Levels and predictors of anxiety, depression, and stress during COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020: A multicenter cross-sectional study.

INTRODUCTION: The provision of quality health care during the COVID-19 pandemic depends largely on the health of health care providers. However, healthcare providers as the frontline caregivers dealing with infected patients, are more vulnerable to mental health problems. Despite this fact, there is scarce information regarding the mental health impact of COVID-19 among frontline health care providers in South-West Ethiopia.
OBJECTIVE: This study aimed to determine the levels and predictors of anxiety, depression, and stress during the COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020.
METHODS: An institutional-based cross-sectional study was conducted among 322 health care providers from November 10-25, 2020 in Gurage zonal health institutions. A simple random sampling technique was used to select the study participants. A pretested self -administered structured questionnaire was used as a data collection technique. The data were entered into the Epi-data version 3.01 and exported to SPSS version 25.0 for analysis. Both descriptive statistics and inferential statistics (chi-square tests) were presented Bivariable and Multivariable logistic regression analyses were made to identify variables having a significant association with the dependent variables.
RESULTS: The results of this study had shown that the overall prevalence of anxiety, depression and stress among health care providers during the COVID-19 pandemic was 36%, [95% CI = (30.7%- 41.3%)], 25.8% [95% CI = (21.1%- 30.4%)] and 31.4% [95% CI = (26.4%- 36.0%)] respectively. Age, Adjusted Odds Ratio [AOR = 7.9], Educational status, [AOR = 3.2], low monthly income [AOR = 1.87], and presence of infected family members [AOR = 3.3] were statistically associated with anxiety. Besides this, gender, [AOR = 1.9], masters [AOR = 10.8], and degree holder [AOR = 2.2], living with spouse [AOR = 5.8], and family [AOR = 3.9], being pharmacists [AOR = 4.5], and physician [AOR = (0.19)], were found to be statistically significant predictors of depression among health care providers. Our study finding also showed that working at general [AOR = 4.8], and referral hospitals [AOR = 3.2], and low monthly income [AOR = 2.3] were found to be statistically significant predictors of stress among health care providers.
CONCLUSION: Based on our finding significant numbers of healthcare providers were suffered from anxiety, depression, and stress during the COVID-19 outbreak. So, the Government and other stakeholders should be involved and closely work and monitor the mental wellbeing of health care providers.

Introduction

Coronavirus (CoV) infections are emerging respiratory viruses that are known to cause illnesses ranging from the common cold to severe acute respiratory syndrome (SARS) [1]. As of January 30th, 2020, the “World Health Organization” (WHO) characterized the ongoing COVID-19 outbreak as a “Public Health Emergency of International Concern” (PHEIC) [2], and later, due to uncased fast spread, the severity of illness, the continual escalation in several affected countries, cases and causalities, WHO declared coronavirus disease 2019 (COVID-19) a global pandemic on 11 March 2020 [3].

The pandemic could have severe effects on the mental health of the general population and health care providers(HCPS) [4]. As a result, people have been comparing the emergence of a novel Coronavirus (2019-nCoV) to “the end of the world,” and the whole world reacts to the event with panic, insomnia, stress, irritability, and feelings of distractibility [5].

Healthcare providers are always at the forefront in the response to emerging infectious disease outbreaks which are encountering many sources of stress, and recent evidence showed that the COVID-19 pandemics can undermine not only physical health but also take a toll on these providers’ mental health and resilience [6, 7]. In a Chinese study, researchers found that a considerable proportion of participants reported symptoms of anxiety (44.6%), moderate to severe depression (50.4%), insomnia (34%), and moderate to severe psychological distress (71.5%) [8]. In addition to this, studies carried out in Italy revealed that 50.1% of participants reported symptoms of clinically relevant anxiety, 26.6% symptoms of depression and 53.8% showed symptoms of post-traumatic distress [9].

Mental health and psychosocial consequences of the COVID-19 pandemic may be particularly serious for health professionals because HCPs often have to respond to demanding and unforeseen medical emergencies [10]. In the initial phase of the SARS-CoV-2 outbreak, 29% of all hospitalized patients were HCPs [11]. A recent report from the International Council of Nurses (ICN), found that health worker infections ranged from 1–32% of all confirmed COVID-19 cases [12].

Globally, there have been more than 230,920,739 infections and 4,733,350 fatalities after the declaration of the pandemic by the WHO. In Africa, there are about 8,269,298 confirmed cases and 207,760 deaths reported as of September 23 /2021 [13]. According to the Amnesty International report, 17,000 health workers have died worldwide from COVID-19 over the last year, which implied that one health care worker was dying every 30 minutes, which was a “tragedy and an injustice” [14].

Ethiopia is one of the countries threatened by COVID- 19, with a total of 336,762 confirmed cases and 5,254 registered deaths as of September 23/2021 [13]. It is now the leading country in East Africa with the highest number of infected people. Thousands of HCPs have been infected with COVID-19 [15]. To minimize the risk of COVID-19 transmission in the community, the Ethiopian government declared an emergency and mandated compulsory physical distancing, the establishment of isolation and quarantine centers for suspected and confirmed cases, the activation of the Federal Emergency Operation Center, frequent hand washing, temporary closure of schools and higher education institutions, establishing alternative working modalities for public servants, and the suspension of mass gatherings [16, 17]. Despite the ongoing preventative and control measures, containing the spread of the virus could be challenging in light of the underlying social and infrastructural settings of the country.

The global COVID-19 pandemic has created a massive public health crisis and several challenges for healthcare providers [6]. The social, economic, and health effects are extensive, where they are related to increased all-cause mortality, occupational disability, poor quality of life, and cardiovascular disease risk [18]. Despite its multiple consequences, mental health is often neglected as a public health agenda [19].

The psychological effects related to the current pandemic are caused by numerous factors, including competency concerns when redeployed without adequate training, uncertainty about the duration of the crisis, misleading information about the effectiveness of the vaccine, depletion of personal protection equipment, feelings of being inadequately supported, the hefty workload, the need to take stressful precautions during the medical examination/ in the operative fields and frequent exposure to patients’ suffering and dying [10, 20–24].

Studies also showed that those health care workers who feared contagion and infection of their family, friends, and colleagues felt uncertainty and stigmatization [25, 26], reported reluctance to work or contemplate resignation and reported experiencing high levels of stress, anxiety, and depression symptoms which could have long term psychological implications. Similar concerns about the mental health, psychological adjustment, and recovery of health care workers treating and caring for patients with COVID-19 are now arising [25, 27].

To decrease the extent of the psychological consequences, some measures are taken such as avoiding intense exposure to COVID-19 media coverage, providing resilience training for HCPs, maintaining a compassionate and positive lifestyle by providing support to others [28]. Besides this, WHO called for action to address the immediate needs and measures needed to save lives and prevent a serious impact on the physical and mental health of healthcare providers [29].

A number of research articles published over the past few months showed that a significant proportion of healthcare providers who worked within primary, secondary, and tertiary hospitals developed adverse mental outcomes while providing service for the needy population [30-34]. Despite this fact, sufficient information is not available regarding the mental health impact of COVID-19 among frontline health care providers in South-West Ethiopia. So, the current study aimed to determine the levels and determinants of anxiety, depression, and stress among frontline healthcare providers in Gurage zonal public hospitals.

Methods and materials

Study design

An institutional-based cross-sectional study design was conducted.

Study period and area

The study was conducted in the Gurage zonal public health institutions of SNNPRE from October–December / 2020. Gurage Zone is one of the fifteen zones and four special woredas found in SNNPR state. Wolkite town is the capital of Gurage zone which is located 158 Km southwest of Addis Ababa and 260 Km from Hawasa. It has 20 woreda and two municipalities. According to the 2012 population projection by CSA the total population is 1,767,518.

There are seven hospitals in the Gurage zone. Five of the hospitals in the zone are primary hospitals, one general hospital and the remaining one is a specialized comprehensive hospital, there are 79 health centers (7 are NGO HC) and 444 Functional health posts serving the total population in the zone. There is also a COVID-19 testing center; some hospitals are readily organized to serve quarantine and treatment centers [35].

