Knowledge, practice, and impact of COVID-19 on mental health among patients with chronic health conditions at selected hospitals of Sidama regional state, Ethiopia.

BACKGROUND: COVID-19 causes worse outcomes and a higher mortality rate in adults with chronic medical conditions. In addition, the pandemic is influencing mental health and causing psychological distress in people with chronic medical illnesses.
OBJECTIVE: To assess the knowledge, practice, and impact of COVID-19 on mental health among chronic disease patients at selected hospitals in Sidama regional state.
METHOD: A facility-based cross-sectional study was conducted. A total of 422 study subjects were enrolled in the study using a two-stage sampling technique. Data were coded and entered using Epi Data version 3.1 and exported to SPSS-20 for analysis. Descriptive analysis was used to present the data using tables and figures. Bivariate and multivariate logistic analyses were used to identify factors associated with the initiation of preventive behavior of COVID-19. Variables with a P-value of less than 0.25 in bivariate analysis were considered as candidate variables for multivariable analysis. The statistical significance was declared at a P-value less than 0.05. RESULT: More than half 237 (56.2%, 95% CI: 50.7-60.9) of the study participants had good knowledge of COVID-19. The practice of preventive measures toward COVID-19 was found to be low (42.4%, 95% CI: 37.9-47.2). Being widowed (AOR = 0.31, 95% CI (0.10, 0.92)), secondary and above educational status (AOR = 2.21, 95% CI (1.01, 4.84)), urban residence (AOR = 2.33, 95% CI (1.30, 4.19)) and good knowledge (AOR = 4.87, 95% CI (2.96, 8.00)) were significantly associated with good practice. In addition, more than one-third of the study participants 37% (95% CI 32.7, 41.5) were experiencing anxiety. While more than a quarter of respondents 26.8% (95% CI 22.5, 31.5) had depression. CONCLUSION AND RECOMMENDATION: Despite more than half of the participants had good knowledge, the prevention practice was low. Hence, multiple information dissemination strategies should be implemented continuously among chronic disease patients. In addition, the magnitude of concurrent depression and anxiety in the current study was high.

Introduction

Since December 2019, the global population is in health crisis because of the COVID-19 pandemic caused by Severe Acute Respiratory Syndrome Corona virus-2 (SARS-COVID-2) which has been identified in Chinese patients with severe pneumonia and flu-like symptoms [1]. COVID-19 is a contagious disease that spreads rapidly via droplets from the sneezing and coughing of an infected person. The disease is highly contagious and has a 14-day incubation period. Its main clinical symptoms are fever, dry cough, sneezing, sore throat, headache, bodily pain, fatigue, chills, and shortness of breath [2].

According to the World Health Organization (WHO) report issued in February 2021, more than 108 million confirmed COVID-19 cases and more than 2.3 million deaths were reported globally [3]. From this figure, more than 2.7 million confirmed cases and over 68 thousand deaths have been reported in the African region. Ethiopia is the third country where deaths due to COVID-19 are high in the regions of Africa, next to South Africa and Algeria [4]. Ethiopia is currently suffering from the critical phase of COVID-19, so there is concern that the infection will spread rapidly.

Not all people are equally affected by the virus; people with chronic medical illnesses were more likely to become infected [5]. In addition, the COVID-19 infection has a worse outcome and a high mortality rate among this group of people [6]. Individuals living with chronic diseases are already viewed as being among the most greatly impacted by stressors related to the COVID-19 pandemic. These underscore the importance of preventive measures (such as social distancing, respiratory hygiene, and wearing a face mask in public) in protecting people with chronic medical conditions. To improve preventive behaviors among these vulnerable groups, it is important to assess their knowledge and action related to COVID-19 and identify the determinants that affect the initiation of preventive behaviors [7].

As the coronavirus pandemic spreads quickly around the globe, it creates a great deal of fear, worry, and concern in the public at large, and among certain groups in particular, such as care providers, older adults, and people with underlying health conditions [8, 9]. In addition, from the past experience, such a pandemic is known to cause beyond a physical illness, it also has an impact on people’s mental health and psychological well-being, particularly those with underlying medical conditions. Due to the severity of the disease among these vulnerable groups, they develop psychiatric disorders such as depression and anxiety during these health crises, which can impede infection control [8]. That is why this study wants to measure the mental health impact of the COVID-19 pandemic among these vulnerable groups.

Ethiopia has made a strong commitment to prevent and slow down the COVID-19 pandemic before it causes a major public health crisis [10]. WHO recommends that apart from case identification, contact tracing, quarantine, and large-scale screening in vulnerable groups; controlling the spread of disease among high-risk groups must be one of the strategies of COVID-19 prevention practice [11]. Despite this, the majority of studies in Ethiopia focused on health professionals and the general population, rather than the vulnerable groups of chronic disease patients. The result of this study may help to direct the efforts and plans of public health authorities and media of the country for better and timely control of COVID-19. Thus, this study aimed to determine the knowledge and practice toward COVID-19, the prevalence of depression and anxiety during the COVID-19 pandemic, and the associated factors of good knowledge and practice among patients with chronic disease at 3 hospitals in the Sidama region.

Methods and materials

Study area

The study was conducted in selected public hospitals in Sidama regional state. Sidama region is one of the regional states of Ethiopia with a population of more than 4 million, where more than 90% of the population lives in the rural part of the region. It has a total of 30 districts and 6 town administrations. It is located 272 km to the southeast of Addis Ababa and the region has a total area of 6,981.8 square kilometers. According to a 2018 estimate, the total population of the region was 4,294,730 of which 2,104,418 are females and 2,190,312 are males [12]. Currently, there are 16 public hospitals, 126 health centers, 531 health posts, 24 medium and 83 primary privates, and 7 NGO clinics [13].

Study design and population

A facility-based cross-sectional study was conducted from June 20 to July 30/2020. The source population of this study was all patients with chronic diseases (hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and chronic kidney disease) who attended the chronic disease follow-up clinic at three hospitals in the Sidama region. While the study population was all patients with chronic disease who attended the chronic disease follow-up clinics at three hospitals during the study period.

Inclusion and exclusion criteria

All chronic disease patients who were on follow-up at the selected hospitals during the study period were included. The study excluded chronic disease patients who were severely ill, had cognitive impairment, were younger than 18 years old, and health professionals.

Sample size determination

The minimum sample size required for the objectives of the study was calculated by using the single population proportion formula, using the following assumptions

n = minimum sample size

Z = Critical value for normal distribution at 95% confidence level which is 1.96 (Z value at α = 0.05, two-tailed)

P = Due to the lack of other studies in a similar setting, we used the anticipated population proportion of 50%.

d = margin of error to be tolerated (5%)

Sample size = 384

After considering a 10% non-response rate, the final sample size was 422

Sampling procedure

The Sidama regional state has a total of 16 hospitals (2 general hospitals, 13 primary hospitals, and 1 comprehensive specialized hospital). Based on patient flows, 3 hospitals were selected purposively, and a sampling frame was prepared for each hospital based on the number of chronic disease patients in the last month who attend the chronic disease follow-up clinics. Based on one month of data, there were around 1376, 1100, and 900 chronic disease patients who attend the chronic disease follow-up clinic at Hawassa university comprehensive specialized hospital, Yirgalem general hospital, and Leku primary hospital respectively. A proportional sample to the number of patients at each hospital was allocated, and then the systematic sampling technique (K = 8) was used to select each study participant from their respective group.

Study variables

The dependent variables were knowledge and practice toward the COVID-19 pandemic. The independent variables were socio-demographic variables such as sex, age, place of residence, educational status, occupation, marital status, monthly income etc…

Data collection procedure and tool

Data was collected using a structured interviewer-administered questionnaire. The questionnaire was adapted from the WHO website and other relevant COVID-19 literature [14, 15]. The questionnaire consisted of four parts (see S1 File). The first part included the socio-demographic characteristics of the study participants. The second part included 16 questions designed to assess the knowledge of COVID-19. The knowledge questions were answered with options Yes/No/I don’t know. In the third part, 15 questions with Yes/No answer options were used to assess practice.

Depression and anxiety were measured by the Hospital Anxiety and Depression Scale (HADS). This tool contains 14 items (seven for each) that are scored in Likert form from 0 to 3; giving a total of 21 points. The scale has been validated in different populations in Ethiopia [16]. Data were collected using 5 diploma nurses and supervised by three supervisors with bachelor’s degrees in public health.

