counting the number of boxes checked in a column. Multiply that number by the value indicated above, then add the subtotal to produce a total score. PHQ-9 total score for the nine items ranges from 0 to 27. Scores of zero, 1-4, 5-9, 10-14, 15-19, and 20-27 represent cut-points for no depression symptoms, minimal, mild, moderate, moderately severe, and severe depression, respectively [27]. For logistic regression analysis we have categorized those who had no symptom as have no depression and coded as “0” and the rest who had at least one symptom categorized as had depression symptoms and coded as” 1”
The age of the mother was recorded based on maternal response later and was grouped as 19-24, 25-29, 30-34, 35-39, and ≥ 40 with codes 1,2,3,4,and 5, respectively, for analysis. Work experience was grouped as < 2 years, 3-5 years, 6-10 years, and >10 years with codes 1, 2, 3, and 4, respectively, for analysis. Data for perceived susceptible was collected by interview using a single question “How likely do you think it is that you will develop COVID-19 during your providing care?” liker scale of five were used and labeled as “Strong unlikely”, “unlikely”, “Neutral”, “likely”, and “Strongly likely” and coded with 1, 2, 3, 4, and 5 respectively. For logistic regression analysis, we categorize as strong unlikely, unlikely, and neutral as no perceived susceptible, no susceptible coded as “1” and susceptible coded as “2”. With a similar pattern. Data for perceived severity was collected by interview using question with a single question “Getting COVID-19 in the future worries me and It is important for me to prevent getting”. Likert scale of five was used and labeled as “Strong unlikely”, “unlikely”, “Neutral”, “likely”, and “Strongly likely” and coded with 1, 2, 3, 4, and 5 respectively. For logistic regression analysis, we categorize as strong unlikely, unlikely, and neutral as no perceived susceptible, no susceptible coded as “1” and susceptible coded as “2”.
Interpretation
PHQ-9 questionnaire is not a screening tool for depression but it is used to monitor the severity of depression and response to treatment. However, it can be used to make a tentative diagnosis of depression in at-risk populations (Table 1).
Table 1: Adapted interpretation of the PHQ-9 Scores for tentative diagnosis of depression in at-risk populations (Table 1).
Interpreting PHQ-9 Scores
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Action
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Minimal depression
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0-4
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The score suggests the patient may not need depression treatment
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Mild depression
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5-9
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Physician uses clinical judgment about treatment, based on patient's duration of symptoms and functional impairment
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Moderate depression
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10-14
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Moderately severe depression
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15-19
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Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment
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Severe depression
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20-27
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Statistical Analysis
Double data entry was made using the Epidata 3.1 software. Then after validation was done the data exported to the STATA statistical package version 14 for further analysis. Descriptive statistics were used to summarize the variable. Continuous variables like age and work experience were first transformed into categorical variables before analyzed. Initially, the crude odds ratio (COR) along with a 95% confidence interval was estimated to assess the association between each independent variable and the outcome variable. Multicollinearity was tested using the Variance Inflation Factor (VIF) test and the tolerance test. No multicollinearity problem was found. The Hosmer-Lemeshow goodness-of-fit tests were used to test for model fitness [25]. The logistic regression model was used to assess the association between predictor variables and the outcome variable depression symptoms. Adjusted Odds Ratio (AOR) along with a 95% confidence interval was estimated to assess the strength of the association. Statistical significance was declared at a p-value ≤of 0.05
Ethical consideration
The study was approved by the Haramaya University, College of Health and Medical Sciences Institutional Health Research Ethics Review Committee (IHRERC). The permission and agreement consent was obtained from East Hararghe Zone, participating District health bureau, and health care facilities office prior to the study. The study participant was informed about the purpose of the study, their right to refuse, and written and signed voluntary consent was obtained prior to data collection. Based on the interpretation and recommendation HCWs who had depression symptoms were obtained management.