Source populations

All health care providers who are working in the selected public health institutions.

Study population

The randomly selected health care providers from the selected public health institution

Inclusion criteria

All health care providers who are working in the selected public health institutions.

Exclusion criteria

Those health care providers who are mentally/critically ill and on annual leave were excluded from the study.

Sample size

The minimum sample size was determined by using a single population proportion formula [n = [(Za/2)2.P (1-P)]/d2] by assuming a 95% confidence level (Z a/2 = 1.96), a margin of error of 5%, P = proportion health care providers who are anxious in Southern Ethiopia (29.3%) [36] and a 5% addition for non-response rate. The final sample size became 334.

Sampling technique and procedure

Six public hospitals were included in the study. The sample size in each hospital was allocated proportionally to the number of health professionals. The study participants were selected using simple random sampling techniques. Within each hospital, the sample was taken from each department based on the proportion of their health professionals (Fig 1).

Fig 1

The schematic presentation of the sampling procedure to select the study participants in Gurage zonal public hospital, SNNPR, Ethiopia, 2020 (n = 322).

Anxiety, Depression, Stress.

Age, gender, religion, ethnicity, levels of education, marital status, job category, residence, monthly income, work experience, working setup, presence of infected colleague, presence of infected family members.

Data collection instrument (tools) and procedure

Data were collected through a pre-tested, structured, and self-administered questionnaire to assess for symptoms of anxiety, depression, and stress using Amharic versions of validated and reliable measurement tools [37, 38].

The questionnaire consisted of five main themes: 1) demographics, which surveyed participants’ socio-demographic information, including gender, age, educational status, marital status, ethnicity, and monthly income, 2) Occupational and personal-related characteristics of the participant such as job description, working setup, working experience, types of hospital, living condition, presence of suspected or confirmed colleagues and family members.

The third part comprised 7 items to assess the symptoms of anxiety by the Generalized Anxiety Disorder Scale (GAD 7-Scale) that contains a self-rated 7-item that asks for how often the participants have been bothered with the indicators over the past 2 weeks on a 4-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day). The total GAD-7 score for the 7 items ranges from 0 to 21 and is classified as normal (0–4), mild (5–9), moderate (10–14), and severe (15–21) [39].

The fourth part comprised 9 items to assess symptoms of depression by the Patient Health Questionnaire (PHQ-9), a self-rated 9-item scale that asks if the participants have experienced symptoms of depression in the previous two weeks rated on a 4-point Likert-type scale ranging from 0 (not at all) to 3 (nearly every day). The total PHQ-9 scores range from 0 (absence of depressive symptoms) to 27 (most severe depressive symptoms) and classified into 0–4 = “Minimal depression,” 5–9 = “Mild depression,” 10–14 = “Moderate depression,” 15–19 = “Moderately severe depression,” and 20–27 = “Severe depression” [40, 41].

The fifth parts focus on the 10-item Perceived Stress Scale (PSS) which assesses the participants’ perceived psychological stress by rating their feelings and thoughts during the past month. Participants are asked to rate their levels of agreement on a 5-point Likert-type scale ranging from 0 (never) to 4 (very often). It consists of two subscales, including a 6-item positive factor asking the ability to manage the stressors and a 4-item negative factor. The summation scores range from 0–40 with a higher score indicating a higher level of stress. The scores from 0–13 indicate low stress, whereas scores from 14–26 and 27–40 indicate moderate and high levels of stress, respectively [42]. The cutoff score for detecting clinically significant anxiety, depression, and stress were 7, 10, and 21, respectively [40, 43, 44]. Participants who had scores greater than the cutoff threshold were characterized as having severe symptoms.

Data quality assurance and control

Data was collected from different healthcare workers in their respective wards using paper-based questionnaires. A questionnaire was developed and tested for reliability and validity and accordingly; the Cronbach alpha coefficient was found to be 0.88, 0.92, and 0.83 for anxiety, depression, and stress respectively. In addition, a pretest was done before actual data collection on 5% of a similar population in one hospital not included in actual data collection to assess flow, readability, and clarity of the questionnaire.

Eight data collectors and two supervisors were recruited for data collection, who have experience in data collection. To keep data quality supervisors and data collectors were oriented on how and what information they should collect from the targeted data sources. The completeness and consistency of the collected data were checked daily during data collection by the supervisor and the principal investigator. Whenever there appear incompleteness and ambiguity of recording, the filled information formats were crosschecked with source data soon. Individual records with incomplete data were also excluded.

Data processing and analysis

The data was cleaned, coded, and entered into EpiData 3.1 and then exported to SPSS version 25.0 statistical package for further analysis. Data cleaning was performed to check for accuracy, consistencies, and missing values and variables.

Descriptive statistics and inferential statistics (chi-square tests) were carried out to illustrate the percentage and frequencies of study variables. Both bivariable and multivariable analyses were used to see the association of different variables. Those variables which revealed a statistically significant value at a p-value of ≤0.25 in the bivariable analysis were selected for multivariable logistic regression. For model fit, Hosmer and Lemeshow test was carried out and found to be 0.28, 0.398, and 0.587 for anxiety, depression, and stress respectively which indicated the final model was well fitted and multi-collinearity was also assessed. An adjusted odds ratio with a 95% confidence interval was used to measure the degree of association between variables. A P-value of ≤ 0.05 was considered statistically significant during multivariable logistic regression.

Ethical considerations

Ethical Clearance approval was obtained from Wolkite University, Ethical Review Committee. Then data was collected after getting an official letter from the Zonal health department and permission from the medical director of each Hospital. The purpose of the study was explained to the study participants; anonymity, privacy, and confidentiality were ensured. Before data collection, informed verbal consent was obtained from the study participants. The respondents’ right to refuse or withdraw from participating in the study was also fully acknowledged. Results

Socio-demographic characteristics of the respondents

There were 322 study participants involved in the study with a response rate of 96.5%. The highest proportion of respondents 157 (48.8%) were within the age group of 26–30 years with a mean age of 28.71 with SD 5.288. It showed that there was nearly equal participation of males (51.9%) and females (48.1). around two-thirds of the participants were Gurage (64.6%) followed by Amhara (17.1%) and Oromo (10.2%). Half of the participants were orthodox Christian and 56.5% of the participants were married. Regarding the educational status of the respondents, 57.8% (186) were degree holders followed by 34.2% (110) diploma (Table 1).

Table 1

Socio-demographic information about health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020.

Variables	Categories	Number	Percent
Age	18–25	92	28.6
	26–30	157	48.8
	31–40	60	18.6
	>40	13	4.0
Sex	Male	167	51.9
	Female	155	48.1
Religion	Orthodox	160	49.7
	Muslim	93	28.9
	Protestant	51	15.8
	Catholic	15	4.7
	Other	3	.9
Marital status	Married	182	56.5
	Single	140	43.5
Ethnicity	Gurage	208	64.6
	Oromo	33	10.2
	Amhara	55	17.1
	Tigre	4	1.2
	Others	22	6.8
Educational status	Diploma	110	34.2
	Degree	186	57.8
	Master’s Degree and above	26	8.1
Average monthly income	Low	142	44.1
	High	180	55.9

Occupational and personal-related characteristics of the respondents

Concerning job description, more than one–thirds (35.1%) of the participants were nurses followed by the pharmacy (11.8%) and general practitioner (11.5%). Around two-thirds (66.1%) of the participants had ≤5 years of working experience with a mean experience of 4.7925 SD 3.58.one-thirds of the participants (34.5%) were employed at General Hospital. Nearly half of the participants (47.2%) of health care providers were living with their spouses. Most of the health care providers were practiced at the medical ward (13.3%) and POD followed by the emergency ward (11.8%) (Table 2).

Table 2

Occupational and personal-related characteristics of health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020.