Data analysis procedure

The collected data were entered into Epi data version 3.1 and exported to the statistical package for social science (SPSS) version 20 for analysis. First descriptive analysis was carried out for each of the variables (including for the outcome variable knowledge and practice). A correct answer (Yes) for the knowledge question was assigned 1 point, and No/I don’t know answer was assigned 0 points. The total knowledge score ranged from 0 to 16, Participants’ overall knowledge was categorized using Bloom’s cut-off point as Good if the score was between 80 and 100% (12.7–16 points), and Poor if the score was less than 79% (<12. 6 points) [15]. The correct answer for the practice question was assigned 1 point and an incorrect answer was assigned 0 point. The total practice score range from 0 to 15. The overall practice score was categorized using Bloom’s cut-off point, as Good if the score was between 80 and 100% (12–15 points) and Poor if the score was less than 79%(< 11.9 points) [15].

HADS tool classifies the status of anxiety and depression symptoms as normal (0–7), borderline (8–10), and 11–21 (abnormal) with a binary cut off point of greater than 8 (including borderline and abnormal) considered as have anxiety and depression [17].

Association between independent variables and dependent variables was assessed and its strength presents using odd ratio and 95% confidence interval. Binary logistic regression analysis was applied. All predictor variables that have an association in bivariable analysis with a p-value < 0.25 were entered into a multivariable logistic regression model. In multivariable logistic regression analysis, those variables with a p-value ≤ 0.05 were considered statistically significant.

Data quality control

The questionnaire was first prepared in English and then translated into Amharic version by a professional translator with a health background who was a native speaker of Amharic language and fluent in English. The backward translation from Amharic to English was done by an independent translator who was a native speaker of the source language and fluent in Amharic language. Consensus on the compatibility of forward and backward translation was assured before the actual data collection activities. Data collectors and supervisors were trained for two days by the principal investigator before the actual study commenced on the objectives of the study. As part of training, the data collection tools were pre-test in 5% of the total sample at Shashemene hospital (adjacent to the study area) before the actual data collection to check the questionnaire addressed the study variables, as well as to check the extent at which questions understood by the interviewee and to identify areas for modification and correction. The principal investigator and supervisors checked the completeness and consistency of the collected data and provided early feedback to the data collectors.

Each questioner was given a code before data entry to make data processing easier. In addition, the data entry format was prepared in Epi data software based on the pre-coded questionnaire. To reduce some errors during data entry, a check file was developed (to detect and refuse some data entry mistakes). Before conducting analysis in SPSS software, data cleaning was done to check for outliers, consistency, and to verify the skip pattern was followed. Furthermore, exploratory data analysis was performed to determine the levels of missing values and the presence of multi co-linearity.

Ethical consideration

Hawassa University’s institutional review board granted ethical clearance under reference number IRB/293/12. Written informed consent was obtained from the study participant before their participation. Study participant’s confidentiality and privacy were protected by excluding their names from the questionnaire and keeping their data safe in password locked computer throughout the whole process of research work. At the end of each interview, study participants received health education on COVID-19 signs and symptoms, transmission routes, and preventive measures.

Result

Socio-demographic characteristics

A total of 422 participants were included in the study, which makes the response rate 100%. The median age of the respondents was 44 years with IQR of (33, 55) years old. Out of the total study participants, 230(54.5%) of them were married. From study participants, 114(27%) of them could not read and write while 164(38.9%) had above secondary educational status. More than half (50.2%) of the participants were from urban areas. The average monthly income of study participants was 3451 (SD± 3003). About 114(27%) and 50(11.8%) were government and private employees respectively. More than one-third (33.9%) of the participants had a diagnosis of Diabetes mellitus, followed by Hypertension 88(20.9%) (.

Knowledge of participants toward COVID-19

Out of 422 study participants, more than half (56.2%, 95% CI: 50.7–60.9) of them had a good knowledge of COVID-19, while the remaining 185 (43.8%) had poor knowledge. Most (93.8%) of the study participants were aware that the main clinical symptoms of the novel COVID-19 are fever, dry cough, shortness of breath, and myalgia. More than half (53.6%) of the participants reported that a person with COVID-19 cannot infect others if he has no symptoms of COVID-19. Frequent proper handwashing with soap for 20 seconds and wearing masks when leaving the house were reported as the means of protection by 359 (85.1%) and 382 (90.5%) participants, respectively (.

Participants practice toward COVID-19 prevention approach

More than half of the participants (57.6%, 95% CI: 52.8–62.1) had poor practice toward COVID-19 prevention methods. Only 179 (42.4%, 95% CI: 37.9–47.2) of the study participants had a good practice. Around 63.7% of the study participants practice physical distancing by remaining 6 feet or 2 meters from others all the time. The majority (77.3%) of respondents limit physical contact such as handshaking. More than two-thirds of participants (69.7%) touch their eyes, nose, and mouth frequently with unwashed hands (.

Prevalence of depression and anxiety among patients with chronic health problems during the COVID-19 pandemic

More than one-third of the study participants 37% (95% CI 32.7, 41.5) were experiencing anxiety. While depression affected more than a quarter of the respondents, 26.8% (95% CI 22.5, 31.5) (.

Factors associated with good knowledge about COVID-19

During the initial bivariate analysis, age, marital status, educational status, place of residence, occupation and monthly income had a significant association with good knowledge at 0.25 P-value. But, after applying a multivariate logistic regression age, marital status, place of residence, and occupation remain in the final model associated with good knowledge at 0.05 P-value.

The odds of having good knowledge in the younger age group (18–39 years) were 2.36 times higher than in the older age group (>61 years). Participants in the study who were single had a 60% lower chance of having good knowledge than those who were married. The odds of having good knowledge in urban residents were 2.02 (1.15, 3.57) times higher than the counterpart (.

Factors associated with a good practice toward COVID-19 prevention approach

From the total variables entered into the multivariable regression, four variables namely marital status, educational status, place of residence, and knowledge about COVID-19 were found to be independently associated with good practice of COVID-19 prevention approaches among chronic disease patients at a P-value of <0.05.

The study participants those who were divorced and widowed were 78% and 69% (AOR = 0.22 (0.07, 0.63) & AOR = 0.31 (0.10, 0.92))) less likely to practice COVID-19 prevention approaches appropriately as compared with married, respectively. Study participants with secondary and above educational status were 2.2 times (AOR = 2.21 (1.01, 4.84) more likely to practice goodly the COVID -19 prevention methods. The odds of good practice among urban study participants were 2.3 times (AOR = 2.33 (1.30, 4.19) higher than among rural study participants. Participants who had a good understanding of COVID-19 were 4.8 (AOR = 4.87 (2.96, 8.00) times more likely to have good practices (.

Discussion

As COVID-19 is causing a significant number of morbidity and mortality globally, putting preventive measures in action is critical to avert its impact. Improving the knowledge and practice of high-risk groups (like chronic ill patients) toward COVID-19 preventive measure are crucial for the effective prevention and control of COVID-19. Furthermore, the pandemic had an impact on the mental health of the entire population, particularly on high-risk groups. This study assessed the knowledge and practice toward COVID-19 and the mental health impact of the pandemic (depression and anxiety) among chronic ill patients in three hospitals in the Sidama regional state.

Our finding indicates that there was a high prevalence of poor knowledge (43.8%) among chronically ill patients. This finding is higher than that of studies conducted in China and Kenya [18, 19]. This difference might be because China and Kenya surveys included urban study participants, whereas our study included nearly half (49.8%) of study respondents from rural areas. In addition, another reason might be due to the fact that 82.4% of study participants held an academic degree or associate’s degree or above in China.

According to this study, younger age groups were more likely to have a good knowledge than the elders. This finding is supported by the study conducted in Egypt [20] and Chicago [21], which reported that younger respondents showed good knowledge. This might be due to the physiological changes during aging. As age increases, the visual performance and hearing ability get decrease. As a result, it is difficult to read and understand various health-related issues, resulting in a lack of knowledge.

Urban residents were two times more likely to have good knowledge than rural residents. This finding is in line with the study conducted in Addis Zemen and China [15, 18]. This is because of better access to the information in urban areas, where there is better access to online Media to update themselves about COVID-19. The vast majority of rural people may lack access to the Internet and social media and rely solely on television and radio for information; which may limit their ability to learn about the disease. A study conducted in Iran showed that participants who got their information from social media, scientific articles, and journals had significant higher knowledge of the disease as compared to news media users who had significantly lower knowledge regarding the transfer routes and groups at higher risk regarding COVID-19 [22]. In addition, the majorities of rural Ethiopians are illiterate and live far from the healthcare facilities where they can get health-related information.

In this study, government employee and private employees were around 5 times and 2 times more likely to have good knowledge than housewives, respectively. This is in line with the study conducted in Jimma [23]. This is because they had strict instructions about COVID-19 infection control and preventive measures at offices compared to housewives. A chance to have a better social network at the workplace might help them in obtaining information about COVID-19.

