HARAMAYA UNIVERSITY

POST GRADUATE PROGRAMS DIRECTORATE

ASSESMENT OF DEPRESSION, ANXIETY AND ITS ASSOCIATED

FACTORS RELATED TO COVID-19 PANDEMIC AMONG HEALTH
CARE WORKERS OF HARAR TOWN WORKING AT HARARA PUPLIC
HOSPITALS, EASTERN ETHIOPIA

MPH RESEARCH PROPOSAL

Fanuel Tesfaye (BSc)

College: Health and Medical Sciences

School/Department: Public Health

Program: General public health

Major Advisor: Dr. Tesfaye Asebe (Assistant prof.)

Co-advisor: Mr. Tilahun Ali (Assistant Prof.)

 August, 2021

Haramaya University, Harar

ACKNOWLEDGMENT

My special gratitude and appreciation go to Haramaya University College of Health and Medical
Science, School of Graduate Studies for giving me this chance. I would like to express my
sincere gratitude to my advisors, Dr. Tesfaye Asebe and Mr. Tilahun Ali for their constructive
guidance, valuable support, and encouragement throughout the whole process of undertaking this
research proposal. My great appreciation also extends to the Librarian and School of Graduate
Studies and Internet room facilitators for their support

I am also greatly valuing the support that I have got from the colleges that provided me the
necessary information in the study area. Last but not a least, I am greatly indebted to all my
family and friends who give constructive comments and initiative encouragement for the
development of this research proposal.
 TABLE OF CONTENTS
ACKNOWLEDGMENT.............................................................................................................................2
TABLE OF CONTENTS............................................................................................................................3
LIST OF Figures............................................................................................................................................5
LIST OF TABLES............................................................................................................................................6
ABBREVIATIONS AND ACRONYMS.........................................................................................................7
SUMMARY...................................................................................................................................................8
1 INTRODUCTION........................................................................................................................................9
1.1 Background........................................................................................................................................9
1.2 Statement of the Problem...............................................................................................................11
1.3 Significant of the Study...................................................................................................................13
1.4 Objectives........................................................................................................................................14
1.4.1 General Objective.....................................................................................................................14
1.4.2 Specific Objectives....................................................................................................................14
2. LITERATURE REVIEW......................................................................................................................15
2.1 Prevalence of Depression and anxiety related to COVID -19 among HCW....................................15
2.2 Factors Associated with Depression and anxiety.............................................................................17
2.2.1 Socio-demographic factors.......................................................................................................17
2.2.2 Clinical Factors.........................................................................................................................19
2.2.3 Social and substance-related factors.........................................................................................20
2.3 Conceptual Framework....................................................................................................................22
3. MATERIALS AND METHODS...........................................................................................................23
3.1 Study Area and Period.....................................................................................................................23
3.2 study design.....................................................................................................................................23
3.3. Source population...........................................................................................................................23
3.4 study population..............................................................................................................................23
3.5 Inclusion and exclusion criteria........................................................................................................23
3.5.1 Inclusion criteria.......................................................................................................................23
 3.5.2 Exclusion criteria................................................................................................................23
3.6. Sample size determination.............................................................................................................23
3.7 Sampling procedure/technique.......................................................................................................26
3.8. Data Collection Method..................................................................................................................26
3.8.1. Data collection instruments......................................................................................................26
3.8.2 Data collectors and Procedure of data collection.....................................................................27
3.9 Variables..........................................................................................................................................27
3.9.1 Dependent variable..................................................................................................................27
3.9.2 Independent variable.........................................................................................................28
3.10 Operational Definitions.................................................................................................................28
3.11 Data Quality Control......................................................................................................................28
3.12 Data processing, Analyses, and interpretation..............................................................................29
3.13. Ethical Considerations..................................................................................................................30
3.14. Expected Outcome.......................................................................................................................30
3.15. Information Dissemination...........................................................................................................30
3.16. Limitation of the Study.................................................................................................................31
4. WORK PLAN.......................................................................................................................................31
5. BUDGET BREAK DOWN...................................................................................................................33
6. REFERENCES..........................................................................................................................................35
7 APPENDIXES:...........................................................................................................................................36
 LIST OF Figures

Figure 1:- Conceptual framework of factors associated with depression and anxiety among HCW
at Harar public Hospitals, eastern Ethiopia. ------------------------------------------------------------23