Variables	Categories	Number	Percent
Job description	Nurse	113	35.1
	Physicians	44	13.7
	Midwifery	34	10.6
	Pharmacy	38	11.8
	Lab Tech	16	5.0
	HO	34	10.6
	Environmental Health	10	3.1
	Others	33	10.2
Living condition	Spouse	152	47.2
	Family	37	11.5
	Friends	7	2.2
	Alone	126	38.8
Year of service (Experience)	≤5	213	66.1
	>5	109	33.9
Working setup	Emergency	38	11.8
	Medical Ward	43	13.3
	Ophthalmology	10	3.1
	Surgical Ward	25	7.7
	Oby/Gyne ward	33	10.2
	Pediatric	23	7.1
	Medical Adult OPD	43	13.3
	Psychiatry OPD	2	.6
	Dental Clinic	1	.3
	Triage	13	4.0
	Pharmacy	31	9.6
	Laboratory	15	4.6
	OR	8	2.5
	ICU	4	1.2
	Others	33	10.2
Types of hospital	Primary	85	26.4
	General	111	34.5
	Referral	47	14.6
	Isolation center	79	24.5
Presence of infected colleagues	Yes	96	29.7
	No	226	70.0
Presence of infected family member	Yes	38	11.8
	No	284	87.9

Prevalence of anxiety among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020

Table 3 shows the respondent’s responses to the 7 items of the GAD-7. Through the past 2 weeks before the study. These respondents responded honestly to the following as occurring for several days, more than half the days, or nearly every day. worrying too much about different things (52.5%); trouble relaxing (50.6%); feeling afraid as if something awful might happen (50.3%); being so restless that it is hard to sit still (48.8%); becoming easily annoyed or irritable (42.2%); not being able to stop or control worrying (38.8%); and feeling nervous, anxious or on edge (36.3%). Based on our findings 174(54%) of health care providers had minimal anxiety, 67(20.8%) had mild anxiety, 49(15.2%) had moderate anxiety and 32(9.9%) had severe anxiety.

Table 3

Prevalence of anxiety among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020.

Variables	Categories
	Not at all number (%)	under half the days	over half the days	nearly every day
		Number (%)		Number (%)
			Number (%)
Feeling nervous, anxious, or on edge	205 (63.7)	61 (18.9)	29 (9.0)	27 (8.4)
Not being able to stop or control worrying	197 (61.2)	63 (19.6)	31 (9.6)	31 (9.6)
Worrying too much about different things	153 (47.5)	84 (26.1)	50 (15.5)	35 (10.9)
Trouble relaxing	159 (49.4)	70 (21.7)	59 (18.3)	34 (10.6)
Being so restless that it’s hard to sit still	165 (51.2)	83 (25.8)	44 (13.7)	30 (9.3)
Becoming easily annoyed or irritable	186 (57.8)	75 (23.3)	37 (11.5)	24 (7.5)
Feeling afraid as if something awful might happen	160 (49.7)	75(23.3)	55(17.1)	32(9.9%)

For descriptive purposes only, a cutoff of ≥7 was used to distinguish severity for anxiety.so.116 (36%) of health care providers had a generalized anxiety disorder (Fig 2).

Fig 2

Prevalence of anxiety among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020 (n = 322).

Factors associated with anxiety among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020

Bivariable and multivariable logistic regression analysis was conducted to see the presence of association and to measure the relative effect of each independent variable on Generalized Anxiety Disorder among health care providers. Age, gender, religion, marital status, educational status, ethnicity, occupation, types of health facility, monthly income, experience, presence of infected colleague and family were significant factors associated with Anxiety among health care providers.

Among fitted variables included in the binary regression model for bivariable analysis, Age, religion, educational status, marital status, monthly income, experience, and presence of infected family were variables taken into consideration for multivariable analysis with p-value < 0.25. Under multivariable analysis, age, Educational status, monthly income, and presence of infected family were found to be statistically significant predictors of Anxiety among health care providers.

Health care providers whose age >40 years old were significantly more likely to develop anxiety than health care providers whose age 18–25 years old [AOR = 7.983; 95% CI (1.443–44.174)].

Based on educational status, respondents whose educational status masters and above were significantly more likely to develop anxiety than respondents whose educational status diploma [AOR = 3.243; 95% CI (1.003–10.482)].

Regarding monthly income, the odds of having anxiety were 1.87 times among respondents who had low monthly income as compared with those respondents who had a high monthly income [AOR = 1.868; 95% CI (1.140–3.061)]. Moreover, Health care providers who had infected family members were significantly more likely to develop anxiety than respondents who didn’t have infected family members [AOR = 3.296; 95% CI (1.503–7.227)] (Table 4).

Table 4

Factors associated with anxiety among health care providers in Gurage Zone health institutions, SNNPR, South West, Ethiopia, 2020.

Variable	Levels of Anxiety		COR(95%, CI)	AOR(95%, CI)
	No Anxiety n (%)	Anxiety n (%)
Age in year
18–25	65(20.18)	27(8.38)	1.00	1.00
26–30	111(34.47)	46(12.8)	0.998(0.567–1.756)	1.064(0.587–1.929)
31–40	28(8.43)	32(9.93)	2.751(1.398–5.416)*	2.019(0.940–4.339)
>40	2(0.62)	11(3.4)	13.241(2.749–63.774)*	7.983(1.443–44.174)**
Monthly income
Low	80(24.8)	62(19.2)	1.808(1.142–2.865)*	1.868(1.140–3.061)**
High	126(39.1)	54(16.7)	1.00	1.00
Educational status
Diploma	73(22.67)	37(11.49)	1.00	1.00
Degree	126(39.13)	60(18.63)	0.940(0.569–1.550)	0.998(0.570–1.747)
Masters and above	7(2.1)	19(5.9)	5.355(2.066–13.883)*	3.243(1.003–10.482)**
Infected family member
No	194(60.25)	90(27.95)	1.00	1.00
Yes	12(3.72)	26(8.06)	4.670(2.255–9.674)*	3.296(1.503–7.227)**

*p value<0.05 at bivariate logistic regression

**p value<0.05 at multivariate logistic regression.

Prevalence of depression among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020

Table 5 shows the respondent’s responses to the 9 items of the PHQ-9. Through the past 2 weeks before the study. these providers replied honestly to the following as occurring for several days, more than half the days, or nearly every day: feeling tired or having little energy (42.5%); poor appetite or overeating (39.4%); little interest or pleasure in doing things (39.1%); moving or speaking so slowly that other people could have noticed; so fidgety or restless that you have been moving around a lot more than usual (37.6%); trouble falling or staying asleep or sleeping too much (37.3%); feeling bad about yourself or that you are a failure or have let yourself or your family down (34.2%); feeling down, depressed, or hopeless (31.4%); thoughts that you would be better off dead or of hurting yourself in some way (30.7%) and trouble concentrating on things, such as reading the newspaper or watching television (30.1%). Based on our finding three-fifth (60.2%) of health care providers had minimal depression, 45(14%) had mild depression, 37(11.5%) had moderate anxiety, 32(9.9%) had moderately severe depression and 14(4.3%) had severe depression.

Table 5

Prevalence of depression among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020.

Variables	Categories
	Not at all number (%)	under half the days	over half the days	nearly every day
		Number (%)	Number (%)	Number (%)
Little interest or pleasure in doing things	196 (60.9)	50 (15.5)	42 (13.0)	34 (10.6)
Feeling down, depressed, or hopeless	221 (68.6)	47(14.6)	38 (11.8)	16 (5.0)
Trouble falling or staying asleep, or sleeping too much	202 (62.7)	55 (17.1)	43(13.4)	22 (6.8)
Feeling tired or having little energy	185 (57.5)	69 (21.4)	45 (14.0)	23 (7.1)
Poor appetite or over eating	195 (60.6)	66 (20.5)	41 (12.7)	20 (6.2)
Feeling bad about yourself or that you are a failure or have let yourself or your family down	212 (65.8)	73 (22.7)	24 (7.5)	13 (4.0)
Trouble concentrating on things, such as reading the newspaper or watching television	196 (69.9)	53(16.5)	50(15.5)	23(7.1%)
Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual	201 (62.4%)	66 (20.5%)	36 (11.2%)	19 (5.9%)
Thoughts that you would be better off dead or of hurting yourself in some way	223 (69.3%)	58 (18.0%)	32 (9.9%)	9 (2.8%)

For descriptive purposes only, a cutoff of ≥10 was used to distinguish the severity of depression. So. One-fourths of (25.8%) of health care providers had depression related to covid-19 pandemics (Fig 3).