In this study, the prevalence of good COVID-19 practice among chronically ill patients was very low (42.4%), which was in line with a finding in Ethiopia [24]. However, it was lower than the finding in Saudi Arabia (81%) [25] and Rwanda (90%) [26]. The possible justification for this disparity might be knowledge differences in the study population, attitudes toward disease, different data collection periods, and the policy of countries toward COVID-19 prevention measures at the time of data collection.

The majority (82.5%) of study participants attend social gathering events and religious activities; however, in China, and Chicago, only a small number of study participants visit any crowded place [18, 21]. This difference is due to the socio-cultural and religious differences in the study population. Measures taken by the government to prevent the transmission of COVID-19 may also be another possible difference. In response to the preventive measures being followed by the study participants, 73.3% claimed that they were using a face mask and 60% of participants said they were washing their hands with soaps and water frequently.

Study participants with secondary and above educational status were more likely to have a good practice toward COVID-19 prevention approaches than those with the educational status of unable to read and write. As with this finding, a study carried out in Iran and Adiss Zemen showed that a higher level of education was associated with a high practice of COVID-19 prevention [15, 22]. People with better educational status have a better chance of acquiring information regarding the COVID-19 prevention techniques. In addition, different studies showed that educated people have positive attitudes regarding how people should behave toward COVID-19 [19, 21, 22]. Having adequate information regarding COVID-19 prevention techniques with a positive attitude toward it leads to good practice.

The odds of good practice among divorced and widowed were 78% and 69% less likely as compared to the married one. The finding agreed with a study conducted in Pakistan [27]. This might be because married people practice COVID-19 prevention practice as they feared the spread of the disease to their partner.

The odds of good practice among urban study participants were 2.3 times higher than among rural study participants. This finding is consistent with the study done in Jimma and China [18, 23]. This might be as different studies showed that people from urban areas have a better knowledge of COVID-19 prevention, because health information that improves the knowledge and practice is becoming more accessible online, however it is not reachable to rural residents [28]. In addition, it might be due to the prevention actions set by governments being implemented well in urban areas as compared to rural.

Patients with good knowledge were more likely to practice well. This finding is in line with the study conducted in China, Adiss Zemen and Adiss Abeba [15, 18, 29]. This might be due to knowing the seriousness and infectiousness of the virus pushing them to practice the preventive measures.

The prevalence of depression (5.73%) and anxiety (32%) among patients living with a chronic medical condition in Ethiopia, before the emergence of COVID-19 [30] was found to be lower compared to the finding of the current study conducted amid the COVID-19 pandemic, which revealed a high prevalence of depression (26.8%) and anxiety (37%). The finding was lower as compared with the findings of Metu referral hospital, which reports 55.7% and 61.8% have depression and anxiety respectively [8]. This could be due to the time of data collection and the tool used to measure the variables.

Limitations of the study

The study has certain limitations; firstly respondents might give socially acceptable answers, for example, practice-related questions were collected through participants’ responses rather than through observation of what they do. In addition, the cross-sectional nature of the study did not allow us to show the cause-effect relationship. Moreover, since the study was conducted in a health facility there is a possibility of bias as the underprivileged population may not have been able to participate in the study.

Conclusion

Insufficient knowledge about COVID-19 still exists among chronic disease patients, which could pose a barrier to good prevention practices. Age (younger age group), marital status, urban residence, and occupation of government employees were significantly associated with good knowledge. Secondary and above educational status, urban residence, and good knowledge were significantly associated with good practice related to COVID-19 prevention practice. In addition, the extent of co-occurring depression and anxiety in this study was high.

The minister of health, regional health bureau, zonal and district health offices should devise appropriate interventions to fill knowledge and practice gaps among chronic ill patients. Parallel to this, special attention should be given to those with low educational attainment who are unable to read or write, as well as the rural community. In patients with chronic health conditions, strategies for early detection and treatment of depression and anxiety should be developed. In addition, other studies should be conducted to identify the predictors of anxiety and depression.

English version survey questionnaire.

(DOCX)

Click here for additional data file.

Raw SPSS data.

(SAV)

Click here for additional data file.

(DOCX)

Click here for additional data file.

14 Dec 2021

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Reviewer #1: This study assesses the knowledge and practice of chronic patients regarding COVID-19 and the frequency of anxiety and depression in these patients. COVID-19 is a current major public health problem and it presents a global challenge especially in developing countries like Ethiopia. The choice of patients with chronic diseases is good as these patients are more affected with severe form of COVID-19. The mental health impact of COVID-19 was addressed in few studies. However, future studies are needed to assess the association between COVID-19 and mental disorders, which could not be verified from this cross-sectional study. Knowledge about COVID-19 was assessed using Yes/No leading questions. Multiple choice questions were better to be used to decrease bias. Substantial language editing is needed for correction of grammatic and typing errors.

Major issues:

1. Please add more details about sampling method. How the participants were recruited from sample frame of last month? Do they pay regular visits to the hospital?

2. Justify the use of p-value of 0.25 as cut-off for significant result. It should be 0.05 as the level of significance used is 5%.

3. Please add limitations of the study.

4. Substantial language editing is needed for correction of grammatic and typing errors.

Minor issues:

1. The introduction section is lengthy, some sentences are repeated, please revise.

2. Page 11 line 96: Sentence between brackets is repeated.

3. Page 11 line 97: The authors would rather use “Assess” their knowledge instead of “know” their knowledge.

4. Page 12 lines 113&114: No studies? (Do you mean in your country? Please clarify)

5. Last paragraph: The introduction is supposed to be written before the study is conducted. The authors of the paper declared what the results would be (poor knowledge and practice) and suggested recommendations. This part should be moved to the conclusion.

6. Page 16: Please provide a reference for Bloom’s cut off point for knowledge and practice assessment.

7. Please add a reference for HADS. Clarify if borderline and abnormal scores are considered to have depression/anxiety.

8. Table 1: add a footnote with the meaning of ETB abbreviation.

9. Table 3: please mark the correct answers.

10. 1st paragraph second line: Please modify as now vaccines and lines of treatment have been developed.

11. Line 388: Is it a selected public hospital or 3 hospitals? Please correct.

12. Lines 391 to 396: please revise the explanation as more than half of the participants lived in urban areas.

13. Page 31 line 434: mention references of the “different studies” mentioned.

14. Line 440: Language is not clear, needs correction.

15. Lines 441 to 446: This part is repeated.

Reviewer #2: Knowledge, practice and impact of COVID-19 on mental well health of chronic disease patients at selected hospitals in Sidama regional states in Ethiopia were evaluated. This is an interesting paper with great potential that needs minor revisions. The paper also needs through editing because at times the language used is rather unclear.

Detailed Comments.

Abstract.

1. In the conclusion section, author reported prevalence of good knowledge and practice to be low yet in the result section author reported more than half of the participants to have good knowledge. I suggest to be consistent in reporting the results and conclusion.

Introduction:

1. This section is excessively long. The authors should shorten this section.

2. Statement on lines 71 – 72 needs to be cited.

3. First statement on paragraph 2 (lines 76-77) can be integrated in first paragraph.

4. Statement on lines 80 – 81 needs to be referenced.

5. Paragraph on lines 86 – 99 needs to be focused on people with chronic medical conditions but not the older adults since the study is on people with chronic medications.

Methods:

1. How did you determine that one had a chronic medical condition? Was it self-reported or tests were done. This needs to be elucidated.

2. Did the study have any exclusion criteria? If yes, this needs to be stated.

3. Kindly Elaborate more on the profession of the translators. What qualification do they need to ensure accurate?

4. Should all preventative measures be given the same weight in scoring?

5. Why choose dichotomous categories for knowledge and practice as opposed to multiple categories? If choosing a dichotomous approach, why use 80% as the cut-off? Please provide justification for your approach in both cases.

Results:

1. Correct the table numbers in the descriptions to align with their titles.

Discussion:

1. Vaccines and treatments: I think you should be clearer here - i.e. There are vaccines currently approved and enrolled. There are treatments that seem to help symptoms and reduce death rates, bit there is no cure.

2. The authors should describe in detail all the biases present in the study and these appear before the conclusions.

Reviewer #3: Abstract

1. Lines 29-31 need revision

2. The following terms should be written correctly: “facility-based” and “cross-sectional”

3. What was the essence of running logistic regression for initiation of preventive behaviour of COVID-19 when that is not the main outcome variable of interest in this study?

4. The study sought to assess knowledge, practice and impact of COVID-19 on mental health of chronic disease patients. However, the study failed to actually assess effect of these variables on mental health. Thus, the bivariate and multivariate logistic regression analysis should have been done on mental health and explanatory variables (socio-demographics, knowledge, practice, and impact of COVID-19).

5. The conclusion made is not consistent with the study purpose/objective. Authors should revise.

Introduction

6. Lines 76-77 is a repeat of Lines 69-70. Authors should delete. Also, provide intext citation to support line 80-82.

7. Line 113-114 is not consistent with the study title and objective stated in the abstract. Authors should revise. Authors should also clearly start the research question or objective in this section.