Figure 2:- Schematic presentation of sampling procedure of prevalence and factors associated
with depression and anxiety among health care workers working at Harar public hospitals,
eastern Ethiopia, 2021---------------------------------------------------------------------------------------27
 LIST OF TABLES
Table 1: -Sample size calculation for factors associated with depression and anxiety for HCW
working at Harar public hospitals, eastern Ethiopia, 2021............................................................23
Table 2፡Tabular presentations for sampling procedure of prevalence and factors associated with
depression and anxiety among health care workers working at Harar public hospitals, eastern
Ethiopia, 2021................................................................................................................................24
Table 3:- work plan for the study prevalence of depression, anxiety and factors associated with it
related to COVID 19 pandemic among HCW working at Harar public hospitals, eastern Ethiopia,
2021...............................................................................................................................................29
Table 4:- Budget break down for the study prevalence of depression, anxiety and factors
associated with it related to COVID 19 pandemic among HCW working at Harar public
hospitals, eastern Ethiopia, 2021...................................................................................................31
 ABBREVIATIONS AND ACRONYMS
A.A Addis Ababa
AOR Adjusted Odds Ratio
CI Confidence Interval
COVID-19 Corona Virus Disease-19
EC Ethiopian Calendar
ETB Ethiopian Birr
HADS Hospital Anxiety and Depression Scale
HCP Health Care Professionals
KM Kilo- Meter
SARS Sever Acute Respiratory Syndrome
RNA Ribonucleic Acid
WHO World Health Organization
 SUMMARY
Background: - Healthcare workers (HCWs) are among the many groups of people who are in
the frontline caring for people and facing heavy workloads, life-or-death decisions, risk of
infection, and have been facing various psychosocial problems and they experienced
unprecedented levels of workload and pressure since the outbreak of coronavirus disease 2019
(COVID-19). Understanding the immediate mental health and psychological response of the
healthcare providers after a public health emergency is important for implementing better
prevention and response mechanisms to a disaster. However, there is a limited study conducted
to assess the magnitude and factors associated with depression, anxiety among health care
workers related to COVID 19 pandemic in Ethiopia including the current study area.

Objectives: The aim of this study will be to assess’ depression, anxiety and its associated factors
related to covid-19 pandemic among health care workers of Harar town working at Harar public
hospitals, Eastern Ethiopia
Methods: Institutional -based Cross-sectional study will be conducted from September 30 to
October 30, 2021 among 407 randomly selected health care professionals working at Harar
public hospitals. Face-to-face interview will used to collect data. Depression and anxiety will be
assessed by using Hospital Anxiety and Depression Scale (HADS). The collected data will be
entered into EPI- data version 3.1 and exported to STATA version 14.2 for analysis. Descriptive
and analytic data will be used to present the finding. Binary logistic regression will be used to
identify factors associated with depression and anxiety. The strength of the association will be
presented by the odds ratio with 95% Confident interval (CI) at P-value less than 0.05

Expected outcome of the study: because of the novelty of the disease and availability of
different triggering factors like chat for depression and anxiety in the study area as well as the
fatality rate of the COVID 19 the prevalence of depression and anxiety related to will be able to
expect to high and different factors will be expected as an associated factors of depression and
anxiety among health care workers.
Work pan and Budget: - The study will be conducted from May to November, 2021 and a total
of 29,516 Ethiopian birr will be needed to carry out the study.

Key Words: Anxiety, COVID 19, Depression, prevalence, Ethiopia.

1 INTRODUCTION
1.1 Background
Coronaviruses are enveloped single-stranded RNA viruses of zoonotic nature that cause
symptoms ranging from those similar to the common cold to more severe respiratory, enteric,
hepatic and neurological symptoms (Wang, 2019)

The WHO announced the occurrence of the novel coronavirus and declared it a Public Health
Emergency of International Concern under the International Health Regulation on 30 January
2020 then after it was officially named by the WHO as COVID-19 on 11 February 2020 (WHO,
2019).

Health care workers (HCWs) who are in the frontline caring for people with COVID-19 infection
have been facing various psychosocial problems, including a high risk of infection and
inadequate protection from contamination, overwork frustration, a lack of contact with their
families, and loved ones so, those severe situation is causing mental health problems such as
depression and anxiety (Zhu.N, 2019).

A depressive disorder is a severe mental disorder that is characterized by a feeling of sadness,

loss of interest or pleasure, feelings of low self-esteem or guilt, and disturbance of sleep or
appetite nearly every day, besides, it leads to decreased energy and poor concentrations that can
last at least for two weeks and can be markedly impairing an individual’s functioning at work or
school or cope with daily life (Akiskal. S, 2005).

In the 2015 World Health Organization (WHO.) estimated, 4.4% (322 million people) of the
global population live with depression globally. On the other hand anxiety disorder is the most
frequently occurring mental health disorder on health care workers related to COVID 19, which
is characterized by excessive worry or fearfulness about events and is associated with heightened
tension, nervousness, and irritability; it may cause physical symptoms such as restlessness,
fatigue, muscle stiffness, and trouble concentrating or sleeping (McEvoy PM, 2017).

According to the studies conducted in the era of Severe Acute Respiratory Syndrome (SARS)
and Ebola epidemics, the onset of a sudden and immediately life threatening illness could lead to
extraordinary amounts of pressure on HCWs and might cause adverse psychological disorders,
such as anxiety and depression (Tam.W, 2013).

1.2 Statement of the Problem

The novel coronavirus was officially named by the WHO as COVID-19 on 11 February 2020,
after which the pandemic has not only caused a high mortality rate from viral infections but also
psychological and mental effects on the rest of the world. The pandemic has not only caused a
high mortality rate from viral infections but also psychological and mental effects on the rest of
the world especially on frontline health care workers (WHO, 2019).