Fig 3

Prevalence of depression among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020 (n = 322).

Factors associated with depression among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020

First Bivariable logistic regression analysis was conducted to detect the presence of association and measure the relative effect of each independent variable against depression. As a result, among all other variables. Age, gender, marital status, educational status, ethnicity, occupation, types of health facility, living condition, monthly income, experience, and presence of infected colleague were found to have an association (i.e. p-value of < 0.25) and become eligible for multivariable analysis. Then, the multivariable logistic regression analysis showed that gender, educational status, living condition, occupation, and presence of infected family were found to be statistically significant predictors of depression among health care providers.

The odds of having depression were 1.9 times among male health care providers as compared with female health care providers [AOR = 1.908; 95% CI (1.040–3.500)].

Based on educational status, the odds of having depression among providers whose educational status masters and above were 10.8 times and degrees were 2.26 times as compared with those respondents whose educational status were diploma [AOR = 10.844; 95% CI (1.131–4.551)], and [AOR = 2.269; 95% CI (3.314–35.482)] respectively.

Health care providers who live with their husband/wife and those respondents who live with their families were significantly more likely to develop depression than health care providers who live alone [AOR = 5.824; 95% CI (1.896–17.888)] and [AOR = 3.938; 95% CI (1.380–11.242)] respectively. On the other hand, the odds of having depression among pharmacists were 4.5 times and among physicians were 0.2 times as compared with nurses, [AOR = (4.519; 95% CI (1.880–11.006)] and [AOR = (0.197; 95% CI (0.60–0.651))] respectively (Table 6).

Table 6

Factors associated with depression among health care providers in Gurage Zone health institutions, SNNPR, South West, Ethiopia, 2020.

Variable	Levels of Depression		COR(95%, CI)	AOR(95%, CI)
	No Depression	Depression
	n (%)	n (%)
Gender
Male	117(36,33)	50(15.52)	1.580(0.951–2.624)	1.908(1.040–3.500)**
Female	122(37.88)	33(10.24)	1.00	1.00
Educational status
Diploma	90(27.95)	20(6.2)	1.00	1.00
Degree	138(42.85)	48(14.90)	1.565(0.872–2.811)	2.269(1.131–4.551)**
Masters and above	11(3.41)	15(4.65)	6.136(2.454–15.345)*	10.844(3.314–35.482)**
Living status
Husband	104(32.29)	48(14.90)	2.308(1.292–4.122)*	5.824(1.896–17.888)**
Family	24(7.45)	13(4.03)	2.708(1.191–6.159)*	3.938(1.380–11.242)**
Friend	6(1.86)	1(0.31)	0.833(0.095–7.286)	0.641(0.063–6.538)
Alone	105(32.06)	21(6.52)	1.00	1.00
Occupation
Nurse	85(26.39)	28(8.7)	1.00	1.00
Physician	38(11.8)	6(1.86)	0.479(0.183–1.253)	0.197(0.60–0.651)**
Midwifery	28(8.7)	6(1.86)	0.651(0.244–1.733)	0.846(0.291–2.458)
Pharmacy	19(5.9)	19(5.9)	3.036(1.411–6.530)*	4.519(1.880–11.006)**
Lab technician	13(4.03)	3(0.93)	0.701(0.186–2.638)	1.303(0.307–5.522)
Health officer	27(8.38)	7(2.17)	0.787(0.309–2.004)	0.543(0.180–1.642)
Environmental Health	6(1.86)	4(1.24)	2.024(0.532–7.693)	0.716(0.142–3.593)
Others	23(7.14)	10(3/1)	1.320(0.560–3.108)	0.787(0.281–2.202)

*p value<0.05 at bivariate logistic regression

**p value<0.05 at multivariate logistic regression.

Prevalence of perceived stress among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020

Table 7 shows the respondents’ responses to the 10 Item perceived stress scale (PSS) during the last month before the study. These providers replied honestly to the following as occurring for sometimes, fairly often, or very often. Felt difficulties were piling up so high that you could not overcome them (64.0%); been upset because of something that happened unexpectedly (58.4%); been angered because of things that were outside of your control (54.3%); found that you could not cope with all the things that you had to do (46.9%); felt that you were unable to control the important things in your life (45.9%); felt nervous and “stressed” (41.3%); been able to control irritations in your life (39.1%); felt that you were on top of things (44.7%); felt confident about your ability to handle your problems (60.5%) and felt that things were going your way (68.4%).

Table 7

Prevalence of perceived stress among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020.

Variables	Categories
	Never (%)	Almost never (%)	Sometimes (%)	Fairly Often (%)	Very Often (%)
Been upset because of something that happened unexpectedly?	89 (27.6)	45 (14.0)	52 (16.1)	62 (19.3)	74 (23.0%)
Felt that you were unable to control the important things in your life?	112 (34.8)	62 (19.3)	71 (22.0)	45 (14.0)	32 (9.9)
Felt nervous and “stressed”?	119 (37.0)	70 (21.7)	64(19.9)	46 (14.3)	23 (7.1)
Felt confident about your ability to handle your problems?	53 (16.5)	74 (23.0)	70 (21.7)	68 (21.1)	57 (17.7)
Felt that things were going your way?	41 (12.7)	61 (18.9)	79 (24.5)	86(26.7)	55 (17.1)
Found that you could not cope with all the things that you had to do?	51 (15.8)	120 (37.3)	75 (23.3)	59 (18.3)	17 (5.3)
Been able to control irritations in your life?	49 (15.2)	147 (45.7)	64 (19.9)	34 (10.6%)	28 (8.7)
Felt that you were on top of things?	47 (14.6)	131(40.7%)	54 (16.8%)	53 (16.5%)	37 (11.5)
Been angered because of things that were outside of your control?	53 (16.5%)	94 (29.2%)	65 (20.2%)	60 (18.6%)	50 (15.5%)
Felt difficulties were piling up so high that you could not overcome them?	65 (20.2)	51 (15.8)	58 (18.0)	69 (21.4)	79 (24.5)

The bold letter indicates a 4-item negative factor asking the ability to manage the stressors.

Based on our finding three-fifth (60.2%) of health care providers had low stress, 45(14%) had moderate stress, and 14(4.3%) had high levels of stress.

The summation scores range from 0–40 with a higher score indicating a higher level of stress. The scores from 0–13 indicate low stress, whereas scores from 14–26 and 27–40 indicate moderate and high levels of stress, respectively.

For descriptive purposes only, a cutoff of ≥21 was used to distinguish the severity of stress. So. 101 (31.4%) of HCPs had stress whereas 221 (68.6%) of HCPs had no stress related to covid-19 pandemics.

Factors associated with stress among health care providers in Gurage Zone, SNNPR, South West, Ethiopia, 2020

Bivariate and multivariate logistic regression analysis was conducted to see the presence of association and to measure the relative effect of each independent variable on overall perceived stress among health care providers. Age, gender, marital status, educational status, ethnicity, occupation, types of health facility, monthly income, experience, presence of infected colleague and family were significant factors associated with stress among health care providers.

Among fitted variables included in the binary regression model for bivariate analysis, gender, marital status, ethnicity, occupation, types of health facility, monthly income and experience were variables taken into consideration for multivariate analysis with a p-value < 0.25. Under multivariate analysis type of health facility and monthly income were found to be statistically significant predictors of stress among health care providers.

Health care providers who are working at general and referral hospitals were significantly more likely to develop stress than health care providers who were working at primary hospitals [AOR = 4.835; 95% CI (2.189–10.680)], and [AOR = 3.263; 95% CI (1.302–8.178)] respectively.

Health care providers who had low monthly income were significantly more likely to develop stress than health care providers who had high monthly income [AOR = 2.289; 95% CI (1.349–3.885)] (Table 8).

Table 8

Factors associated with stress among health care providers in Gurage Zone health institutions, SNNPR, South West, Ethiopia, 2020.