Methods

8. In line 139, authors should capitalize “Sidama”. Again, instead of “It has got a total of 19…” it should instead be “It has a total of 19…” Provide citation for the population stated in Lines 144-145. Also, as earlier stated, the terms in Line 148 should be “facility-based” and “cross-sectional”.

9. Lines 149-153 needs revision to improve the text. Line 166 should be in past tense.

10. Authors need to clarify what their dependent and independent variables are. Based on the topic, the dependent variable is mental health while knowledge and practice towards COVID-19 and socio-demographics are the independent variables. There is the need for the authors to harmonize their variables through the study topic and objectives to the study variables and subsequent inferential analysis. Lines 184-187, 189-192, and 195-196 should be included in the analysis section.

11. How was confidentiality, anonymity and privacy of the participants ensured in the study? How were these addressed? Change the subsection “Ethical statement” to “Ethical consideration”

Results

12. Lines 248-256 needs revision there are lots of grammatical errors. Also, when using phrases like “more than two thirds”, “more than one third”, authors should not combine both frequency and percentage. This should be rechecked and revised throughout the entire section.

13. Revise the table titles to concise form. They are too long.

Discussion

14. There are grammatical and typographical errors in Lines 389-396. For instance, countries names have not been capitalized.

15. Also, authors failed to proffer explanations/reasons for the study observations made. The discussion is thus not exhaustive.

Conclusion

16. The conclusion made is not consistent with the study purpose/objective. Authors should revise.

17. Also, recommendations should be specific and directed/targeted at agencies/organization.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Farrukh Ishaque Saah

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Submitted filename: Comments.docx

Click here for additional data file.

19 Jan 2022

Yilkal Simachew

Lecturer and Researcher

Hawassa University, Ethiopia

joemakalister123@gmail.com

Dr. Vanessa Carels

Editorial Department

Journal of PLOS ONE

em@editorialmanager.com January 19, 2022

Subject: Revision and resubmission of manuscript (PONE-D-21-17635)

Dear Dr. Vanessa

Thank you for giving us the opportunity to submit a revised draft of the manuscript “Knowledge, practice and impact of COVID-19 on mental health among patients with chronic health condition at selected hospitals of sidama regional state, Ethiopia”, for publication in the journal of PLOS ONE. We appreciate the time and effort that you and the reviewers dedicated to providing feedback on our manuscript and grateful for the insightful comments on and valuable improvements to our paper. We have incorporated most of the suggestions made by the reviewers. The changes are marked in the revised manuscript.

We have included the Reviewers and Editor Comments immediately after this letter and responded to them individually, indicating exactly how we addressed each concern and describing the changes we have made. Please note that reviewers’ comments are shown in bold type and our responses in plain type. Changes to the manuscript that have been made are marked in blue color in the revised version. The removal of text at certain locations is highlighted with red color in the revised manuscript.

We hope the revised manuscript will better suit the journal of PLOS ONE, but we are happy to consider further revisions and we thank you for your continued interest in our research.

Sincerely,

Yilkal Simachew

Lecturer and Researcher at Hawassa University, in Ethiopia

REPLY TO ACADEMIC EDITOR’S COMMENTS

Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

Response: we have now reformatted the manuscript (font size, font style, line spacing, figure caption, table caption, reference citation and file naming) according to the guidelines and style requirements of PLOSE ONE.

Comment 2: We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

Response: we apologize for the inconsistency; during resubmission we have included the source of fund, the grant number of award, name of author who received award and the role of funders.

Comment 3: In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available.

Response: During the resubmission, we have included the minimal data set in supporting information file, with file name of “S2_File.save”.

REPLY TO REVIEWERS’ COMMENTS

Comments from reviewer # 1, major issues

Comment 1: Please add more details about sampling method. How the participants were recruited from sample frame of last month? Do they pay regular visits to the hospital?

Response: We thank the Reviewer for the useful suggestion. According to the suggested we have revised the sampling method and explained in detail how the study participants were recruited from the sample frame. The sample frame prepared for each hospital based on the number of chronic disease patients in the last one month who attend the chronic disease follow-up clinics. Based on one month data, there was around 1376, 1100 and 900 chronic disease patients who attend the chronic disease follow-up clinic at Hawassa university comprehensive specialized hospital, Yirgalem general hospital and Leku primary hospital respectively. Proportional sample to the number of patients at each Hospital was allocated, and then the systematic sampling technique (K=8) was used to select each study participant from their respective group. We have included how the sample frame for each hospital was prepared and how the study participants were recruited from the sample frame (Revised manuscript, line #178-182).

Comment 2: Justify the use of p-value of 0.25 as cut-off for significant result. It should be 0.05 as the level of significance used is 5%.

Response: We would like to apologize for this inconvenience. We believe that this has to do with the way we write. Actually, we have used P-value of 0.05 as a cut off for significant value. However, before developing the final model (multivariable logistic regression), we have identified candidate variables by running bivariate analysis. To improve the power of the study and to avoid losing some important variables, we took all predicator variables that have association in bivariate analysis with P-value of <0.25 as candidate variables for the final model (multivariable logistic regression). We have rewritten this section to make the idea clear (Revised manuscript, line #221-225).

Comment 3: Please add limitations of the study.

Response: Thank you for pointing this out, accordingly we have incorporated your suggestion. The points included under limitation of the study are: since practice-related questions were collected by the participants’ response, not by observation of what they do, respondents might give socially acceptable answers. In addition the cross sectional nature of study did not allow to show the cause-effect relationship. Moreover, since the study was conducted in a health

facility there is a possibility of bias as the underprivileged population may not have been able to

participate in the study. Limitations of the study including the above points added before conclusion part (Revised manuscript, line #476-482).

Comment 4: Substantial language editing is needed for correction of grammatic and typing errors.

Response: We have gone through the entire manuscript carefully to correct the grammatical and typo errors with the help of language professionals. In addition, we used “grammarly” online software to edit the spelling, grammar and language usage.

Comments from reviewer # 1, minor issues

Comment 1: The introduction section is lengthy, some sentences are repeated, please revise.

Response: Based on the comment we have revised the introduction section. We have merged repeated sentences (Revised manuscript, line #71-72), and also rewritten some paragraphs to make it concise and clear enough to the readers (Revised manuscript, line #94-98, lime#119-126).

Comment 2: Page 11 line 96: Sentence between brackets is repeated.

Response: we agree with the reviewer, we mentioned who are the vulnerable groups repeatedly. So, we have removed the repeated sentence in the bracket (Revised manuscript, line #102).

Comment 3: Page 11 line 97: The authors would rather use “Assess” their knowledge instead of “know” their knowledge.

Response: we appreciate the reviewer suggestion for more accurate wording. We have substituted “know” to “assess” (Revised manuscript, line #103).

Comment 4: Page 12 lines 113&114: No studies? (Do you mean in your country? Please clarify)

Response: Thank you for pointing out this. What we tried to show the readers was, controlling the spread of COVID-19 among vulnerable groups is one of the strategies to control the pandemic. To facilitate the prevention and control of COVID-19 among high risk groups in Ethiopia, there is an urgent need to assess their knowledge and practice of COVID-19 prevention at this critical time. Despite this fact most studies in Ethiopia targeted health professionals and the general population, but not the vulnerable groups with chronic disease patients. As suggested by reviewer to clarify, we have rewritten this section including the above points (Revised manuscript, line #119-126).

Comment 5: Last paragraph: The introduction is supposed to be written before the study is conducted. The authors of the paper declared what the results would be (poor knowledge and practice) and suggested recommendations. This part should be moved to the conclusion.

Response: We thank the Reviewer for the critical review and the useful suggestions. In the revised version of the manuscript, we have moved this section to conclusion part, and instead we have putted significant of the study and the aim of the study at finally paragraph of introduction part (Revised manuscript, line #121-126).

Comment 6: Page 16: Please provide a reference for Bloom’s cut off point for knowledge and practice assessment.

Response: Thank you for the comment. We have added a reference (Revised manuscript, line #209 and 213). However since reviewer #3 commented us to move this part (which state how we analyzed and categorized knowledge and practice) to data analysis, it is moved to analysis section.

Comment 7: Please add a reference for HADS. Clarify if borderline and abnormal scores are considered to have depression/anxiety.

Response: Thank you for the comment. We added citation for HADS (Revised manuscript, line #216). In addition, we have clarified the classification of HADS; have depression and anxiety means when the score is above 8 including both borderline and abnormal score, and normal when the score is between 0-7 (Revised manuscript, line #215-216). Based on the reviewer #3 comment we have moved this to data analysis section.