On 18, June 2021, there were 178, 279, 77 confirmed cases of COVID-19 and 3,859, confirmed
deaths worldwide. In Ethiopia, there were 27775 confirmed cases of COVID-19 and deaths in
the same period(WHO, 2021).

On other hand HCWs are expected to wear heavy protective garments and other personal
protective equipment during pandemic like COVID-19, making it much more difficult to carry
out medical operations or procedures than under normal conditions as a result these factors,
together with the fear of being contagious and infecting others, physical exhaustion, inadequate
personal equipment, and the need to make ethically difficult decisions on the rationing of care
could increase the possibility of psychological issues among HCWs (Teshome.A, 2020).

The pandemic had resulted in the prevalence of a wide range of psychological problems such as
fear, anxiety, stigma, prejudice, marginalization towards the disease, and its relation to all people
from healthy individuals and at-risk individuals to care workers and mass quarantine could cause
a sense of mass hysteria, fear and anxiety in healthcare workers (HCWs) working in hospitals as
well as isolation units (Mak IWC, 2009). Medical HCWs who are exposed and have direct
contact with confirmed and suspected coronavirus cases are called frontline HCWs, so that they
are prone to increased workload, higher risk of infection and mental health problems (Wang D,
2019)

The COVID-19 pandemic has resulted in unprecedented psychological stress on HCWs, such as
anxiety, fear, panic attacks, post-traumatic stress symptoms, psychological distress, stigma,
avoidance of contact, depressive tendencies, sleep disturbances, helplessness, interpersonal and
isolation from family and social support, as well as concerns about their friends and family being
exposed to infection (Zheng W, 2019).

Although mental health problems and psychosocial issues are common among HCWs, most
health professionals do not often seek or receive regular mental healthcare(Xiang Y-T, 2020). In
addition, the mental health problems of HCWs would negatively affect their attention, cognitive
functioning and clinical decision-making, leading to a subsequent increase in the incidence of
medical errors and incidents, and thus putting patients at risk and it was also well known that
acute stress in disasters can have a long term effect on overall well-being (Mulfnger N, 2019)

Adverse psychological outcomes among medical care workers are usually determined by a
variety of factors during an outbreak of infectious disease like COVID -19 with high level of
mortality, including uncertain quarantine duration, inadequate medical supplies, fears of
infection, stigma and discrimination and meanwhile, the support they gained from others and the
coping strategies they adopted during the event had been reported to be associated with their
psychological status during the epidemic of infectious disease so as a result less support and
more negative coping strategies were proved to be common predictors of both acute and chronic
mental health problems (Ming.Y, 2020).

By understanding the psychological outcomes caused by an outbreak on health care workers and
studying the mechanism underneath, effective intervention and treatment can be developed and
provided to this population, hence to improve their psychological wellbeing.

The psychological pressure exerts on HCW has an adverse effect on the quality of care given for
patient making it much more difficult to carry out medical operations or procedures than under
normal conditions. These factors, together with the fear of being contagious and infecting others,
physical exhaustion, inadequate personal equipment, and the need to make ethically difficult
decisions on the rationing of care could increase the possibility of psychological issues among
HCWs (Ming.Y, 2020).

Therefore, the mental health problems of HCWs in the COVID-19 pandemic have become an
urgent public health concern. To date, research on the psychological impact of COVID-19 on
HCWs is still under investigation. To date, the Ethiopian government’s focus has been on
managing the medical needs of people during the pandemic, rather than providing resources to
meet short- and long term mental health implications. So that the current study aims to evaluate
mental health outcomes among HCWs who interact with patients with COVID-19 by quantifying
the magnitude of symptoms of depression, anxiety, and by analyzing the potential risk factors
associated with these symptoms.

1.3 Significant of the Study

Depression and anxiety is linked with a higher risk of morbidity and all-cause mortality. Lack
of adequate understanding of the relationship between COVID 19 and its effect on mental health
of the HCW is a problem that has major clinical and policy implications.

The primary beneficiaries of the study will be health care professionals by helping them to
understand the factors that lead to depression and anxiety to take preventive actions to reduce its
prevalence.

The finding of this research may also help the hospitals to know the prevalence of depression and
anxiety related to COVID-19 among health care workers and understands factors associated with
it and to intervene accordingly

The findings of this study will be useful for decision-makers, service planners and other
stakeholders working to implement mental health services in Harar town in general and Hiwot
Fana specialized university hospital and Jugol hospital in particular.

The findings will also create awareness in the whole Health care workers who works out of
Harar public hospitals about the problem and contribute towards formulating locally appropriate
interventions to reduce the prevalence of depression and anxiety related to COVID-19 pandemic.

Finally, it may help to the health professionals to initiate early screening, diagnosing and
management of depression and anxiety related to COVID -19 that has significance in reducing
the burden of depression and anxiety. It may also be used as a reference for further studies or
may it will open room for other researchers to investigate more on this topic.

