Anxiety and depression in patients with chronic cardiovascular disease—factors differentiating rural and urban subpopulations

Background. People suffering from cardiovascular diseases (CVD) increasingly experience depression and anxiety disorders. Therefore, it is essential to improve identication strategies and methods of coping for these conditions. Objectives. The aim of the study was to analyse selected variables differentiating rural from urban populations as well as identify potentially increased levels of depression and anxiety. Material and methods. The study was carried out in 193 CVD patients home-cared by a district nurse. Results. Women constituted the majority of respondents (71.7%, n = 81 City-C vs 65.8%, n = 50 Village-V). The median age of the C patients was 76 (range 17-101) vs. 72 (range 18-94) for the V patients. The correlation coecients displayed signicant differences in anxiety, number of cardiologist visits (p = 0.005) and interventions provided by a district nurse (p = 0.03). The rural population stood out in number of home visits, age, assessment of needs and QoL. In addition, a strong relationship between anxiety and age was noted in the rural population (1/OR=1.04; 95% CI: 0.91–0.99), the assessment of satised needs (1/OR=293.86; 95% CI: 0.00001–0.56), depression (OR=5.85; 95% CI: 1.58–25.66), QoL in physical (OR=1.56; 95% CI: 1.11–2.33), social (1/OR=1.53; 95% CI: 0.04–0.94) and environmental domains (OR=1.67; 95% CI: 1.06–3.00) as well as between depression and anxiety (OR=4.60; 95% CI: 1.45–16.28), QoL in physical (1/OR=1.39; 95% CI: 0.50–0.97) and psychological (OR=1.37; 95% CI: 1.01–1.93) domains.

Background Cardiovascular diseases decrease mobility, reduce work and social activity and thus are a cause of social isolation. This health condition may also result in chronic anxiety, depressed mood and, consequentially, development and aggravation of depressive and anxiety syndrome [1][2][3].
It is estimated that anxiety disorders are found in 28-44% of young people and 14-24% of old people with CVD [4]. Conversely, patients with anxiety disorders have also been noted to have a higher chance of developing coronary artery disease [5]. The risk of death caused by ischemic heart disease is doubled if patients develop panic disorder as well [6]. A high level of anxiety has also been proven to be a significant predictor of recurrent heart incidents [7,8]. High emotional states and levels of anxiety might directly lead to the development of sudden cardiological incidents as well [9].
The incidence of depression in CVD patients is twice as high as in the general population and results in a worse medical prognosis for these patients [10]. One out of five patients with ischemic heart disease or heart failure suffers from depression, three times as high as in the general population. Depression affects an even higher percentage of post-stroke patients (one out of three) [2]. Depressed mood is found in 66.6% of hospitalized patients who have experienced a heart infarct, while depression is diagnosed in 15%. Patients with chronic heart failure are even more prone to depression (10-40% of cases) [11,12].
Depression in patients suffering from coronary heart disease is the strongest prognostic factor of death (depressive patients have a doubled risk of death over patients without depression) [13]. The state is also related to the aggravation of functional disorders, lower therapeutic compliance and reduced participation in cardiological rehabilitation [14]. It was shown that patients with depression develop CVD in the subsequent 6 years two or three times more often [15]. In Poland, depression is diagnosed in 5-16% of population, with symptom severity increasing with age [16]. The economic and health-related indicators of CVD and depression result in higher treatment costs, higher demand for health services and decreased efficiency [17].
Although diagnosis of depression is steadily increasing (it is currently the 3 rd most common cause of all GP appointments), a great number of cases remain unnoticed or treated late [18]. Research shows that depression is found less frequently in depressive CVD patients than in patients with similar symptoms but not suffering from cardiovascular disease [19].
As mental condition has a huge impact on treatment and prognosis, the need for better identification strategies is increasingly recognized. The disorders ought to be diagnosed earlier and appropriate treatment given [20][21][22]. Anxious and depressive patients without social support, whose symptoms of diseases do not progress, might develop an unfavourable attitude towards disease, helplessness and anxiety. The symptoms of anxiety Page 4/27 and depression decrease the motivation for changing lifestyle, tend towards social isolation and even mental escape from crucial issues [23].
Taking into consideration the role of primary health care, it is important to examine the epidemiology of anxiety and depressive disorders thoroughly as well as the risk factors for their occurrence in CVD patients in relation to Poland's primary health services.
There is no scientific research on the factors affecting anxiety and depression comparing rural and urban CVD patient populations.
The aim of the study Taking into account the above, the aim of the study was to identify variables differentiating rural and urban populations and potentially relating to primary healthcare effectiveness provided to CVD patients.
The identification of positive results will provide insight into the process of creating systems to identify risk groups in whom the level of health services is low, the development of clinical information systems and support decision-making to design personal care models and identification systems for CVD patients living in rural and urban areas needing psychological support.