Comment 8: Table 1: add a footnote with the meaning of ETB abbreviation.

Response: As correctly suggested by the reviewers we have added a footnote with the meaning of ETB under TABLE 1 (Revised manuscript, line #291).

Comment 9: Table 3: please mark the correct answers.

Response: we would like to thank the reviewer for the detail comment. As suggested we have now marked the correct answers by making bold for both knowledge and practice questions at Table 2 and Table 3 (Revised manuscript, line #307 and line# 333).

Comment 10: 1st paragraph second line: Please modify as now vaccines and lines of treatment have been developed.

Response: Thank you for pointing out this important information. Since vaccines have been developed after we submitted this research work, it needs revision as reviewer suggested. We modify accordingly (Revised manuscript, line #388-390).

Comment 11: Line 388: Is it a selected public hospital or 3 hospitals? Please correct.

Response: As suggested we corrected, instead of saying “a selected public hospital” we corrected as “three hospitals” (Revised manuscript, line #395).

Comment 12: Lines 391 to 396: please revise the explanation as more than half of the participants lived in urban areas.

Response: Thank you for the comment. We have revise this section, including the following points: as compared to China and Kenya the prevalence of poor knowledge in our study was high, This difference might be due to the fact that China and Kenya survey included urban study participants, but our study included around half of (49.8%) of study respondents from rural area. In addition, another reason might be due to the fact that 82.4% of study participants held an academic degree and associate’s degree and above in China. However, in our study only 38.8% of the study participants had above secondary educational status. We have revised including the above points at (Revised manuscript, line #398-401).

Comment 13: Page 31 line 434: mention references of the “different studies” mentioned.

Response: Thank you for the comment. We now have mentioned the references (Revised manuscript, line #449).

Comment 14: Line 440: Language is not clear, needs correction.

Response: Thank you for the comment. We have revised the language and hopefully it is clearer now (Revised manuscript, line #453-455).

Comment 15: Lines 441 to 446: This part is repeated.

Response: Thank you for your comment. When we conducted a multivariate logistic regression for knowledge and practice, an independent variable name “place of residence” show statistical significant at P-value of less than 0.05 with both knowledge and practice. As the reviewer commented the discussion for this variable seems similar. We have now rewritten this paragraph (Revised manuscript, line #460-462).

Comments from reviewer # 2

Abstract.

Comment 1: In the conclusion section, author reported prevalence of good knowledge and practice to be low yet in the result section author reported more than half of the participants to have good knowledge. I suggest to be consistent in reporting the results and conclusion

Response: Thank you for the comment. As suggested by reviewer, we have revised this section. The result and conclusion are now made consistent (Revised manuscript, line #53-56).

Introduction:

Comment 1: This section is excessively long. The authors should shorten this section.

Response: we thank the reviewer for the useful suggestion. Based on the suggestion, we have revised the introduction section. We have merged repeated ideas (Revised manuscript, line #71-72), and also rewritten some paragraphs to make it concise and clear enough to the readers (Revised manuscript, line #94-98, line# 119-126).

Comment 2: Statement on lines 71 – 72 needs to be cited.

Response: Thank you for pointing this out. We have provided citation for the line that state the causative agent of the COVID-19, where it has been identified first and the symptoms of the disease (Revised manuscript, line #74).

Comment 3: First statement on paragraph 2 (lines 76-77) can be integrated in first paragraph.

Response: Thank you for the suggestion. As suggested, we have integrated with the first paragraph (Revised manuscript, line #71-72).

Comment 4: Statement on lines 80 – 81 needs to be referenced.

Response: Thank you for the comment. We added citation (which is WHO COVID-19 situational dashboard) for the statement about the number of confirmed COVID-19 cases and death globally (Revised manuscript, line #83).

Comment 5: Paragraph on lines 86 – 99 needs to be focused on people with chronic medical conditions but not the older adults since the study is on people with chronic medications

Response: We would like to thank the reviewer for the insightful comment. As commented we have revised the paragraph by focusing only on people with chronic medical illness. In the revised paragraph we try to show the readers why this study wants to focus on patients with chronic medical illness (Revised manuscript, line #94-98).

Methods:

comment 1: How did you determine that one had a chronic medical condition? Was it self-reported or tests were done. This needs to be elucidated.

Response: Thank you for raising an important point here. Actually our study population was those with chronic disease who attended the chronic disease follow-up clinics at 3 hopsitals of Sidama region during the study period. We included patients who already diagnosed with the chronic medical condition and visit selected hospital for follow-up. As correctly suggested by the reviewer, we have elucidated this point by rewrite the source population and study population (Revised manuscript, line #147-153).

Comment 2: Did the study have any exclusion criteria? If yes, this needs to be stated.

Response: Yes, it has. We have included eligibility criteria (both inclusion and exclusion criteria) that we have used during the time of recruiting the study participants (Revised manuscript, line #157-160).

Comment 3: Kindly Elaborate more on the profession of the translators. What qualification do they need to ensure accurate?

Response: Thank you for your suggestion. As suggested by the reviewer, we have elaborated who were participated in the translation of the questioner/tool. To maintain the cross-cultural adaptation of the tool, we were used the forward and backward translation technique. First the forward translation (from English to Amharic version) was done by professional translator with health background who was native speaker of Amharic language and fluent in English. The backward translation (from Amharic to English version) was done by independent translator who was native speaker of source language and fluent in Amharic language. As correctly suggested by reviewer we have elaborated the profession of translators and the translation process by including the above points (Revised manuscript, line #227-230).

Comment 4: Should all preventative measures be given the same weight in scoring?

Response: Thank you; you have raised an important point here. However, before we started the analysis, the research teams also have raised the same question: is it right to give the same weight of scoring for all preventive measures? We have consulted scholars and reviewed different literatures and based on our assessment different literatures give the same weight of scoring for all preventive measures (In addition to the previously published surveys of other pandemics (Iliyasu G, Ogoina D, Otu AA, Dayyab FM, Ebenso B, Otokpa D, et al. A multi-site knowledge attitude and practice survey of Ebola virus disease in Nigeria. PLoS ONE. (2015) 10:e0135955. doi: 10.1371/journal.pone.0135955) different studies on COVID-19 gives same weight in scoring of preventive measures. In addition, scholars suggested that each preventive measure have equal capacity of preventing the COVID-19 infection. Based on the output of comprehensive literature review and scholars suggestion, we have given the same weight of scoring for all preventive measures.

Comment 5: Why choose dichotomous categories for knowledge and practice as opposed to multiple categories? If choosing a dichotomous approach, why use 80% as the cut-off? Please provide justification for your approach in both cases.

Response: We choose to use dichotomous categories because of the tool we have used in the study and the research question of the study. In addition we have used different published literatures as a source for categorizing our study dependent variables including (Abate H, Mekonnen CK. Knowledge, attitude, and precautionary measures towards covid-19 among medical visitors at the university of gondar comprehensive specialized hospital northwest Ethiopia. Infection and Drug Resistance. 2020;13:4355), (Feleke BT, Wale MZ, Yirsaw MT. Knowledge, attitude and preventive practice towards COVID-19 and associated factors among outpatient service visitors at Debre Markos compressive specialized hospital, north-west Ethiopia, 2020. Plos one. 2021 Jul 15;16(7):e0251708). We use 80% as the cut-off, because the original Bloom’s cut off points (80-100%, 60-79% and < 59%) were adapted and modified from the KAP study conducted on COVID-19 among Gondar, Debre Markos and Adiss Zemen.

Results:

Comment 1: Correct the table numbers in the descriptions to align with their titles.

Response: As suggested we corrected the table numbers in the description (Revised manuscript, line #317, line #350, line #372).

Discussion:

Comment 1: Vaccines and treatments: I think you should be clearer here - i.e. There are vaccines currently approved and enrolled. There are treatments that seem to help symptoms and reduce death rates, bit there is no cure.

Response: Thank you for the comment. During the time of our manuscript submission, vaccine was not developed. But now as correctly commented by the reviewer, different countries have been developed COVID-19 vaccine to fight against the global pandemic. Therefore, we have updated this section (Revised manuscript, line #388-390).

Comment 2: The authors should describe in detail all the biases present in the study and these appear before the conclusions.

Response: we appreciate the reviewer suggestion. Accordingly, before the conclusion we have described the biases in the study under limitation of the study subsection including the following points: since practice-related questions were collected by the participants’ response, not by observation of what they do, respondents might give socially acceptable answers. In addition the cross sectional nature of study did not allow to show the cause-effect relationship. Moreover, since the study was conducted in a health facility there is a possibility of bias as the underprivileged population may not have been able to participate in the study. (Revised manuscript, line #476-482).

Comments from reviewer # 3

Abstract

Comment 1: Lines 29-31 need revision

Response: Thank you for the comment. The sentence has been revised (Revised manuscript, line #29-30).