1.4 Objectives
1.4.1 General Objective
 To assess the prevalence and factors associated with depression and anxiety related to
COVID-19 pandemic among Health care workers at Harar public Hospitals, Eastern
Ethiopia from September 30, to October 30, 2021
1.4.2 Specific Objectives
 To determine the prevalence of depression related to COVID -19 among HCW at Harar
public Hospitals, Eastern Ethiopia
 To determine the prevalence of anxiety related to COVID -19 among HCW at Harar
public Hospitals, Eastern Ethiopia
 To identify factors associated with depression among HCW at Harar public Hospitals,
Harar, Eastern Ethiopia
 To identify factors associated with anxiety among HCW at Harar public Hospitals, Harar,
Eastern Ethiopia
 2. LITERATURE REVIEW
2.1 Prevalence of Depression and anxiety related to COVID -19 among HCW
The WHO declared COVID-19 a pandemic on March 11, 2020. Currently, till on 18, June 2021,
there were 178, 279, 776 infected by COVID-19 worldwide (Chekole.Y, 2020)

A systematic review and meta-analysis by WHO among HCW the prevalence of depression and
anxiety related to COVID-19 pandemic shows that the prevalence of anxiety in 17 studies with a
sample size of 63,439 were 31.9%, and the prevalence of depression in 14 studies with a sample
size of 44,531 people as 33.7% (Salari. N, 2020) and similar finding rival that prevalence of
symptoms of at least mild anxiety was highest in Peru at 41% and lowest in Vietnam at 9%
(Porter.C, 2021).

Based on a national survey at USA on health care workers’ mental health and quality of life
during covid-19 pandemic, among 833 health care workers 31% HCW endorsed mild anxiety,
and 33% clinically meaningful anxiety; 29% reported mild depressive symptoms, and 17% (233
of 1,341) moderate to severe depressive symptoms (Kevin.P, 2020)

According to a systematic review and meta-analysis research conducted in US Alaska by 2020

the prevalence of anxiety and depression among health care workers related to COVID -19 was
23.2% and 22.8% respectively (Mohamed.H et al., 2021).

Moreover one national survey at USA using HADs’ assessment tool among a total of 520
participants revealed that 43.8% and 40.0% of participants had normal anxiety and depression
scores; while 22.4% showed borderline abnormal anxiety/depression scores (33.8%) and (33.8%)
were classified to have abnormal anxiety scores, while a smaller proportion (26.2%) was
classified to have abnormal depression scores (Iman A. BashetiI.D, 2021).
On the other hand across sectional study done in china on the psychological impact of COVID-
19 among health care workers working at governmental hospitals in china Using hospitalized
anxiety and depression assessment tool shows that the prevalence of having mild to extremely
severe symptoms of depression and anxiety were 13.6%, and 13.9%, respectively and another
similar study at china on factors associated with mental health outcomes among health care
workers exposed to coronavirus disease, the prevalence of depression and anxiety among HCW
as a result of COVID 19 were 50.4% and 44.6% respectively (Ming.Y, 2020).

Beside a cross sectional research conducted at Netherlands using Beck inventory depression and
scale among a total of 577 indicated that regarding depression, 15.5%, 11.7%, and 9.2% of the
participants reported mild, moderate, and severe to extremely severe depression, respectively and
for anxiety, 7.0%, 16.5%, and 13.2% of the respondents had mild, moderate, and severe to
extremely severe anxiety, respectively (Cherng. L, 2021)

According to the data from Bangladesh Cross sectional study on mental health of HCW during
COVID-19 outbreak using PHQ-9 among 1122 study participants indicated that the prevalence
of anxiety and depression were 32.5% and 34.2%, respectively (Porter.C, 2021)

According to a cross sectional study research conducted at Ecuadorian general hospital in Gina
among a total of 626 participants using hospitalized anxiety, depression and stress scale
(HADSS) approximately 17.7% of the respondents had moderate to very severe levels of
depression and 30.7% had similar levels of anxiety (Mautong.H, 2021)

Based on a cross sectional research conducted at Egypt, among a total of 262 participants using
Generalized Anxiety Disorder 7-item questionnaire (GAD-7) and Patient Health Questionnaire
(depression module) 9 (PHQ-9) assessment tool about 9.5% of the health workers did not
experience generalized anxiety, while the remaining 90.5% had different degrees of anxiety as
mild anxiety showed the highest percent affecting about 40% of participants followed by
moderate anxiety about 32% then severe anxiety, 18.5% and with regard to depression, 94% of
participants showed mild to severe form of depression as a result of COVID 19 pandemic
(Mohamed.H et al., 2021).