Variable	Levels of Stress		COR(95%, CI)	AOR(95%, CI)
	No Stress n (%)	Stress n (%)
Types of health facility
Primary	75(23.29)	10(3.1)	1.00	1.00
General	64(19.88)	47(14.6)	5.508(2.577–11.774)*	4.835(2.189–10.680)**
Referral	31(9.63)	16(4.97)	3.871(1.583–9.465)*	3.263(1.302–8.178)**
Isolation center	51(15.84)	28(8.7)	4.118(1.841–9.209)*	5.270(2.275–12.209)**
Monthly income
Low	85(26.3)	57(17.7)	2.073(1.286–3.342)*	2.289(1.349–3.885)**
High	136(42.2)	44(13.67)	1.00	1.00

*p value<0.05 at bivariate logistic regression

**p value<0.05 at multivariate logistic regression.

Generally, 36.0%, 25.80%, and 31.4% of health care providers in the Gurage zonal institution had anxiety, depression, and stress respectively (Fig 4).

Fig 4

Overall prevalence of anxiety, depression, and stress among HCPs in Gurage Zonal Health Institution’s, SNNPR, Ethiopia, 2020 (n = 322).

Discussion

The results of this study had shown that the overall prevalence of anxiety among health care providers in Gurage Zonal Public hospital was 36%, [95% CI = (30.7%- 41.3%)] which is in line with the previously reported study from Ethiopia(29.3%) [45], Nepal (38%) [46], India (31.6) [47].However, it is less than the findings in Gondar (69.6%) [48], Debre Tabor (63%) [49], Central Ethiopia (78%) [50], Addis Ababa (51.6) [51], Egypt, and Saudi Arabia (58.9%) [52]). Mali (73.3%) [53], Saudi Arabia (51.4%) [54], (78.8%) [55], Iran (67.55%) [56], Iraq (48.9%) [57], Nepal (41.9%) [58], Turkey (45.1%) [59], China (41.1%) [60], (44.6%) [4], North Italy (50.1%) [61], and USA (43%) [62]. However, it is higher than the study conducted in St Peter hospital, Addis Ababa (21.2%) [63], St Paul Hospital (21.9%) [64], multinational multi-center study (8.7%) [65], Middle East country (23.6%) [66], Iran (25.8%) [67], China 8.5% [68] (14.3%) [69], India (17.7%) [47], Italy (19.8%) [70], Malaysia (29.7%) [71], and Australia (21%). This discrepancy may be due to differences in workload, socioeconomic, cultural, and environmental factors, variation in the availability of personal protective equipment and resources, the difference in emotional response related to previous experience/exposure with SARS, MERS, and H1N1 epidemics, and also it may be related to the different cut-off scores used to define levels of clinically significant anxiety.

According to this study being older than 40 years is significantly associated with anxiety. The finding is also supported by a study reported from Debre tabor [49], Saudi Arabia [72, 73]. South Korea [74] and India [75]. This may be due to older health care providers are among the most affected by the COVID-19 pandemic in terms of illness severity and mortality, increased risk of transmission more prone to complications, and they could also live with young children and/or have older people in their extended family, which could cause them to worry about bringing the virus home to their family members as well as older health care workers tend to have lower stress reactivity, poor emotional regulation and well-being than younger HCPs. Moreover, they are also more likely to suffer psychological impacts such as anxiety due to isolation, heavy workload, and facts about the COVID-19 pandemic which is complicated by pre-existing physical health problems, medical comorbidities, and existing mental health symptoms.

Our finding also showed that having infected family members is significantly associated with anxiety. It is supported by a previous study conducted in Debre tabor [49], Gondar [76], and China [77]. This anxiety might arise from close family relationships and concerns about family members’ health conditions, the absence of specific treatments for COVID-19 during the initial periods of the pandemic, and isolation from their loved ones during quarantine for prolonged periods.

Our study also revealed that those health care providers who had low monthly income were significantly associated with anxiety. This is supported by research done in St Peter hospital [63]. This may due to preoccupation with fear of how to cope with the potential economical challenge faced during the pandemic and increased psychological and economic pressure resulting from socioeconomic challenges that may critically impact mental health.

Our study finding showed that 25.8% [95% CI = (21.1%- 30.4%)] of Gurage Zone health care providers are suffering from depression during COVID-19 outbreak which is in line with study done in Iran(24.3%) [67], Middle East counties (27.4%) [66], Saudi Arabia (26.1%) [55], India 25%) [78], Turkey (23.6%) [59], Australia (27.6%), Italy (24.73%, 26%) [61, 70], and USA(26%) [62].This finding is higher than the study conducted in St Paul Hospital, Ethiopia (20.2%) [79], multinational multi-center study (5.3%) [65], India (11.4%) [47], China (9.5%) [68], (10.7%) [69]. However, it is lower than in study carried out in Gondar (55.3%) [48], St Peter Hospital, Addis Ababa (36.5%) [63], Central Ethiopia (60.3%) [50], Mali (71.9%) [53], Egypt and Saudi Arabia (69%) [52], (55.2%) [54], systematic review in Iran (55.89%) [80], Oman (32.3%) [81], Nepal (37.5%) [58], Malaysia (31%) [71], China (46.9%) [60], (50%) [4]. The discrepancy could be explained by the difference in socioeconomic status, social support, study setting, variability of health care workers, sample size variation, the difference in methods, environmental and organization culture, as well as social and cultural issues, which might contribute to this difference.

Our study revealed that Males health care providers were about two times more likely to become depressed than females. This is in line with the study carried out in India [78]. This might be due to our socio-cultural norms males HCPs had an economic burden which is expected to help other members of the family and relatives as a result, they are more prone to financial deprivation, which leads to developing depression than their counterparts. But this finding is inconsistent with other studies conducted in Egypt and Saudi Arabia [52], Low and Middle-income countries [82], Middle East countries [66], Turkey [59], Iran [83], India [47, 84], Poland [85], Italy [70, 86], and United Kingdom [87] which states female HCPs were more prone to depression due to females being more commonly exposed to mental illness, cultural factors, and hormonal fluctuations.

Our finding also revealed that participants with high educational levels were more depressed than those with lower educational statuses. This could be related to the increments of workload to those who had higher educational attainment and they conducted and explored different types of scientific researches about the virulent nature of the COVID-19 pandemic which induces depression.

According to our study, Health care providers living with their spouse and family were more likely to develop depression than those HCPs living alone. This finding is supported by research findings in St Paul, Ethiopia [64], Saudi Arabia [55], India [75, 84], and the United Kingdom [87]. which states that HCWs who were either married or married with children were more depressed than those among unmarried HCWs/ living alone [84]. The possible explanation could be primary worry of all HCPs was the safety of their families during the COVID-19 pandemic, which was regarded as a major depressive factor. Furthermore, married HCPs were found to be more hopeless, concern for family members and their wellbeing could contribute to their feeling of hopelessness.

The results of our study found that Nurse and Pharmacists were more likely to develop depression. Similar results were reported in research conducted in Mali [53], Middle East countries [66], China [69, 88], and Brazil [89]. The possible explanation might be due to nurses are frontline healthcare workers, directly engaged in diagnosis, treatment, and care of patients with COVID-19 and they have long work shifts and closer contact with patients, by undertaking most of the tasks related to infectious disease containment, as a result, they are prone to fatigue, tension, and depression. Besides these in a study conducted in low and middle-income countries (LMICs) showed that Nurses and other HCPs in non-physician roles experienced greater depressive symptom severity compared to HCPs in physician roles [82]. The pharmacist is also involved directly to provide drugs for patients with COVID-19 and they are at high risk for developing depression.

Our study finding showed that during the COVID-19 pandemic, 31.4% [95% CI = (26.4%- 36.0%)] of HCPs had stress. Which is congruent with study finding in Central Ethiopia (33.8%) [50], benchi-sheko (32.5%) [90], The finding is less than study reported from Addis Ababa (43.4%) [91]), Dilla, Ethiopia (51.6%) [43], Egypt and Saudi Arabia (55.9%) [52], a systematic review in Iran (45%) [67], (62.9%) [80], China (69.1%) [60], and USA (80.1%) [62]. However, it is higher than in study done in Gondar (20.5%) [48], multinational multi-center study (2.2%) [65], Oman (23.8%) [81], Malaysia (23.5%) [71], and Italy(21.90%, 8.9%) [70, 92].