Study design
The study is a part of a wider range of research which aims at clarifying a purposeful and most effective model of home care over chronically ill patients with CVD in the scope of primary health services.

Setting
The study was carried out among Polish CVD patients who received home care from a family nurse working within primary health services in Opolskie, Lower Silesian, Masovian, Lublin and Podlesian Voivodeships. Eight primary health care institutions took part in the study. The patients were encouraged to take part in the examination by their family nurse Page 5/27 during planned home visits. The respondents filled in the questionnaires in their home environment. One set of questionnaires was provided to the patients, and the nurses filled out an additional questionnaire concerning the patient (paired questionnaires about the same patient). Data was collected from March 2016 through January 2017.

Participants
The main factors including the patient in the study were age (over 18) and a diagnosis of chronic CVD provided at least 12 months prior to the study. The patient was supposed to stay at home and be provided with family nurse services. The criteria of exclusion (disqualification was performed by a family nurse) were cognitive and aggravated mental disorders as well as difficulties participating in the study such as vision disorders and non-Polish nationality.

Variables
The study examined 31 variables, including socio-demographic ones, such as sex, age, test coherence for the whole questionnaire was 0.90 [24,25].
The Health-Related Behaviour Inventory by Juczynski (HBI) consists of 24 statements measuring four pro-health behaviour categories, i.e., proper eating habits, preventive behaviours, proper mental attitudes and health practices, was also used in the study. The respondents determine the frequency of health behaviours and proper activity based on the scale in which 1 corresponds to hardly ever, 2-rarely/seldom, 3-from time to time, 4often, 5-usually/almost always. The values marked by examinees are then summed up to calculate an overall measure of health activity intensity, with a value ranging from 24 to 120 points. The higher the value, the higher the intensity of pro-health behaviours. were informed about the study aims, methods, and the ability to withdraw participation at any stage of the examination.

Statistical methods
The results of the study were subjected to statistical analysis using the R statistical package Depression test because of a very small sample). Using the models selected, the odds ratio for the events examined were calculated and conclusions formulated on their basis.

The evaluation of anxiety and depression
The analysis of anxiety and depression occurrence in the group of patients, calculated into standard ten, is presented in   Table 3).