Comment 2: The following terms should be written correctly: “facility-based” and “cross-sectional”

Response: We thank the reviewer for the suggestion. The term has been corrected throughout the document (Revised manuscript, line #35, line #146).

Comment 3: What was the essence of running logistic regression for initiation of preventive behaviour of COVID-19 when that is not the main outcome variable of interest in this study?

Response: We appreciate the comment of reviewer. However, as we mentioned the general objective of the study was to assess knowledge, practice and impact of COVID-19 on mental health among chronic disease patients. The specific objective was to measure the level of COVID-19 related knowledge and to identify the factors that affect their knowledge. The second specific objective was to measure the COVID-19 prevention practice among patients with chronic medical condition and to identify the factors that affect their COVID-19 prevention practice. The other is to assess the mental health status of patients with chronic medical condition at the time of pandemic (specifically to assess anxiety and depression). We have conducted logistic regression for prevention practice of COVID-19, because one of the specific objectives of the study was to identify the factors that affect the prevention practice of COVID-19 among chronic disease patients. We agree with the reviewer, we didn’t explain the objective of the study clearly and specifically. To make it clear we have mentioned the aim of the study specifically at the end on introduction section (Revised manuscript, line #123-126).

Comment 4: The study sought to assess knowledge, practice and impact of COVID-19 on mental health of chronic disease patients. However, the study failed to actually assess effect of these variables on mental health. Thus, the bivariate and multivariate logistic regression analysis should have been done on mental health and explanatory variables (socio-demographics, knowledge, practice, and impact of COVID-19).

Response: We would like to apologize for this inconvenience. We believe that this has to do with the way we write the study objective. As we have mentioned on our response for comment 3, we have now re-written the objective of study clearly and specifically (Revised manuscript, line #123-126). Our study objective was to assess the level of knowledge, prevention practice of COVID-19 and the factors that affect it. In addition, our study assesses the mental health status of patients with chronic medical condition during the time of COVID-19 pandemic (specifically measure anxiety and depression level). So, we used simple descriptive statistics to assess mental health, but we have used bivariate and multivariate logistic regression for knowledge and practice.

Comment 5: The conclusion made is not consistent with the study purpose/objective. Authors should revise.

Response: We agree with the reviewer. We now have revised and included the impact of COVID-19 pandemic on mental health as well, which is the level of anxiety and depression during this pandemic among patients with chronic medical illness (Revised manuscript, line #55-56).

Comment 6: Lines 76-77 is a repeat of Lines 69-70. Authors should delete. Also, provide intext citation to support line 80-82.

Response: Thank you for the comment. As suggested we have deleted (Revised manuscript, line #78-79). In addition we have provided intext citation to support the line that state the number of confirmed COVID-19 cases and death globally and at Africa region (Revised manuscript, line #82).

Comment 7: Line 113-114 is not consistent with the study title and objective stated in the abstract. Authors should revise. Authors should also clearly start the research question or objective in this section.

Response: Thank you for pointing this out. As correctly suggested by the reviewer, we have revised this section including a clear statement of research objective (Revised manuscript, line #119-126).

Methods

Comment 8: In line 139, authors should capitalize “Sidama”. Again, instead of “It has got a total of 19…” it should instead be “It has a total of 19…” Provide citation for the population stated in Lines 144-145. Also, as earlier stated, the terms in Line 148 should be “facility-based” and “cross-sectional”.

Response: Thank you for the comment. Based on the comment revision have made throughout the manuscript (capitalize Sidama) and fixed the typo error (Revised manuscript, line #137 and line#139). In addition we have provided citation for the estimated population of Sidama region by 2018 (Aynalem Adugna_SNNPR_January_2021http://www.ethiodemographyandhealth.org/) (Revised manuscript, line #142). The term also corrected as commented early (Revised manuscript, line #146).

Comment 9: Lines 149-153 needs revision to improve the text. Line 166 should be in past tense.

Response: we agree with the reviewer. We have revised the text and hope that it is now clearer (Revised manuscript, line #147-154). In addition, we have rewritten line 166, the new sentence read as follow “After considering a 10% non-response rate, the final sample size was 422” (Revised manuscript, line #174).

Comment 10: Authors need to clarify what their dependent and independent variables are. Based on the topic, the dependent variable is mental health while knowledge and practice towards COVID-19 and socio-demographics are the independent variables. There is the need for the authors to harmonize their variables through the study topic and objectives to the study variables and subsequent inferential analysis. Lines 184-187, 189-192, and 195-196 should be included in the analysis section.

Response: we apologize for the lack of clarity in our first version of the manuscript, which have given rise to the confusion. To ensure clarity of our objective and to indicate the dependent variable of the study we have revised the aim of the study at the end of introduction section (revised manuscript, line# 123-126).

Comment 11: How was confidentiality, anonymity and privacy of the participants ensured in the study? How were these addressed? Change the subsection “Ethical statement” to “Ethical consideration”

Response: we thank the reviewer for pointing this out. Accordingly, we have included a sentence which describes how the confidentiality, anonymity and privacy of study participants were maintained. We added the following sentence to (revised manuscript, line# 251-253) in the Ethical consideration: “study participants confidentiality and privacy were maintained by excluding their name from the questionnaire and keeping their data safe in password locked computer throughout the whole process of research work”. In addition, as suggested we have changed [Ethical statement] to [Ethical consideration] (revised manuscript, line# 248).

Results

Comment 12: Lines 248-256 needs revision there are lots of grammatical errors. Also, when using phrases like “more than two thirds”, “more than one third”, authors should not combine both frequency and percentage. This should be rechecked and revised throughout the entire section.

Response: Based on the reviewer comment, we have revised and rewritten the socio-demographic part under result section (revised manuscript, line# 269-276). In addition, as suggested we have revised throughout the result section and used only percentage when we use descriptive phrases (revised manuscript, line# 296, 298, 299, 312, 315, 316).

Comment 13: Revise the table titles to concise form. They are too long

Response: Thank you for the suggestion. We have revised the table titles and hope that it is now concise. We have revised table 2 title from [Knowledge on symptoms, transmission, prevention and practice towards COVID 19 among Chronic Disease Patients, at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N=422)] to [Knowledge about COVID-19 among chronic disease patients at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N=422)] (revised manuscript, line#306-307).

We have revised table 3 title from [Frequency of Response by Chronic Disease Patients for Practice Questions, at selected public hospital of Sidama regional state, Ethiopia, 2020(N=422)] to [Preventive practice toward COVID-19 among chronic disease patients at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N=422)] (revised manuscript, line# 332-333).

Discussion

Comment 14: There are grammatical and typographical errors in Lines 389-396. For instance, countries names have not been capitalized.

Response: We like to thank the reviewer for detail comment to improve our research work. According to the comment we have revised and rewritten the paragraph with the help of professional language experts. The revised paragraph can be found at (revised manuscript, line# 397-401).

Comment 15: Also, authors failed to proffer explanations/reasons for the study observations made. The discussion is thus not exhaustive.

Response: Thank you again for the insightful comment on our research work. We have revised the discussion part with a brief explanation of the study findings by relate the findings to similar studies and discussed the implications (revised manuscript, line#398-401, 409-412, 453-455, 460-462).

Conclusion

Comment 16: The conclusion made is not consistent with the study purpose/objective. Authors should revise.

Response: Thank you for this excellent observation. We believed the way we wrote the study objective at first version of the manuscript was unintentionally misleading. Since we have rewritten the objective clearly and specifically at the revised version (revised manuscript, line#123-126), we hope the conclusion made is consistent with study objective.

Comment 17: Also, recommendations should be specific and directed/targeted at agencies/organization.

Response: Thank you for the suggestion. Accordingly we have revised the recommendation. We hope the recommendation is specific and targeted to the responsible bodies (revised manuscript, line#491-497).

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

4 Apr 2022

14 May 2022

Yilkal Simachew

Lecturer and Researcher

Hawassa University, Ethiopia

joemakalister123@gmail.com

Dr. Chong Chen

Editorial Department

Journal of PLOS ONE

em@editorialmanager.com May 14, 2022

Subject: Revision and resubmission of manuscript (PONE-D-21-17635R1)

Dear Dr. Chong

Thank you for giving us the opportunity to revise and resubmit the manuscript “Knowledge, practice and impact of COVID-19 on mental health among patients with chronic health conditions at selected hospitals of Sidama regional state, Ethiopia”, for publication in the journal of PLOS ONE. We wish to express our appreciation to the editor and the anonymous reviewers for your in-depth comments, suggestion, and corrections, which have greatly improved the manuscript. We have carefully considered all suggestions and concerns and tried our best to address every one of them. The changes are marked in the revised manuscript.

