COVID-19 pandemic and self-reported symptoms of depression, anxiety, and stress among health care workers in Ethiopia

The Coronavirus Diseases 2019 (COVID-19) pandemic has become a major problem in many of the world nations including Ethiopia. Moreover, it is a public health emergency of the community concern and poses a mental health problem to health care workers (HCWs). Therefore, this study aimed to assess the level of self-reporting symptoms of depression, anxiety, and stress during the COVID-19 pandemic among healthcare workers in Ethiopia. An institutional-based cross-sectional study was conducted using an online survey from June 25, 2020, to July 25, 2020, in Ethiopia. The data were collected using a self-reported Depression, Anxiety, and Stress Scale (DASS-21). Data were cleaned, coded, and entered using Epi info version 7.5.1 and exported for analyzed to the Social Science package software Version 23 Statistical Package. Moreover, multiple logistic regression analysis was used to identify the associated factors at p-value less than 0.05. to SPSS version 23. The descriptive data analysis was done and presented in table, and graphs. The outcome cut off point for binary logistic regression was above 9, 7 and 14 for depression, anxiety and stress respectively. The analytic part was analyzed, odds ratio with their 95% condence interval, and two-tailed P-value was calculated to identify the presence and strength of the association. Variables with P value ≤ 0.2 in the binary analysis were included in a multivariable logistic regression analysis to control the confounding effect among the variables. Statistical signicance was declared if P-value < 0.05.

emergency with compulsory physical distancing, quarantine, frequent hand washing, and reduced the capacity of public transportation by half as a policy to reduce transmission of the pandemic. Despite many efforts to reduce the COVID-19 pandemic, mental health problem, and psychological impact among healthcare providers has remained high. Health care workers on the front line who is directly involved in the diagnosis, treatment, and care of patients with COVID-19 are at risk of developing mental health symptoms. Therefore, this study aimed to assess the prevalence of self-reported symptoms of depression, anxiety, and stress among health care workers in Ethiopia.

METHODS
Study design, area, period and study population: An institution-based cross-sectional study design was conducted in central Ethiopia (Addis Ababa, and Oromiya region (North Shoa, East Shoa, and West Shoa) from June 25/2020 to July 25/2020. All health care providers who are working in health care facilities in Ethiopia were included and health care workers who were on annual leave and critically ill were excluded from the study.

Sample size and sampling technique
The sample size was determined using Epi-info version 7.5.1 considering the power of 80%, with a 95% CI, 5% margin of error, assuming a 50% prevalence due to lack of previous study and 10% none response rate was assumed. After using design effect 2, the total sample size was 846. Samples were regionally strati ed by their geographic location (Addis Ababa city, and Oromiya region). Addis Ababa was most severely affected; more health care facilities in Addis Ababa were randomly sampled. A total of 12 health care facilities from Addis Ababa (8 COVID-19 isolation treatment centers, and 4 governmental hospitals), and 12 health care facilities from Oromia regional state (2 hospitals and 1 COVID-19 treatment isolation center from each of North Shoa, West Shoa, and East Shoa Zone of Oromiya region and 3 COVID-19 isolation treatment center from Oromiya especial zone of Oromiya region). Two department clusters were taken from each hospital (20 clusters), and 14 clusters of COVID-19 treatment centers. A total of 24 health facilities (10 hospitals and 14 COVID-19 treatment centers) were involved. All health care workers working in clustered departments were invited online surveys through e-mail and telegram groups voluntarily which coordinated by data managers.

Data processing and analysis
Data were coded, edited, cleaned, and entered into Epi-info version 7.5.1 and transported to SPSS version 23. The descriptive data analysis was done and presented in table, and graphs. The outcome cut off point for binary logistic regression was above 9, 7 and 14 for depression, anxiety and stress respectively. The analytic part was analyzed, odds ratio with their 95% con dence interval, and two-tailed P-value was calculated to identify the presence and strength of the association. Variables with P value ≤ 0.2 in the binary analysis were included in a multivariable logistic regression analysis to control the confounding effect among the variables. Statistical signi cance was declared if Pvalue < 0.05.

Ethical consideration
Ethical clearance was obtained from the Salale University ethical review committee. After thoroughly discussing, the ultimate purpose and method of the study, and, informed verbal consent was obtained from each respondent. The respondents were informed that their inclusion in the study is voluntary and they were free to withdraw from the study if they were not willing to participate. If any question they do not want to answer they have the right to do so. To ensure the con dentiality of respondents, their names were excluded from the questionnaire. The con dentiality of the respondents was kept in a password locked computer.