Results of logistic regression
The logistic regression analysis in the group of CVD patients living in urban areas (Table   4a) led to the selection of models, which allowed for the odds ratio calculation (Table 4b).  In patients who differed in the level of Qol in the psychological domain of WHOQOL-BREF questionnaire by 1 degree, those with a higher score have a 1.49 times higher chance of anxiety occurrence than those with a lower one. In patients who differed in this score by 14.66, those with a higher result have a 48.75 times higher chance of anxiety abnormalities.
It was found that in patients who differed in the level of Qol in the intensity of health practices of WHOQOL-BREF questionnaire by 1 degree, those with a lower score have a 1.79 times higher chance of anxiety occurrence than those with a higher one. In patients who differed in this score by 2.83, those with a lower one have a 5.21 times higher chance of developing anxiety.
It was also discovered that for patients who differed in the assessment of depression in HADS-M scale by 1 degree, those with a higher score have a 4.07 times higher chance of anxiety occurrence than those with a lower one. The logistic regression analysis in the group of CVD patients living in rural areas (Table 5a) led to the selection of models, which allowed for odds ratio calculations (Table 5b). pi ≤ 0,05, null hypothesis is rejected that bi coefficient =0 which means that i-variable is relevant in the model); n-group quantity. In patients who differed in the Camberwell evaluation of needs by 0.83, those with a lower score have a 113 times higher chance of anxiety occurrence than those with a higher assessment. In patients who differed in the assessment by 1, those with a lower assessment have a 293.86 times higher chance of such abnormalities.
In patients who differed in the level of Qol in physical domain of WHOQOL-BREF questionnaire by 1 degree, those with a higher score have a 1.49 times higher chance of developing anxiety than those with a lower one. In patients who differed in this assessment by 14.28, those with a higher assessment have a 585 times higher chance of anxiety disorders.
In patients who differed in the level of Qol in social relations domain of WHOQOL-BREF questionnaire by 1 degree, those with a lower score have a 1.53 times higher chance of anxiety occurrence than those with a higher one. In patients who differed in this assessment by 14.66, those with a lower one have a 522 times higher chance of anxious behaviours.
It was also discovered that in patients who differed in the level of Qol in the environment domain of WHOQOL-BREF questionnaire by 1 degree, those with a higher score have a 1.67 times higher chance of anxiety occurrence than those with a lower one. In patients who differed in this assessment by 11.92, those with a higher one have a 473 times higher chance of anxiety disorders.
It was confirmed that in patients who differed in the assessment of depression by 1 on HADS-M scale, those with a higher score have a 5.85 times higher chance of anxiety Page 15/27 disorders than those with a lower score.
In patients who differed in the number of a family nurse visits in the last 12 months by 1, it was found that those with a lower number of visits have a 1.11 times higher chance of anxiety development than those with a greater number of visits. However, in patients who differed in the number of visits by 28, those with a smaller number have a 51.39 times higher chance of such behaviours.
Patients who differed in the level of Qol in psychological domain of WHOQOL-BREF questionnaire by 1 degree, those with a higher score have a 1.32 times higher chance of anxiety occurrence than those with a lower score. But, in patients who differed in this assessment by 14, those with a higher score have a 51.39 times higher chance of developing anxiety. The analysis of logistic regression in chronically ill CVD patients living in rural areas (Table   6a) led to the identification of models which permitted calculation of the odds ratio (Table   Page 16/27 6b). n-group quantity. Table 6b presents the results of the odds ratio in the model of logistic regression for the risk of depression in chronically ill CVD patients living in rural areas.
In patients who differed in the level of Qol in physical domain of WHOQOL-BREF questionnaire by 1 degree, those with a lower score have a 1.39 times higher chance of depression than those with a higher score. In patients who differed in this assessment by 14.28, those with a lower score have a 118.39 times higher chance of developing such conditions.
In patients who differed in the level of Qol in the psychological domain of WHOQOL-BREF questionnaire by 1 degree, those with a higher score have a 1.37 times higher chance of depressive behaviours than those with a lower score. For patients who differed in this assessment by 14, those with a higher score have 89.07 times higher chance of such abnormalities. Page 17/27 It was also found that in patients who differed in the assessment of anxiety on HADS-M scale by 1, those with a higher score have a 4.6 times higher chance of depression than those with a lower score.