Similarly the same cross sectional study at Egypt using GAD-7 and PHQ-9 assessment tool from
a total of 337 participants among Egyptian physicians during COVID-19 pandemic shows that
the majority (63%) suffered from severe or extremely severe depression and 77.6% had
extremely severe form of anxiety (Khalaf. O, 2020)

Based on an online cross sectional study at Ethiopia by EPHI on anxiety and associated factors
among Ethiopian health professionals at early stage of covid-19 pandemic shows that the overall
prevalence of anxiety was found to be 26.8% (DagneI. H, 2021)

One cross sectional study in southern Ethiopia on generalized anxiety disorder and its associated
factors among health care workers fighting covid-19 from a total of 798 HCWs, reviled that the
prevalence of mild and moderate anxiety disorder among HCWs using HADSS assessment tool
was 29.3% and 6.3%, respectively (Teshome.A, 2020).

2.2 Factors Associated with Depression and anxiety

Moreover, the lack of knowledge about COVID-19, misinformation from the media, the lack of
effective treatments, travel restrictions, significant economic losses, strict isolation requirements,
and more importantly, the alarming mortality rate among HCW may result in negative
psychological consequences such as higher levels of depression and anxiety during the COVID-
19 pandemic (Mautong.H, 2021)

2.2.1 Socio-demographic factors

A systematic review and meta-analysis by WHO among HCW the prevalence of depression and
anxiety related to COVID-19 pandemic shows that Women were most affected in all countries
except Ethiopia. Pandemic-related stressors such as health risks/expenses, economic adversity,
food insecurity, and educational or employment disruption were risk factors for anxiety and
depression, though showed varying levels of importance across countries (Porter.C, 2021)

According to a cross-sectional study conducted in Uberlandia, Brazil, the odds of women

exhibiting symptoms of depression were 4.4 higher compared to men, and the odds of adults
exhibiting such symptoms were 7.4 higher compared to the other age ranges(Knychala MA.,
2019)

Across sectional study conducted at Bangladesh among a HCW the findings revealed that marital
status, work per day and current job location were the main risk factors for anxiety while sex,
age, and marital status were the main risk factors for depression (Khatun. F, 2021)
According to the research conducted in China among health care workers regarding their
educational level of the participants, shows that nurses were more likely to be anxious than
others among medical care workers during the COVID-19 pandemic (Ming.Y, 2020)

According to research conducted in India, factors like staying away from family, children <5
years or elderly >60 years at home, fear of infecting the family members were more prevalent in
HCWs as compared to the administrative staff (P < 0.001) (Kevin.P, 2020).

According to a research conducted in Iran being female (CI: − 1.299; − 0.248). Education level
(CI: − 0.252; − 0.017), living with a high risk family member (CI: 0.0301; 1.160), have a relation
with anxiety score while, depression score was in significant relation with education level (CI: −
0.263; − 0.022), having a high-risk family member (CI: 0.292; 1.155), 0.476) (Khademian. F,
2021)

Based on the study conducted in equatorial Ginny, showed that HCWs being a student was a risk
factor for having more severe levels of depression (OR =3.67; 95% CI = 2.56–5.26, p: 0.0001),
anxiety (OR= 1.86; 95% CI= 1.35–2.55, p: 0.0001) and also having a relative with COVID-19
was also found to be a risk factor only for depression (OR= 1.70; 95% CI= 1.03–2.80, p: 0.036)
and anxiety (OR = 2.17; 95% CI= 1.35–3.47, p: 0.001) and on the other hand, male sex, older
age, and having more children were found to be protective factors for anxiety and depression
conditions (Mautong.H, 2021)

Of the research conducted in Egypt among Egyptian physicians during COVID-19 pandemic,
female physicians had significantly higher depression and anxiety than male physicians (p =
0.001, and < 0.001 respectively) and age had a significantly negative correlation with DAS
anxiety (p = 0.031) and depression scores (p = 0.037) (Khalaf. O, 2020)

Based on an institution-based cross-sectional study conducted among Healthcare Providers in

Ethiopia, being at the age range of 25–31 years, master’s and above in their qualification, nurse
professionals, and pharmacist professionals were variables found to have a strong statistically
significant association with depression and anxiety of coronavirus disease (Chekole.Y, 2020).
From the finding at Metu university Ethiopia, shows that female gender (AOR = 1.66, 95% CI
(1.06, 2.59, widowed/divorced (AOR = 3.92, 95% CI (1.59, 9.64)) and separated (AOR = 3.66,
95% CI (1.64, 8.19)), were significantly associated with depression alone (DagneI. H, 2021)

As a research conducted Addis Ababa Ethiopia showed that the odds of developing anxiety
among the HCW with a monthly income of 2001-4999 birr and greater than 10,000 birr had
69.7%(AOR:0.303; 95%CI:0.102-0.901) and 79.5%(AOR:0.205, 95%CI: 0.064- 0.653) higher
odds as those with a monthly income of less than 2000 birr (f21) and similar study also revealed
that being unmarried (AOR 11.43, 95%CI ( 2.67, 48.90)), Self-employed (AOR 2.45,, 95%CI
(1.07, 5.60)), had statistically significant association with anxiety alone (Assefa, 2020)