We have included the Reviewers and Editor Comments immediately after this letter and responded to them individually, indicating exactly how we addressed each concern and describing the changes we have made. Please note that reviewers’ comments are shown in bold type and our responses in plain type. Changes to the manuscript that have been made are marked in blue color in the revised version. The removal of text at certain locations is highlighted with red color in the revised manuscript.

We thank you for your continued interest in our research.

Sincerely,

Yilkal Simachew

Lecturer and Researcher at Hawassa University, in Ethiopia

REPLY TO ACADEMIC EDITOR’S COMMENTS

Comment 1: Thank you for submitting your revised manuscript to PLOS ONE. The three reviewers have accepted all your responses and revisions. The manuscript, however, will benefit from English editing by either a native speaker, someone proficient in English, or a professional editing service.

Response: Thank you for considering our revised paper for further revision, we would like to thank all reviewers for their time and valuable comments to improve our paper. We thank you for advising us to make edition to the manuscript's English writing. A native speaker edited the manuscript’s language. Based on the report of edition, we have made changes throughout the manuscript. The changes that have made found in revised manuscript with track changes.

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Response: We have uploaded a marked-up copy named “Revised Manuscript with Track Changes”.

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Response: We have uploaded revised paper named “Manuscript”.

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Response: Our study does not have any laboratory protocol to deposit.

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Response: We've updated the reference list to make it complete and accurate. We updated the references to conform to the International Committee of Medical Journal Editors' reference format (ICMJE). The following is a list of updated references to ensure that it is complete and accurate, as required by the journal.

Reference number 1: According to ICMJE citation style, it is an online paper with a DOI. As a result, we have included the entire DOI next to the volume (issue) and page numbers in the revised manuscript (Revised manuscript, line #500-502).

Reference number 2: The responsible body was not mentioned in the previous format; this has been corrected in the revised version. According to the ICMJE, because the journal article is available in two languages (English and Chinese), the journal title should be presented in its original language (Chinese). We have made the necessary changes and added the DOI and PMID (Revised manuscript, line #505-509).

Reference number 3: The source is a website, but the accessed date is missing in the previous format. We have made the necessary changes (Revised manuscript, line #511-513).

Reference number 4: The source is a website, but the accessed date is missing in the previous format. We have made the necessary changes (Revised manuscript, line #516-519).

Reference number 5: The order of the authors' names was incorrect in the previous format. It also lacks the journal's name. The authors' names have been rearranged, and the journal title has been abbreviated in accordance with the NLM catalogue of NCBI journals (Revised manuscript, line #522-525).

Reference number 6: The accessed date is missing in the previous format. We have now mentioned the accessed date of the website (Revised manuscript, line #531-534).

Reference number 7: According to the ICMJE citation style, only the first word and proper nouns are capitalized in the title of the article. We have made the necessary changes. Furthermore, the journal title has been abbreviated in accordance with the NLM catalogue of NCBI journals. To make the citation complete, we've added DOI and PMID after the page number (Revised manuscript, line #538-542).

Reference number 8: In the previous format, authors are listed by their first name rather than their surname. We have now revised the author's name to include the surname first, followed by the first initial. Furthermore, the previous format lacked the journal title, which we have corrected (Revised manuscript, line #545-548).

Reference number 9: In the previous format, the journal title was written in its full extent (International Journal of Environmental Research and Public Health). We have now revised it and included the journal title in its abbreviated form as per the NLM catalogue of NCBI journals (Int J Environ Res Public Health). In addition, the DOI and PMID have been updated (Revised manuscript, line #552-555).

Reference number 11: The accessed date is missing in the previous format. We have now mentioned the website's access date (Revised manuscript, line #566-569).

Reference number 12: The author's name was not written correctly in the previous format. Furthermore, the web address was incomplete. We have now corrected the author's name and written the complete web address (Revised manuscript, line #571-572).

Reference number 14: The accessed date is missing in the previous format. We have now mentioned the website's access date (Revised manuscript, line #576-578).

Reference number 15: The arrangement of the author's name was incorrect in the previous format. We have now rearranged the author's name. Furthermore, the DOI and PMID are inserted next to the page number (Revised manuscript, line #581-584).

Page number 16: We have included the article's DOI and PMID (Revised manuscript, line #587-590).

Reference number 17: We listed all ten authors in the previous version. However, the ICMJE citation style limits the number of authors to six, followed by "et al." We made the necessary changes and added the DOI and PMID of article (Revised manuscript, line #594-597).

Reference number 18: We limited the number of authors to six and used et al (Revised manuscript, line #601-605).

Reference number 19: The previous format did not indicate that this reference was preprint. We have now added [Preprint] next to the article title. In addition, we mentioned the citation date (Revised manuscript, line #608-612).

Reference number 20: We limited the number of authors to six and used et al. In addition, we have included the article's DOI and PMID (Revised manuscript, line #616-620).

Reference number 21: We limited the number of authors to six and used et al. In addition, we have included the article's DOI and PMID (Revised manuscript, line #624-628).

Reference number 22: The previous format did not indicate that this reference was preprint. We have now added [Preprint] next to the article title (Revised manuscript, line #631-635).

Reference number 23: We have included the article's DOI and PMID (Revised manuscript, line #640-643).

Reference number 24: The list of authors' names has been updated. DOI and PMID have also been added (Revised manuscript, line #646-649).

Reference number 25: The journal title was misspelt in the previous format (Front Public Heal). We have made the necessary changes (Front Public Health) (Revised manuscript, line #652-656).

Reference number 26: The list of authors' names has been updated. DOI and PMID have also been added (Revised manuscript, line #659-662).

Reference number 27: We have included the article's DOI and PMID (Revised manuscript, line #665-668).

Reference number 28: The list of authors' names has been updated. The journal title was misspelt in the previous format. We have made the necessary changes. In addition, a DOI has been added (Revised manuscript, line #671-674).

Reference number 29: We have included the article's DOI and PMID (Revised manuscript, line #678-681).

Reference number 30: We have included the article's DOI and PMID (Revised manuscript, line #684-687).

Response to Reviewers' comments:

Reviewer #2

Comment 1: Generally, the authors appropriated response to my comments and suggestions. However, some change is needed before publication: I believe that your manuscript could benefit by English language professional service.

Response: Thanks for your kind comments. We appreciate your suggestion to revise the manuscript's English writing; we have addressed all concerns in this revision. The language of the manuscript was edited by a native speaker. We made changes throughout the manuscript based on the edition report. The changes found in the revised manuscript with track changes.

Reviewer #3

Comment 1: Well done. All the issues raised have been sufficiently addressed. I believe the manuscript has improved greatly now.

Response: Thank you very much.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

17 May 2022

Knowledge, practice, and impact of COVID-19 on mental health among patients with chronic health conditions at selected hospitals of Sidama regional state, Ethiopia

PONE-D-21-17635R2

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20 May 2022

PONE-D-21-17635R2

Knowledge, practice, and impact of COVID-19 on mental health among patients with chronic health conditions at selected hospitals of Sidama regional state, Ethiopia

Dear Dr. hunegnaw:

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Table 1

Socio-demographic characteristics of chronic disease patients, at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N = 422).

Variables	Frequency (%), N = 422
Sex
Male	230 (54.5)
Female	192 (45.5)
Age (years)
18–39	162 (38.4)
40–61	194 (46.0)
>61	66 (15.6)
Marital status
Married	289 (68.5)
Single	65 (15.4)
Divorced	26 (6.2)
Widowed	42 (10)
Residence
Urban	212 (50.2)
Rural	210 (49.8)
Monthly income (ETB) b
<1500	141 (33.4)
1500–3000	106 (25.1)
>3000	175 (41.5)
Occupation
Merchant	69 (16.4)
Government employee	114 (27)
Private employee	50 (11.8)
Farmer	94 (22.3)
Housewife	71 (16.8)
Others	24 (5.7)
Type of chronic diseases
Diabetes mellitus	143 (33.9)
Hypertension	88 (20.9)
Heart disease	84 (19.9)
Chronic lung disease	99 (23.5)
Other*	8 (1.9)

*HIV, Gout

bETB, Ethiopian Birr.

Table 2

Knowledge about COVID-19 among chronic disease patients at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N = 422)].