Results
In this study, 846 health care workers asked to participate, 816 respondents (96.5%) completed the survey online. Majority 376(46.1%) of respondents have participated from the Addis Ababa location and all participants were living in urban areas. A total of 244(29.9%) participants were frontline health care workers that directly involved in diagnosing, caring, or treating of patients with COVID-19 or suspected. Most of the participants were male 540 (66.2%), were aged 26 to 30 years 308 (37.7%), were married 476(58.3%), and had an educational level of second degree or undergraduate 332(40.7%). Nurses 236(28.9%) were the majority of healthcare workers and 340(41.7%) of participants had 5-10 years of working experience. More than two-thirds of study participants had trained online about COVID-19 infection prevention and 580(71.1%) of health care workers had a shortage of personal protective equipments (Table 1). Table 1 Socio-demographic characteristics of healthcare workers in Central Ethiopia, from June 25/2020 to July 25/2020 (n = 816).  1).
Factors associated with depression, anxiety and stress

Discussion
This cross-sectional survey revealed a high prevalence of mental health symptoms among health care workers who involved patient care during COVID-19 in central Ethiopia. Overall, 60.3%, 78%, and 33.8% of the study participants were self-reported symptoms of depression, anxiety, and stress respectively. This study was found higher than the study conducted among healthcare workers in China that showed 50.7% of symptoms of depression, 44.7% of anxiety, and 73.4% of stress (7). Again, our study was higher than the result in Iraq that revealed 45% of depression, 47% of anxiety, and 18% of stress (13). This difference may be due to high fear of COVID-19 with a lack of personal protective equipment that indicated 71.1% of respondents report limited personal protective material in our study. In resourced countries like China this is not much concern as low resourced counties.
Most age categories have a risk of developing stress symptoms and the age category of 26 to 30 had signi cantly associated with depression when compared to the age category of 18 to 25. This result was in line with the study done in China (14). As age advanced, there is a higher burden of the family, which in uences the symptoms of mental health status, as they are more likely to worry about their families (15). Married healthcare workers had also a higher odds ratio of depression and stress. This can be explained by when pandemic disease happened with severe morbidity and mortality that high-risk transmission to their family, health care workers might have more stress, and depression.
In this study, depression, anxiety, and stress were higher in women, showing that the mental health status during the COVID-19 pandemic highly signi cant in women. This is in line with the study report done in Turkey (16) and that con rmed female gender has been identi ed as potentially exposed to symptoms of mental health problems after the happening of pandemics (17). A study from China found that women have three-folds higher anxiety, depression, and stress than in men during the COVID-19 pandemic (18).
In this study, we found that healthcare workers who have working in Addis Ababa and Oromiya especial zone were signi cantly associated with symptoms of depression, anxiety, and stress. This may be because Addis Ababa and Oromiya especial zone have a higher incidence of the COVID-19 infected patients and increasing every day than other central Oromiya regions. Regarding professional attributes, compared with pharmacists, medical laboratory professionals had a higher risk of depression, anxiety, and stress, whereas nurses had a higher risk of depression symptoms. This may be due to medical laboratory technologists/technicians and nurses have higher exposure to bloodcontacting, workload, and stay in the ward a long time and provide direct nursing practice to patients respectively. This was reported in the studies in done China (19,20). This situation may be in uenced in their mental health status symptoms of depression, anxiety, and stress.
The study result shows that healthcare workers who had working in the COVID-19 treatment center had a higher risk of symptoms of depression, anxiety, and stress. This result was similar to the study conducted in China (8). Again, healthcare workers who have working in the emergency department, surgical department, outpatient department, and the laboratory department had signi cantly associated with self-reporting symptoms of depression. This was observed in the studies reported in Fujian, China (20), China (14), and Landon, United Kingdom (6). This can also be explained by the high-risk exposure area of the working department.
In this study, healthcare workers who have working experience of less than 10 years had a higher risk of depression and anxiety symptoms. This explained by those health care workers who have low experience in their working environment during a disease outbreak might have a higher fear of contagion, depression, and anxiety. Additionally, the study participants who have no training had higher anxiety. During the occurrence of outbreak disease, training regarding the prevention and control mechanisms, personal protection methods, the severity of the disease, transmission method and in addition to psychological intervention should be provided in time for health care workers (20,21). In This study, we found 71.1% of health care workers reported a shortage of personal protective equipment which has signi cantly associated with symptoms of depression. Ensuring staff protection from the COVID-19 pandemic is very essential to have a better capacity for disease prevention and mental health outcome that targeted to minimize the fear of the pandemic (21). A systematic review and meta-analysis study found that having personal protective medical equipment, following preventive actions and timely informed about the COVID-19 are among protective factors (19).
Limitation of the study This study has several limitations; rst, as a cross-sectional nature of the study, it does not show a causal relationship. Second, the study restricted only in the central Ethiopia, which cannot generalizable for the other region of Ethiopia. Third, to minimize the spread of the COVID-19 infection, all study participants in the working department were taken, which may have a selection bias.

Conclusion
In this study of health care workers in central Ethiopia, health care workers had reported a high prevalence of symptoms of depression, anxiety, and stress. Female gender, Oromiya especial zone, medical laboratory professionals, and HCWs who have working in the COVID-19 treatment isolation centers were signi cantly associated with depression, anxiety, and stress. Caring for health care workers is a signi cant element of public health actions for controlling the COVID-19 epidemic and focus should be concentrated for the mental well-being of health care workers during the COVID-19 pandemic. Psychological intervention for health care workers in central Ethiopia needs special attention. Figure 1 The prevalence of depression, anxiety and stress among health care workers in central Ethiopia, from June 25/2020 to July 25/2020 (n=816).