Health care providers who are working at general and referral hospitals were more likely to become stressed than health care providers who were working at primary hospitals. This is supported by a systematic review and meta-analysis conducted in china which states that a considerable proportion of healthcare workers within secondary and tertiary hospitals developed adverse psychological outcomes during the COVID-19 pandemic [32]. A similar study conducted in China showed that those HCPs working in secondary hospitals reported high levels of psychological problems [4].

In this study HCPs who had low monthly income were more likely to be stressed than those HCPs who had high monthly income. This is supported by research conducted in Addis Ababa, Ethiopia. This could be due to the socioeconomic impact of a virus might be much significant to the extent of unable to buy safety measures of prevention, such as facemask, soaps, and sanitizers. In addition during this pandemic period, they were not able to fulfill their basic needs of day-to-day life [93].

Strength of the study

We have used a previously validated and well-established instrument to measure our outcome variables GAD-7, PHQ, and PSS for the assessment of anxiety, depression, and stress respectively. Moreover, there was a proportionate representation of health care providers from each department in this study; this would likely mitigate the bias of having a higher number of nurses/ doctors as in previous studies conducted in other regions of Ethiopia.

Limitation of the study

The study has certain limitations which must be acknowledged. First, we did not explore the common risk factors for anxiety, depression, and stress, like a history of anxiety, depression, and stress, comorbidities like chronic diseases, social support, and communication. Second, responses to the survey were self-reported. It may have resulted in reporting biases for social desirability which may have affected the results and finally, this study cannot show cause and effect relationship since it is a cross-sectional type. Despite the identified limitations, these results contribute to the information relating to the overwhelming problem faced by HCPs especially related to the commonly encountered mental health problems while caring not only in Ethiopia but also at the global level.

Conclusion and recommendation

Based on our findings, significant numbers of healthcare workers were suffered from anxiety, depression, and stress during the COVID-19 outbreak. On most occasions, the mental health impact of a disease outbreak is usually neglected during pandemic management although the consequences are costly. Therefore, the Federal Ministry of Health in collaboration with hospitals should pass emergency legislation to protect healthcare providers who are at high risk of exposure to mental health problems. This should include financial protections for healthcare providers who contract COVID-19 and supplement additional safety requirements for healthcare facilities. Moreover, mental health professionals should pay attention to the role of family members’ health and monitor the mental wellbeing of health care providers too.

The finding revealed that age, educational status, monthly income, and the presence of infected families were statistically associated with anxiety. Besides this, gender, educational status, living condition, and occupation were found to be statistically significant predictors of depression among health care providers. Our study finding also showed that type of health facility and monthly income were found to be statistically significant predictors of stress among health care providers.

(SAV)

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12 Aug 2021

PONE-D-21-20584

Levels and predictors of anxiety, depression, and stress during COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020: A Multicenter Cross-Sectional Study

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Reviewer #1: GebreEyesus et al performed cross-sectional study about health care providers’ (HCPs) mental burden in six public hospitals in the south-west part of Ethiopia. They received responses from 322 participants, a response rate of 95%. They used Generalized Anxiety Disorder scale (GAD-7), Patients Health Questionnaire (PHQ-9), and 10-item Perceived Stress Scale (PSS) as rating scales for anxiety, depression, and psychological distress, respectively. In their participants, 36% were shown to have moderate or greater anxiety, 25% had moderate or greater depression, and 31% had moderate or greater menta distress. They showed multiple risk factors for psychiatric symptoms in HCPs: low income was a risk factor for anxiety and mental distress, and having a family member with COVID-19 was a risk factor for anxiety and depression. While these results presented in this manuscript are valuable in the field, there are some major concerns:

Major points:

1. The authors seem to be confusing “AOR” with relative risk. For example, page 22 lines 3-5, “Health care providers whose age >40 years old were about eight times [AOR=7.983; 95% CI (1.443-44.174)], more likely to develop anxiety than health care providers whose age 18-25 years old”, is it correct? If AOR means adjusted odds ratio (unfortunately the authors did not spell AOR out in the manuscript), “an odds ratio of 8” is not synonymous with “an 8-fold increase in risk”.

2. The authors should clearly describe the specific methods for collecting information of GAD-7, PHQ-9, and PSS from participants. For example, mailing paper-based questionnaires, SNS, telephone interview, etc.

3. Did the authors not obtain written consent? If so, please clearly state how the authors ensure that the participants could later withdraw their consent.

4. Did the authors have a validated Ethiopian version of the GAD-7, PHQ-9, and PSS? If the authors translated the English version of these questionnaires independently, did the authors train questioners to ask participants exactly the same way? Were there any biases in the answers given by different questioners?

5. The authors should add information on social restrictions in Ethiopia during the study period. Were strict social restrictions with legal penalties enforced during the study period?

Minor points:

1. Please correct the text in the manuscript: there are many inconsistent notations, unexplained abbreviations, and mistakes in spaces, dots, colons, and text color.

2. Is there any differences in the ratio of men to women by occupation?

3. Page 27 lines 10-12, “They are also more likely to suffer … limited access to accurate information and facts about the COVID-19 pandemic”, does it apply to skilled HCPs over the age of 40 as well?

4. Page 27 lines 16-19, this part looks confusing. It is natural for HCPs who already have infected family members to be concerned about the health of themselves and their affected family members. It should be distinguished from the HCPs feeling that they might infect their family members with COVID-19 in the future.

5. To describe income, please use the U.S. dollar or Euro as a key currency or use a simple classification such as “low income” or “high income”. Otherwise, it is difficult for a foreigner to imagine the relationship between local prices and income.

6. Page 28 lines 14-16, the authors should pick up the references with similar conditions to their study and add further discussion.

7. Page 28 lines 17-23, it looks confusing. Do the authors consider female HCPs to be home-makers? Female HCPs have the same social responsibilities as men as HCPs. Are there gender differences in occupations and income in the authors’ study, and do women tend to work in occupation with lower income and less responsibility?

8. There are duplicate sentences: page 27 line 14- and page 30 line 6-, page 27 line 20- and page 31 line 1-.

9. About figure 1, why is the sum of the numbers in the figure 325, but the inside of the oval is listed as 334?

10. About Figure 2 to 4, is there a reason why the figure should be in 3D?

11. About Figure 2, the total number in the figure is 322, which is different from the description in the text.

12. About Figure 4, what do Yes/No mean? What does the bar for the frequency mean?

13. About table 2, what do “husband” mean? If the authors mean “a married couple living together”, they should use "spouse”.

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14 Oct 2021

To: PLOS ONE

Subject: Replay to Review Report #1

Manuscript Ref. No: [PONE-D-21-20584] - [EMID:528479536e1a8b26]

Manuscript title: “Levels and predictors of anxiety, depression, and stress during COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020: A Multicenter Cross-Sectional Study:”

Date: September 23/ 2021

Authors:

Fisha Alebel GebreEyesus* 1, Tadesse Tsehay Tarekegn1 , Baye Tsegaye Amlak 1, Bisrat Zeleke Shiferaw1 , Mamo Solomon Emeria 1, Omega Tolessa Geleta 1 Tamene Fetene Terefe 1, Mtiku Mamo2, Melkamu Senbeta Jimma 3, Fatuma Seid Degu14, Elias Nigusu Abdisa5 , Menen Amare Eshetu6, Natnael Moges Misganaw7, Ermias Sisay Chanie 7

Dear Reviewers and editors:

Greetings of the day!

First of all, we would like to present our gratitude acknowledgment, and appreciation for the effort you made to improve our manuscript throughout the review process during this difficult time of the COVID-19 pandemic. Also, we wish to thank you for considering this manuscript for publication in your journal.

Dear Reviewers and editors, on behalf of the authors I am submitting the revised version of the manuscript. We have gone through your constructive comments and question and devote all our effort to incorporate the feedback. All the authors are grateful to the reviewers and editors for their candid comments and timely communication.