S. No	Knowledge questions	Yes (%)	No (%)	I don’t know (%)
1	The main clinical symptoms of COVID-19 are fever, dry cough, shortness of breath, and myalgia	396 (93.8)	10 (2.4)	16 (3.8)
2	Unlike the common cold, stuffy nose, runny nose, and sneezing are less common in persons infected with the COVID-19 virus	243 (57.6)	134 (31.8)	45 (10.7)
3	COVID-19 symptoms appear within 2–14 days	254 (60.2)	35 (8.3)	133 (31.5)
4	Currently, there is no effective treatment or vaccine for COVID-2019, but early symptomatic and supportive treatment can help most patients to recover from the infection	347 (82.2)	31 (7.3)	44 (10.4)
5	Not all persons with COVID-19 will develop severe cases. Those who are elderly, have chronic illnesses, and with suppressed immunity are more likely to be severe cases	367 (87.0)	21 (5.0)	34 (8.1)
6	Touching or shaking hands of an infected person would result in the infection by the COVID-19 virus	396 (93.8)	14 (3.3)	12 (2.8)
7	Touching an object or surface with the virus on it, then touching your mouth, nose, or eyes with the unwashed hand would result in the infection by the COVID-19 virus	379 (89.8)	33 (7.8)	10 (2.4)
8	The COVID-19 virus spreads via respiratory droplets of infected individuals through the air during sneezing or coughing of infected patients	381 (90.3)	18 (4.3)	23 (5.5)
9	Persons with COVID-19 cannot infect the virus to others if he has no any symptom of COVID-19	226 (53.6)	103 (24.4)	93 (22.0)
10	Wearing masks when moving out of home is important to prevent the infection with COVID-19 virus	382 (90.5)	28 (6.6)	12 (2.8)
11	Children and young adults do not need to take measures to prevent the infection by the COVID-19 virus	243 (57.6)	147 (34.8)	32 (7.6)
12	To prevent the COVID-19 infection, individuals should avoid going to crowded places such as public transportations, religious places, Hospitals and Workplaces	377 (89.3)	34 (8.1)	11 (2.6)
13	Washing hands frequently with soap and water for at least 20 seconds or use an alcohol based hand sanitizer (60%) is important to prevent infection with COVD-19	359 (85.1)	42 (10.0)	21 (5.0)
14	Traveling to an infectious area or having contact with someone traveled to an area where the infection present is a risk for developing an infection	378 (89.6)	34 (8.1)	10 (2.4)
15	Isolation and treatment of people who are infected with the COVID-19 virus are effective ways to reduce the spread of the virus	389 (92.2)	20 (4.7)	13 (3.1)
16	People who have contact with someone infected with the COVID-19 virus should be immediately isolated in a proper place	376 (89.1)	25 (5.9)	21 (5.0)

Table 3

Preventive practice toward COVID-19 among chronic disease patients at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N = 422).

S. No	Practice questions	Yes (%)	No (%)
1	Do you participate in meetings, religious activities, events, and other social gatherings or any crowded place in areas with ongoing community transmission?	348 (82.5)	74 (17.5)
2	In recent days, have you worn a mask when leaving home?	311 (73.7)	111 (26.3)
3	If yes, do you touch the front of the mask when taking it off?	305 (72.3)	117 (27.7)
4	Do you reuse a mask?	350 (82.9)	72 (17.1)
5	Do you wash your hands with soap and water frequently for at least 20 seconds or use sanitizer/60% alcohol	253 (60.0)	169 (40.0)
6	Do you touch your eyes, nose, and mouth frequently with unwashed hands?	294 (69.7)	128 (30.3)
7	Do you clean and disinfect frequently touched objects and surfaces	260 (61.6)	162 (38.4)
8	Do you practice “physical distancing” by remaining 6 feet or 2 meters away from others at all times?	269 (63.7)	153 (36.3)
9	Do you use other workers’ phones, desks, offices, or other work tools and equipment?	296 (70.1)	126 (29.9)
10	Do you limit contact (such as handshakes)	326 (77.3)	96 (22.7)
11	Do you eat or drink in bars and restaurants?	229 (54.3)	193 (45.7)
12	Do you cover your nose and mouth during coughing or sneezing with the elbow or a tissue, then throw the tissue in the trash	354 (83.9)	68 (16.1)
13	Do you prefer to stay at home, in a room with the window open during the transmission period	357 (84.6)	65 (15.4)
14	Do you stay home when you were sick due to common cold-like infection during the transmission period	268 (63.5)	154 (36.5)
15	Do you listen and follow the direction of your state and local authorities?	361 (85.5)	61 (14.5)

Table 4

Factors associated with good knowledge of COVID-19 among chronic disease patients, at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N = 422).

Variables	Good knowledge		COR (95% CI)	AOR (95% CI)
	Yes	No
Age
18–39	101	61	2.24 (1.25, 4.02)*	2.36 (1.12, 4.96)
40–61	108	86	1.70 (0.96, 2.99)	1.19 (0.60, 2.37)
>61	28	38	1	1
Sex
Male	134	96	1.20 (0.82, 1.77)
Female	103	89	1
Marital status
Married	174	115	1	1
Single	39	26	0.99 (0.57, 1.71)*	0.40 (0.19, 0.81)
Divorced	17	9	1.24 (0.53, 2.89)*	0.85 (0.32, 2.25)
Widowed	7	35	0.13 (0.05, 0.30)*	0.23 (0.09, 0.59)
Educational status
Unable to read & write	41	73	1	1
Read & write	51	32	2.83 (1.58, 5.09)*	1.63 (0.80, 3.32)
Elementary	28	33	1.51 (0.80, 2.84)	0.91 (0.42, 1.95)
Secondary & above	117	47	4.43 (2.66, 7.38)*	1.54 (0.70, 3.41)
Residence
Urban	148	64	3.14 (2.10, 4.69)*	2.02 (1.15, 3.57)
Rural	89	121	1	1
Occupation
Housewife	48	23	1	1
Government employee	88	26	7.06 (3.64, 13.69)*	4.80 (1.73, 9.30)
Private employee	31	19	3.40 (1.59, 7.26)*	2.94 (1.14, 7.56)
Farmer	46	48	2.00 (1.05, 3.79)*	2.13 (1.04, 4.37)
Merchant	35	34	2.14 (1.08, 4.26)*	2.21 (0.91, 5.36)
Other a	14	10	2.92 (1.12, 7.56)*	2.80 (0.91, 8.54)
Monthly income
<1500	68	73	1	1
1500–3000	52	54	1.03 (0.62, 1.71)	0.55 (0.28, 1.05)
>3000	117	58	2.16 (1.37, 3.41)*	0.72 (0.37, 1.40)

Notes

*P-value less than 0.25 in the bivariate analysis, 1 indicates reference category, bold numbers are P-value <0.05 in the multivariate analysis

a daily laborer.

Table 5

Factors associated with good practice of COVID-19 prevention methods among chronic disease patients, at selected public hospitals of Sidama regional state, Ethiopia, 2020 (N = 422).

Variables	Good practice		COR (95% CI)	AOR (95% CI)
	Yes	No
Sex
Male	134	96	1.23 (0.83, 1.82)
Female	103	89	1
Age
18–39	101	61	1.57 (0.86, 2.82)*	0.82 (0.36, 1.86)
40–61	108	86	1.36 (0.76, 2.44)	0.83 (0.39, 1.74)
>61	28	38	1
Marital status
Married	174	115	1	1
Single	39	26	0.59 (0.34, 1.04)*	0.52 (0.26, 1.07)
Divorced	17	9	0.37 (0.15, 0.92)*	0.22 (0.07, 0.63)
Widowed	7	35	0.13 (0.05, 0.36)*	0.31 (0.10, 0.92)
Educational status
Unable to read & write	37	77	1	1
Read & write	37	46	1.67 (0.93, 3.00)*	1.08 (0.50, 2.32)
Elementary	22	39	1.17 (0.61, 2.25)*	1.06 (0.47, 2.40)
Secondary & above	83	81	2.13 (1.29, 3.50)*	2.21 (1.01, 4.84)
Residence
Urban	105	107	1.80 (1.22, 2.66)*	2.33 (1.30, 4.19)
Rural	74	136	1	1
Occupation
House wife	28	43	1	1
Government employee	61	53	1.76 (0.96, 3.22)*	0.22 (0.07, 0.64)
Private employee	19	31	0.94 (0.44, 1.97)	0.20 (0.07, 0.59)
Farmer	38	56	1.04 (0.55, 1.95)	0.64 (0.30, 1.35)
Merchant	24	45	0.81 (0.41, 1.62)	0.31 (0.11, 0.81)
Other a	9	15	0.92 (0.35, 2.39)	0.60 (0.20, 1.84)
Knowledge about COVID-19
Good	140	97	5.40 (3.48, 8.37)*	4.87 (2.96, 8.00)
Poor	39	146	1	1
Monthly income
<1500	52	89	1	1
1500–3000	43	63	1.16 (0.69, 1.95)	1.60 (0.80, 3.19)
>3000	84	91	1.58 (1.01, 2.48)*	1.76 (0.85, 3.62)

Notes

*P-value less than 0.25 in the bivariate analysis, 1 indicates reference category, bold numbers are P-value <0.05 in the multivariate analysis

a daily laborer.