Study design and period
Community based cross sectional study was employed to assess prevalence and associated factors of depression among unemployed young adults in Gedeo zone, Southern Ethiopia from May to July, 2019.
The study was conducted in the Gedeo zone, Southern Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia. It is located about 375 km south of the capital city, Addis Ababa. The total population of the zone is 1,129051 persons (565,145 men; 563,906 women) living in six districts and two town administrations. According to the report from zonal office of women, children, and youth, the unemployment rate among young adults in 2019 was 24.9% (34,724 persons).
All unemployed young adults aged 18-30 years old who were graduated from college or university and living in the study area (in the selected districts and town administration of the zone) for at least six months prior to the study were study population. Unemployed young adults who were severely ill and unable to communicate during study period were excluded. In addition, young adults who did not finish schools, or dropped out of college/university were excluded from the study because it is unlikely to be available for work (i.e. being ready for a paid employment) without having educational certificate (i.e. diploma or degree certificate).
Sample Size determination and Sampling procedures
In this study, we have tried to calculate sample size for both specific objective one (i.e. prevalence of depression) and specific objective two (i.e. associated factors of depression) and took the largest sample size. Sample size for specific objective one of our study (i.e. prevalence of depression) was calculated by using single proportion formula taking assumptions of: 95% confidence interval, 5% margin of error, and the prevalence of depression among unemployed young adults in Ethiopia is considered to be 50% because per our search we did not find published and even unpublished studies in our country, Ethiopia. Then we added 10% of non-response rate to the sample size, giving the final sample size of 423. Sample size for specific objective two of our study (i.e. associated factors of depression) was calculated using EPI-Info version 7 statistical software (Epi-info/StatCalc) by taking the following assumptions: 80% power, 95% confidence interval, 15% proportion of depression among exposed group (female) and 9.6% among unexposed group (male) which was taken from previous study. We added 10% of non-response rate to the sample size, giving the final sample size of 1452. Therefore, we took the larger sample size for this study (i.e. 1452).
Out of the six districts and two town administrations of Gedeo zone, two districts (Bule district and Gedeb district) and two town administrations (Dilla town and Yirgacheffe town) were randomly selected. Then from each selected town administration and town of selected district three kebeles (the smallest administrative unit in Ethiopia) were randomly selected again. The lists of unemployed young adults were obtained from Office of Job creation opportunity and food security of each selected district and town administration. According to updated registration from the zonal office of Job creation opportunity and food security, the number of unemployed young adults in the Dilla town administration, Yirgacheffe town administration, Gedeb district, and Bule district were 5483, 3008, 4543, and 4103 respectively. To fix a sampling frame, we conducted census of households with unemployed young adults prior to actual data collection for one week by eight data collectors and numbering of households was done in the selected kebeles. Population proportion allocation was done to identify representative study participants from each district and town administration based on the number of the unemployed young adults they have. Finally, systematic sampling technique with an interval (K) was used to select study participants. The first study participant was randomly selected, and every three households was interviewed for Dilla town, every four household was interviewed for Gedeb district, every four household was interviewed for Bule district and every six household was interviewed for Yirgacheffe town. In situations where households had two or more eligible study participants, only one was randomly selected.
Data collection tools and procedures
The structured questionnaire was used to collect data regarding information about the study participants’ socio-demographic characteristics such as age, sex, marital status, ethnicity, religion, educational level and duration of unemployment.
Patient health questionnaire-9(PHQ-9) based on the DSM-IV criteria was used to assess the presence of depression with recall period of two weeks. The scale consists of 9-items representing symptoms of depression and each symptom will be rated on a 4-point scale indicating the occurrence and the severity of symptoms: 0(not at all), 1(several days), 2(more than half the days) and 3(nearly every day). The PHQ-9 items showed good internal reliability with Cronbach’s alpha of 0.84 for primary health care setting and general population. A cutoff score of 10 was established for the PHQ-9 (sensitivity 86.49%, specificity 89.36%), correctly classifying 86.4% of patients with current depression in primary health care setting.
The presence of substance use was measured by using WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) tool, an eight item questionnaire developed to assess both lifetime substance use (i.e. Question 1) and current time substance use (i.e. Questions 2-7). Lifetime substance use is defined as consuming any substances at least once in lifetime and current substance use is defined as use of at least one of specified substances for non-medical purpose in the last three months. The ASSIST was developed for the World Health Organization (WHO) by an international group of researchers and clinicians as a technical tool to assist with early identification of substance use related health risks and substance use disorders in primary health care, general medical care and other settings. Each question on the ASSIST has a set of responses to choose from, and each response has a numerical score. The Specific Substance Involvement score is calculated by adding together the responses to Questions 2-7 for each of the following locally available substances: tobacco, alcohol, khat (amphetamine type stimulants), and cannabis (marihuana, hashish, ganja). The ASSIST specific substance involvement scores of ≥10 for alcohol and ≥4 for any substance are an indication of problematic substance use. The ASSIST items showed an accepted internal consistency with Cronbach alpha of 0.946 in the current study.
The self-esteem was measured with Rosenberg Self-esteem Scale (RSES). The scale is a 10-item self-report scale designed to measure global self-esteem with a Cronbach alpha reliability range of 0.79 to 0.86 . Responses are provided on a 4-point Likert scale ranging from “Strongly Agree” (with 3 marks), “Agree” (2 marks), “Disagree” (1 mark) and “Strongly Disagree” (0). The scale ranges from 0 to 30: a score greater than 15 suggest high self-esteem and scores less than 15 suggest low self-esteem .
Social support was measured by using three items Oslo social support scale (OSS-3) . The OSS-3 provides a brief measure of social support and functioning and it is considered to be one of the best predictors of mental health. It covers different fields of social support by measuring the number of people the respondent feels close to, the interest and concern shown by others, and the ease of obtaining practical help from others. In order to score OSS-3, total scores are calculated by adding up the raw scores for each item. The sum of the raw scores has a range from 3-14. The scores of”3-8” indicate poor social support, “9-11” indicate moderate social support, and “12-14” indicate strong social support. The Cronbach alpha of OSS-3 in the present study was 0.64.
The questionnaire was first prepared in English and translated to Amharic (local working language) by language experts and was translated back to English by another person to ensure consistency and accuracy. The data collectors and supervisors were recruited based on previous experience on data collection and supervision. Training was given for three consecutive days for data collectors and supervisors by the researchers on how to interview, handle ethical issues, supervise and maintain confidentiality and privacy of study subjects. The data collection instrument was pre-tested on 5% of the actual sample size in similar setting, and amendments were made accordingly. Data was collected by eight trained BSc Psychiatry Nurses and supervised by four MSc Mental health professionals and the principal investigator. Finally, after checked completeness of the required type of data by principal investigator and supervisors the completed data was coded.
The supervisors and principal investigator checked the data for completeness, coded and entered into Epi-Data version 3.1 and exported to statistical package for social sciences (SPSS) version 20 for analysis. Means, frequencies, and percentages were used to summarize data and figures, tables and text to present data. Bivariate analysis was done to describe the associations of each independent variable with depression among unemployed young adults. Variables which had p-value less than 0.2 were considered for the multivariable logistic regression to control the effects of confounding variables. The Hosmer-Lemeshow goodness of fit test was checked for the model. Finally, Variables which had P-values less than 0.05 on multivariable logistic regression were considered as statistically significant and were identified on the basis of odds ratio (OR) with 95% confidence intervals (C.I).