All the essential revisions are incorporated in the main manuscript and next to this cover letter please, kindly have a point-by-point guide on the response given to the comments/concerns and questions raised by reviewer # 1.

Sincerely,

Fisha Alebel GebreEyesus (MSc) - (corresponding author) on behalf of all authors)

Response to Reviewer#1

Dear reviewer,

First of all, we would like to present our gratitude acknowledgment, and appreciation for the effort you made to improve our manuscript throughout the review process during this difficult time of the COVID-19 pandemic. We also would like to express our heartfelt gratitude for your candid comments which we have addressed to the best of our abilities to improve the quality of our manuscript.

Reviewer comment/question # 1 Major points:

1. The authors seem to be confusing “AOR” with relative risk. For example, page 22 lines 3-5, “Health care providers whose age >40 years old were about eight times [AOR=7.983; 95% CI (1.443-44.174)], more likely to develop anxiety than health care providers whose age 18-25 years old”, is it correct? If AOR means adjusted odds ratio (unfortunately the authors did not spell AOR out in the manuscript), “an odds ratio of 8” is not synonymous with “an 8-fold increase in risk”.

Response by the authors

Dear reviewer,

Thank you for your constructive comments;

It is corrected as an Adjusted odds ratio based on your kind and constructive comment. Please kindly refer to the list of abbreviations in declaration section page 35 line number 6

Reviewer comment/question # 2 Major points:

2. The authors should clearly describe the specific methods for collecting information on GAD-7, PHQ-9, and PSS from participants. For example, mailing paper-based questionnaires, SNS, telephone interviews, etc.

Response by the authors

Dear reviewer,

Thank you for your constructive comments;

It is stated and clearly explained under the data quality assurance and control section.

Data was collected from different healthcare workers in their respective wards using paper-based questionnaires. please kindly refer to page 12 line number 2-3

Reviewer comment/question # 3 Major points:

3. Did the authors not obtain written consent? If so, please clearly state how the authors ensure that the participants could later withdraw their consent

Response by the authors

Dear reviewer,

Thank you for your constructive comments

As we all know Ethics is the branch of philosophy that deals with distinctions between

rights and wrongs. It is strongly recommended after Tuskegee Syphilis Study conducted on

the natural course of untreated syphilis among rural black males in Macon Country, Alabama

The purpose of ethical review is to consider the features of a proposed study in light of

ethical principles. To ensure that investigators have anticipated and satisfactorily resolved possible ethical objections and to assess their response to ethical issues raised by the study.

The purpose of the study was explained to the study participants; anonymity, privacy, and confidentiality were ensured. As we know informed consent may be written or verbal consent. In our case, the health care providers are neither vulnerable to foreseeable risks and discomforts nor require compensation for possible injuries/harms due to participation in our studies so only verbal consent is necessary. So, the respondents’ right to refuse or withdraw from participating in the study was also fully acknowledged. We know whether the respondents were withdraw from the study in terms of response rate. If the response rate was 100% all eligible participants are fully engaged.

Reviewer comment/question # 4 Major points:

4. Did the authors have a validated Ethiopian version of the GAD-7, PHQ-9, and PSS? If the authors translated the English version of these questionnaires independently, did the authors train questioners to ask participants the same way? Were there any biases in the answers given by different questioners?

Response by the authors

Dear reviewer,

Thank you for your constructive comments

Yes, we have a validated Ethiopian version of the GAD-7, PHQ-9, and PSS. We measured symptoms of anxiety, depression, and stress using Generalized Anxiety Disorder 7-item (GAD-7), Patient Health Questionnaire 9-item (PHQ-9), and Perceived Stress Scale 10-item (PSS-10) respectively. The score of each measurement scale was used for anxiety symptoms (0 to 21), depression symptoms (0 to 27), and stress symptoms (0 to 40) in the analysis. The measurement item (GAD-7, PHQ-9, and PSS-10) is widely used in different research and validated in different settings and population groups. GAD-7, PHQ-9, and PSS-10 have been validated in Ethiopia using different cut-off points.

To ensure the quality data, the questionnaire was translated from English into the local language (i.e., “Amharic”) for appropriateness and easiness in approaching the study participants and retranslated to English for analysis using language experts. . A two-day extensive training was given for both data collectors and supervisors before data collection, and common understanding was established on the data collection method and procedure. As a result of this, there was no bias rising from answering the questions raised by different data collectors. Moreover, the questionnaires were a four-point Likert scale ranging from 0 (“Not at all”) to 3 (“Nearly every day”) for anxiety and depression and a 5-point Likert-type scale ranging from 0 (never) to 4 (very often) for perceived stress which is clear, simple and didn’t result in any response bias and mutual agreement is reached between the data collector and the study participants in each value.

Reviewer comment/question # 5 Major points:

5. The authors should add information on social restrictions in Ethiopia during the study period. Were strict social restrictions with legal penalties enforced during the study period?

Response by the authors

Dear reviewer,

Thank you for your constructive comments. Please kindly refer to page 6 line number 16-23

Ever since the official announcement of confirmed cases of COVID-19 in Ethiopia on 13 March, the Government has taken several preventive and control measures to contain the spread of the disease in the country. These include, but are not limited to, screening of incoming passengers

at international entry points, temporary flight suspensions to 30 countries, border closures, compulsory 14-day quarantine for arriving passengers, the establishment of isolation and quarantine centers for suspected and confirmed cases, laboratory diagnosis of COVID-19, procurement of medical supplies, community engagement, and risk awareness campaigns, resource mobilization, the activation of the Federal Emergency Operation Center, market control, disinfection of public transportation, temporary closure of schools and higher education institutions, establishing alternative working modalities for public servants, and the suspension of mass gatherings. Despite the ongoing preventative and control measures, containing the spread of the virus could be challenging in light of the underlying social and infrastructural settings of the country. Additionally, in Ethiopia, inherent cultural norms such as ritualistic greetings and strong social ties challenge key prevention methods such as social

distancing

Reviewer comment/question # 1 Minor points

1. Please correct the text in the manuscript: there are many inconsistent notations, unexplained abbreviations, and mistakes in spaces, dots, colons, and text color

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected based on your constructive comments.

Reviewer comment/question # 2 Minor points

2. Are there any differences in the ratio of men to women by occupation?

Response by the authors

Dear reviewer,

Thank you for your constructive comments

Based on our findings from the total 322 participants enrolled in the study, the proportion of male health care providers was found to be 167(51.9%) whereas the number of female participants was 155 (48.1%). So, we can infer from this there was nearly equal involvement of male and female health providers in our study.

Reviewer comment/question # 3 Minor points

3. Page 27 lines 10-12, “They are also more likely to suffer … limited access to accurate information and facts about the COVID-19 pandemic”, does it apply to skilled HCPs over the age of 40 as well?

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected by your constructive comment. Please kindly refer to page 29 line number 20-22, page 30 1-6

Reviewer comment/question # 4 Minor points

4. Page 27 lines 16-19, this part looks confusing. It is natural for HCPs who already have infected family members to be concerned about the health of themselves and their affected family members. It should be distinguished from the HCPs feeling that they might infect their family members with COVID-19 in the future.

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected based on the comments provided. Please kindly refer to page 30 lines 9-12

Reviewer comment/question # 5 Minor points

5. To describe income, please use the U.S. dollar or Euro as a key currency or use a simple classification such as “low income” or “high income”. Otherwise, it is difficult for a foreigner to imagine the relationship between local prices and income.

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected as low income and high income based on your constructive comment. Please kindly refer to Tables 1, 4 and 8

Reviewer comment/question # 6Minor points

6. Page 28 lines 14-16, the authors should pick up the references with similar conditions to their study and add further discussion.

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected based on your constructive comment. Please kindly refer to pages 31:5-9

Reviewer comment/question # 7Minor points

7. Page 28 lines 17-23, it looks confusing. Do the authors consider female HCPs to be home-makers? Female HCPs have the same social responsibilities as men as HCPs. Are there gender differences in occupations and income in the authors’ study, and do women tend to work in occupations with lower income and less responsibility?