Discussion
This is the first Polish research study to examine selected variables potentially affecting the enhancement of primary health services provided to CVD patients living in urban and rural areas who experience increased levels of anxiety and depression.
Previous research has found that CVDs disproportionately affect females [30]. The results prove the conclusion above as women were the majority of respondents both in cities life [23,31]. Anxiety and depression are common in CVD patients [2,4,32]. The results of this study correlate with these findings. The study found anxiety disorders in 66.1 % (n = Page 18/27 72) of patients living in cities and 68.9% (n = 51) of these living in villages. Depression was observed in 68.8% (n = 75) of urban respondents and 68% (n = 51) of rural respondents.
No statistically significant differences between city and village residents were found.
Anxiety has a negative influence on the prognosis of diagnosed CVD patients as relating to the increased risk of series of cardiovascular incidents such as stroke or death caused by cardiovascular failure [7][8][9]. In analysing the results of the study, we noted that the number   [39]. This study showed unequivocally that more home visits are associated with a lower risk of anxiety occurrence in CVD patients.
Healthcare behaviours are viewed as the main element in CVD prevention. The World Health Organization [40], the American Heart Association (AHA) [41] and European guidelines related to the prevention of CVD in clinical practice [42] underline the value of healthcare behaviours in preventing and decreasing CVD morbidity. The study showed that lower intensity of pro-health behaviours might foster the risk of anxiety disorders as in patients living in cities who differed in the intensity of the behaviours by 1 degree. Those with a lower score have a 1.79 higher chance of anxiety occurrence than those with a higher score.
It was also confirmed that the presence of anxiety and depression among patients, especially elderly ones, is more common in rural than urban areas [43]. It was observed in the study that younger age and village residence determines higher risk of anxious behaviours.
The relationship between the level of met needs and the risk of anxious behaviours might also be interesting. The analysis of healthcare systems concerning primary health care over the chronically ill emphasises the issue of health needs. It is believed to be an outcome of the level of a clinical condition and factors deriving from it such as the quality of life, healthcare behaviours and the evaluation of medical services. It is assumed that recognition Page 20/27 of a need is equal to the identification of a problem and allows for proper intervention [27,44]. In the process of shaping primary health systems, determining individual biopsychosocial needs of patients is becoming more and more essential [44]. We found here that when the level of needs met in patients living in rural areas decreases, the risk of the occurrence of anxiety increases.
Examining the relationship between anxiety and depression requires particular attention in the discussion about select variables affecting the improvement of primary health care over CVD patients who experience these abnormalities. We found that a higher score in HADS-M Depression scale is related to a higher risk of anxiety occurrence in CVD patients regardless of the place of residence. What is more, a higher score in HADS-M Anxiety scale increases the risk of depression in rural patients.
The characteristics presented here might constitute the basis for deeper research into the concepts and shows a huge need for professional support. Patients who fit the characteristics ought to be targeted with medical and social programmes that ensure their stable condition and improve the quality of their lives.

Limitations
This study may be limited by a small sample size. It could significantly limit the possibility of the results' generalization to the whole population of CVD patients in Poland. The findings discovered in the study, however, remain valuable and might be used in the course of interventions supporting the development of a systemic model of home care over chronically ill patients. Research using a greater number of CVD patients and healthcare institutions in urban and rural areas is encouraged.

Conclusions
The programmes of early anxiety prevention in diagnosed CVD patients should embrace patients living in rural areas who might be characterised by younger age, greater number of visits to cardiological clinics, greater number of family nurse interventions, fewer home visits, lower assessment of met needs and a higher score in physical, psychological and Page 21/27 environmental domains as well as lower score in the social domain of Qol. The programme of early depression prevention should be targeted at CVD patients living in rural areas whose score in physical domain is lower but higher in psychological domain. Urban residents whose score in physical domain is lower but higher in psychological domain and also display lower assessment of pro-health behaviours (health practices category) and depression have a higher risk of anxiety.

Declarations
Abbreviations: CVD -Cardiovascular disease C -City

V -Village
Ethics approval and consent to participate The study was approved by the Bioethical Commission at Wroclaw Medical University (No KB -86/2016). Participation in the study was voluntary and anonymous. All participants gave oral consent to participate in the study, were informed about the study's aims, methods, and the possibility of study withdrawal at any stage. The Bioethical Commission approved the procedure for obtaining oral consent from study participants, because the study only used anonymous surveys.

Consent for publication
Not applicable in this section.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.