Another conducted at Gonder university Ethiopia among health care works during the early stage
of COVID -19 showed that being female (AOR: 1.88; 95% C.I:1.11, 3.19) and those employed at
private healthcare institutions (AOR: 2.40; 95% C.I:1.17, 4.90 were more likely to be anxious
(DagneI. H, 2021)

2.2.2 Clinical Factors

Based on a national survey at USA on health care workers’ mental health and quality of life
during covid-19 pandemic, Pediatric HCWs reported greater anxiety than did others and HCWs’
mental health history increased risk for anxiety (odds ratio [OR]=2.78, 95% confidence interval
[CI]=2.09–3.70) and depression (OR=3.49, 95% CI=2.47–4.94), as did barriers to working,
which were associated with moderate to severe anxiety (OR=2.50, 95% CI=1.80–3.48) and
moderate depressive symptoms (OR=2.15, 95% CI=1.45–3.21) (p,0.001 for all comparisons)
(Kevin.P, 2020)

A study was done in University of Southern California; Los Angeles, USA reveals depression
severity was significantly associated with diabetes complications, medical comorbidity, greater
anxiety, dysthymia, financial worries, social stress, and poorer quality-of-life (Ell K., 2019).A
similar study conducted in China found that severe fatigue (p = 0.003, OR = 1.266, 95% CI =
1.081–1.483), poor sleep quality (p < 0.001, OR = 1.283, 95% CI = 1.171–1.405), and history of
pre-existing psychiatric disorders (p < 0.001, OR = 5.085, 95% CI = 2.144–12.06) were
independently associated with higher odds of anxiety and whereas only manifesting having
chronic illness were associated with depression among the HCWs (Zhou.Y, 2021). The same
study conducted in China showed that Frontline health care workers engaged in direct diagnosis,
treatment, and care of patients with COVID-19 were associated with a higher risk of symptoms
of depression (OR, 1.52; 95% CI, 1.11-2.09; P = .01) and anxiety (OR, 1.57; 95% CI, 1.22-2.02;
P < .001) (Jianbo.L, 2019)

According to research conducted in India, factors like frequent weight changes (weight loss more
common), acquiring new health problems (gastritis and headache), and worsening of previous
health problems in the HCWs compared to the administrative staffs (P < 0.001) (Khalaf. O,
2020)

According to a research conducted in Iran health status (CI: − 0.682; − 0.471), risk of disease
(CI: 0.154; 0.674), and following COVID-19 news (CI: 0.046; 0.401) have a relation with
anxiety score and depression score was associated with health status (CI: − 0.687; − 0.476), risk
of disease (CI: 0.144; 0.667), and following Covid-19 news (CI: 0.053; 0.408) (Khademian. F,
2021)

Besides based on the research conducted in Malawi revealed that frustration because of loss of
daily routine and study disruption and having preexisting medical, depressive, and anxiety
disorders were associated with elevated depressive symptoms, after adjusting for age, gender,
and marital status, while it was also found that frustration because of study disruption and having
preexisting medical depressive, and anxiety disorders were associated with elevated anxiety
symptoms, after adjusting for age, gender, and marital status (Cherng. L, 2021)

Of the research conducted in Egypt among Egyptian physicians during COVID-19 pandemic, the
anxiety scale was significantly higher in those with chronic diseases (p = 0.040) (Khalaf. O,
2020).

Based on a research conducted at southern Ethiopia revealed that, Contact with confirmed or
suspected cases, no COVID-19 updates, no confidence on coping with stresses, and COVID-19-
related worry were positively associated with higher-order anxiety disorder. However, not
feeling overwhelmed by the demands of everyday life and feeling cannot make it were
negatively associated with a higher order of anxiety (Teshome.A, 2020)
From the finding at Metu university Ethiopia, shows that longer duration of illness (AOR = 1.82,
95% CI (1.15, 2.89)) were significantly associated with depression, whereas earlier age at onset
of illness, having more than three co-morbid diagnoses, were found to have significant
association with anxiety (DagneI. H, 2021)

Another conducted at Gonder university Ethiopia among health care works during the early stage
of COVID -19 showed that, visiting/treating 30–150 patients per day (AOR: 3.44; 95% C.I:1.51,
7.84 who do not believe that COVID-19 is preventable (AOR: 2.04; 95% C.I:1.04, 4.03) and
those who reported lack of PPE (AOR: 1.98; 95% C.I:1.04, 3.79) were more likely to be anxious
(DagneI. H, 2021).