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected based on your comment. Please kindly refer to page 31 line number 11-19

Reviewer comment/question # 8Minor points

8. There are duplicate sentences: page 27 line 14- and page 30 line 6-, page 27 line 20- and page 31 line 1-.

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected based on your comment. Please kindly refer to page 30: line 9-12, page 30 line 15-17, page 33 line 15-20

Reviewer comment/question # 9Minor points

9. About figure 1, why is the sum of the numbers in figure 325, but the inside of the oval is listed as 334?

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

Our total sample size was 334 but there were 322 study participants involved in the study with a response rate of 96.5%. So we correct it based on your comment. Please kindly refer to figure 1

Reviewer comment/question # 10 Minor points

10. About Figures 2 to 4, is there a reason why the figure should be in 3D?

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

We have used 3D to increase the resolution and quality of figures. Based on your comment we have changed figure 2 and figure 4 into 2D. please kindly refer to figure 2 and figure 4

Reviewer comment/question # 11 Minor points

11. About Figure 2, the total number in the figure is 322, which is different from the description in the text.

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected based on your kind and constructive comment.

Reviewer comment/question # 12 Minor points

12. About Figure 4, what do Yes/No mean? What does the bar for the frequency mean?

Response by the authors

Dear reviewer,

Thank you for your constructive concern

For the sake of clarity, we have changed the figure. Please kindly refer to figure 4

Yes Implies the magnitude of anxiety, depression, and stress Whereas No means the difference between 100% to the magnitude of each mental health problem respectively.

The bar frequency on the right side shows the exact frequency of each mental health problem faced by health care providers. i.e 36%, 25.8%, and 31.4% of health care providers working in Gurage zonal Hospital had anxiety, depression, and stress respectively. Whereas the frequency mentioned on the left side indicates the proportion of health care providers who had no anxiety, depression, and stress respectively.

Reviewer comment/question # 13 Minor points

13. About table 2, what does “husband” mean? If the authors mean “a married couple living together”, they should use "spouse”.

Response by the authors

Dear reviewer,

Thank you for your constructive concern;

It is corrected as Spouse. Please kindly refer to table 2 page 15

Yours sincerely,

Fisha Alebel GebreEyesus (MSc) - (corresponding author) on behalf of all authors)

,

Submitted filename: Replay to Editorial and Reviewer.docx

Click here for additional data file.

19 Oct 2021

PONE-D-21-20584R1Levels and predictors of anxiety, depression, and stress during COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020: A Multicenter Cross-Sectional StudyPLOS ONE

Dear Dr. GebreEyesus,

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Kensaku Kasuga

Academic Editor

PLOS ONE

Additional Editor Comments:

Please respond to the reviewer's comments.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed the most of the issues except for the following.

They still mistakes “odds ratio” for “relative risk”. “Odds ratio = 2.0” dose not mean “two times more likely”. We can say “two times more likely” only when the relative risk is 2.0 in a prospective cohort study. As this study is a cross-sectional case-control studies, they cannot mention the relative risks. The odds ratio can be occasionally used as an approximation of the relative risk when patients with diseases are less than 1% in general. However, the odds ratio often dissociates from the relative ratio in cohorts including many patients with diseases. Considering the substantial numbers of participants with symptoms in the study, they should not handle the odds ratio as the relative risk.

For example (in the result section):

“Health care providers whose age >40 years old were about eight times

[AOR=7.983; 95% CI (1.443-44.174)], more likely to develop anxiety than health care

providers whose age 18-25 years old”,

I agree that the difference is statistically significant, but the risk is not “eight times”.

So, how about just changing like the below?

“Health care providers whose age >40 years old were significantly more likely to develop anxiety than health care providers whose age 18-25 years old” [AOR=7.983; 95% CI (1.443-44.174)],

Please also revise the many other descriptions regarding AOR.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

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26 Oct 2021

To: PLOS ONE

Subject: Replay to Review Report #2

Manuscript Ref. No: [PONE-D-21-20584] - [EMID:528479536e1a8b26]

Manuscript title: “Levels and predictors of anxiety, depression, and stress during COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020: A Multicenter Cross-Sectional Study:”

Date: October 26/ 2021

Authors:

Fisha Alebel GebreEyesus* 1, Tadesse Tsehay Tarekegn1 , Baye Tsegaye Amlak 1, Bisrat Zeleke Shiferaw1 , Mamo Solomon Emeria 1, Omega Tolessa Geleta 1 Tamene Fetene Terefe 1, Mtiku Mamo2, Melkamu Senbeta Jimma 3, Fatuma Seid Degu14, Elias Nigusu Abdisa5 , Menen Amare Eshetu6, Natnael Moges Misganaw7, Ermias Sisay Chanie 7

Dear Reviewers and editors:

Greetings of the day!

First of all, we would like to present our gratitude acknowledgment, and appreciation for the effort you made to improve our manuscript throughout the review process during this difficult time of the COVID-19 pandemic. Also, we wish to thank you for considering this manuscript for publication in your journal.

Dear Reviewers and editors, on behalf of the authors I am submitting the revised version of the manuscript. We have gone through your constructive comments and question and devote all our effort to incorporate the feedback. All the authors are grateful to the reviewers and editors for their candid comments and timely communication.

All the essential revisions are incorporated in the main manuscript and next to this cover letter please, kindly have a point-by-point guide on the response given to the comments/concerns and questions raised by reviewer # 1.

Sincerely,

Fisha Alebel GebreEyesus (MSc) - (corresponding author) on behalf of all authors)

Response to Reviewer#1

Dear reviewer,

First of all, we would like to present our gratitude acknowledgment, and appreciation for the effort you made to improve our manuscript throughout the review process during this difficult time of the COVID-19 pandemic. We also would like to express our heartfelt gratitude for your candid comments which we have addressed to the best of our abilities to improve the quality of our manuscript.

Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed the most of the issues except for the following.

They still mistakes “odds ratio” for “relative risk”. “Odds ratio = 2.0” dose not mean “two times more likely”. We can say “two times more likely” only when the relative risk is 2.0 in a prospective cohort study. As this study is a cross-sectional case-control studies, they cannot mention the relative risks. The odds ratio can be occasionally used as an approximation of the relative risk when patients with diseases are less than 1% in general. However, the odds ratio often dissociates from the relative ratio in cohorts including many patients with diseases. Considering the substantial numbers of participants with symptoms in the study, they should not handle the odds ratio as the relative risk.

For example (in the result section): “Health care providers whose age >40 years old were about eight times [AOR=7.983; 95% CI (1.443-44.174)], more likely to develop anxiety than health care providers whose age 18-25 years old”,

I agree that the difference is statistically significant, but the risk is not “eight times”. So, how about just changing like the below? “Health care providers whose age >40 years old were significantly more likely to develop anxiety than health care providers whose age 18-25 years old” [AOR=7.983; 95% CI (1.443-44.174)], Please also revise the many other descriptions regarding AOR.

________________________________________

Response by the authors

Dear reviewer,

Thank you for your constructive comments;

It is corrected based on your kind and constructive comment. Please kindly refer to page 19 line number 15-19, page 20 line 1-5, page 23 line 11-20, page 24 line 1-2 and page 27 line 13-18

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Response by the authors

Dear reviewer,

Thank you for your constructive comments;

It is corrected based on the comment. Please kindly refer page 34 line 16-21 and page 35 line 1-2

Yours sincerely,

Fisha Alebel GebreEyesus (MSc) - (corresponding author) on behalf of all authors)

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

29 Oct 2021

Levels and predictors of anxiety, depression, and stress during COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020: A Multicenter Cross-Sectional Study

PONE-D-21-20584R2

Dear Dr. GebreEyesus,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Kensaku Kasuga

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

All comments have been addressed

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for revising the manuscript. All issues that I pointed out have been addressed now. This article is now acceptable for the journal.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

4 Nov 2021

PONE-D-21-20584R2

Levels and predictors of anxiety, depression, and stress during COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020: A Multicenter Cross-Sectional Study

Dear Dr. GebreEyesus:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Kensaku Kasuga

Academic Editor

PLOS ONE