A study conducted in Addis Ababa Ethiopia having diagnosed chronic illness (AOR 2.56,
95%CI (1.19, 5.53)), having COVID-19 Symptoms for below 7 days and for 8-14 days ((AOR
3.21, 95%CI (1.21, 8.58)) & AOR 3.70, 95%CI (1.55, 8.84)) respectively) had statistically
significant association with anxiety (Assefa, 2020)

2.2.3 Social and substance-related factors

A systematic review and meta-analysis by WHO among HCW the prevalence of depression and
anxiety related to COVID-19 pandemic shows that prior parent/ peer relationships were
protective factors, while long-term health or emotional problems and lack of social support were
risk factors (Porter.C, 2021)

A study conducted in Cyberjaya, Selangor have shown that Heavy smoking, lack of physical
activity, excessive alcohol drinking are all lifestyle factors associated with depression and
anxiety (Bahari R, 2019) and another study at USA stated that Smoking (p = 0.022), and use of
alcohol (p = 0.032) were positively associated with higher (worse) anxiety and depression
symptoms (Iman A. BashetiI.D, 2021)

According to the research conducted in China among health care workers shows that perceived
social support and active coping strategies were negatively associated with depression and
anxiety (Ming.Y, 2020)
 According to a research conducted in Iran being female poor social relationship (CI: − 0.236; −
0.048), and depression score was also significantly associated with poor social support (CI: −
0.235; − 0.048) (Khademian. F, 2021)

Besides based on the research conducted in Malawi revealed that having a greater degree of
family and friends social support was associated with less depressive symptoms after adjusting
for age, gender, and marital status and having a greater degree of family support were factors
associated with less anxiety symptoms after adjusting for age, gender, and marital status
(Cherng. L, 2021)

From the finding at Metu university Ethiopia, shows that poor social support (AOR = 1.94, 95%
CI (1.10, 3.42)), were significantly associated with depression, whereas tobacco use and poor
social support were found to have significant association with anxiety (DagneI. H, 2021)

A study conducted in Addis Ababa Ethiopia those who had Poor/low Social Support (AOR 3.42,
95%CI (1.21, 9.63)) had statistically significant association with anxiety (Assefa, 2020)

2.3 Conceptual Framework

Clinical factors
Social and behavioral
Socio-  Present of
related Factors
demographic chronic disease
factors  Poor social support  Types the
disease
 Age  Physical inactivity  Duration of the
 Financial worries disease
 Gender DEPRESSION & anxiety
 Types of
 Marital status
medication
 Occupational  complication
status  sleep quality
 pre-existing
 Educational
psychiatric
status/level disorder
 Income  contact with
Substance-related Factors COVID-19
 Residence
suspected/confir
 Religion  Tobacco med case
 Ethnicity  Alcohol  treating patients
 Living per day
 Khat
circumstance  lack of PPE
 shisha
 Current job
location

Figure 1:- Conceptual framework of factors associated with depression and anxiety among
HCW at Harar public Hospitals, eastern Ethiopia (Assefa, 2020, Iman A. BashetiI.D, 2021,
Mohamed.H et al., 2021 )

3. MATERIALS AND METHODS

3.1 Study Area and Period
This study will be conducted in Harar Town at public hospitals from September 30 to October
30, 2021. Harar is located 526 km away from Addis Ababa, the capital city of Ethiopia Based on
(CSA, 2007) the total population of Harar Town was 183,415 (91,099 females vs. 92, 316 were
males). Of the total population, 54% of them were urban dwellers and the rest were rural
dwellers (CS, 2007). In Harar, there are three hospitals (two are public hospitals and one is
police hospital), one private general hospital, 8 health centers, and 26 Health posts. The two
public hospitals have a total of 1819 HCW, 1021 in HFSUH and 798 in Jugal Hospital. This
study will be conducted in two public hospitals (Hiwot Fana Specialized University Hospital and
Jugal General Hospital) (HRHB, 2013)

3.2 study design

An institution-based quantitative cross-sectional study will be conducted

3.3. Source population

All health care workers working at Harar public hospitals

3.4 study population

All health care professionals who will be volunteers to participate in the study
3.5 Inclusion and exclusion criteria

3.5.1 Inclusion criteria

Those health professionals working at Harar public hospitals

3.5.2 Exclusion criteria

Health professionals who are diagnosed as depression and anxiety previously

3.6. Sample size determination

For objective 1

The sample size for the study will be determined using a single population proportion formula:

𝑛𝑖= z(𝑎/2)2p𝑞)

𝑑2

Where ni= required an initial sample size

𝑍𝑎/2 =critical value for normal distribution at a 95% confidence interval which equals

1.96 (𝑍value at alpha = 0.05)

𝑃= proportion of success; that is, the prevalence of depressive and anxiety symptoms
using DAS the study conducted in Gonder, Ethiopia was 40.4%

𝑞= proportion of HCW not having comorbid depression and anxiety (0.596)

𝑑= marginal error (0.05)

The sample size was calculated by assuming a 5% marginal error (d), 95% CI (alpha=0.05) and
40.4% the prevalence.

𝑛𝑖 = (1.96)2× (0.404) × (0.596)

(0.05)2
 𝑛f = 370

Where:

nj - was the final sample size

𝑛𝑖- was the initial sample size determined using the formula, and

𝑁 - was the size of the source population.

By considering 10% nonresponse rate, the total sample size is 407 HCW

For objective 2:- The sample size of the second objective of this study was determined by
considering different factors that significantly associated with depression, and anxiety
using a two-sided confidence level of 95 %, a margin of error of 5% and power of 80 %
and using EPI Info version 7, statistical software for double population proportions
formula.

Table 1: -Sample size calculation for factors associated with depression and anxiety for HCW
working at Harar public hospitals, eastern Ethiopia, 2021

Factors Prevalence Sample A sample Reference

Associated size size of
with 10% non-
depression and responden
anxiety (95% t
CI)

Exposed Non exposed

present Have medical Not have medical 342 376 (Habtewol

underline condition=28% condition 15 d TD.,
medical 2019)
condition
social support Poor social support Poor social support 256 281.6 (Getachew
with depression and without depression R., 2019)
anxiety and anxiety

Therefore, the large sample size which is 407 (the maximum from the first objective) will be
taken as a sample size of this study

3.7 Sampling procedure/technique

A systematic random sampling technique will be used to select study participants. Accordingly,
from the two hospitals selected for the study, the number of study subjects will be allocated to
each hospital proportionally to their total number of HCW. Then individual will be identified by
calculating sampling interval (𝑁/𝑛=k=1819/407=4), where 𝑁 is the total number of HCW
working at in the two hospitals and n is the calculated sample size. Accordingly, every 4th
individuals will be selected from each hospital. The first participants (out of four) will be
selected randomly and every 4th patient will be interviewed until getting the final sample size.

Harar governmental hospital

HFSUH Jugal hospital

Total number of HCW at Total number of HCW at

HFSUH= 1021 Jugal hospital= 798

By proportional allocation

Total number of HCW from Total number of HCW from

HFSUH= 229 Jugal hospital = 178

By using systematic random sampling technique

 407 total sample size
Figure 2:- Schematic presentation of sampling procedure of prevalence and factors associated
with depression and anxiety among health care workers working at Harar public hospitals,
eastern Ethiopia, 2021

3.8. Data Collection Method

3.8.1. Data collection instruments

The data collection tool will be developed by reviewing different literature which contains five
parts:

Part I: socio-demographic factors, the questionnaire of socio demographic related information

was assessed using a structured questionnaire developed by reviewing similar related articles.
Part II: question-related to clinical factors and psychological factors: This independent variables
that could affect the occurrence of depression and anxiety among HCW were also developed by
reviewing other similar studies Part III: Questionnaire related Social Support;:- this Oslo 3-item
social support scale part was a standard tool developed to provides a brief measure of social
functioning and it is considered to be one of the best predicators of depression and anxiety
(Dalgard.OS, 2013).

Part IV: question-related to substance:- this part of questionnaire will be developed by

reviewing the WHO Alcohol, Smoking and Substance involvement Screening Test ( WHO
ASSIST v3.0) to assess the substance behavior of the participants (WHO, 2018).

Part V: question related to depression and anxiety: - Depression and anxiety will be assessed by
the Hospital Anxiety and Depression Scale (HADS). This tool has 14 items (seven for each)
which, scored in a Likert manner from 0–3, yield a total of 21 points and distinguishes the status
of anxiety and depression symptoms as normal (0–7), borderline (8–10) and 11–21 (abnormal or
case) with a binary cut off point of greater than 8. The scale has been validated in different
populations in Ethiopia and internal consistency (Cronbach’s alpha) was ranged from 0.78 to
0.81 for anxiety and 0.76 to 0.78 for depression subscales (Bjelland.I, 2012).

3.8.2 Data collectors and Procedure of data collection

Four trained nurses who are fluent in speaking Afan-Oromo and Amharic languages will be
selected to collect the data through face-to-face interviews. One Health officer (BSc) and the
principal investigator will supervise daily. Data collectors and the supervisor will be trained for
two days by the principal investigator on the study instrument, consent form, how to interview
and data collection procedure. The principal investigator and the supervisor will take the
responsibility to supervise, monitor and follow up the whole activities of data collection
throughout the study period.

3.9 Variables

3.9.1 Dependent variable

Prevalence of Depression and anxiety
3.9.2 Independent variable
 Socio-demographic factors:- Age , Gender, Marital status, Occupational status,
Educational status/level, Income, Residence , Religion, Ethnicity, Living circumstance,
Current job location , Family size
 Clinical factors:- Present of chronic disease , Types the disease, Duration of the disease,
Types of medication , complication, sleep quality , pre-existing psychiatric disorder,
previous medical problem, contact with COVID-19 suspected/confirmed case, treating
patients per day, lack of PPE
 Social and behavioral related Factors:- social support , Physical inactivity, Financial
worries
 Social and substance-related factors;- Tobacco, Alcohol, Khat , shisha, Illicit drugs

3.10 Operational Definitions

Depression: A participants with a score of 8 and above of HADS score considered as having
depression (Zigmond.As, 1983).
Anxiety: A participants with a score of 8 and above of HADS score considered as having
depression (Zigmond.As, 1983).
Current use of a substance - in this study is defined as the use of at least one of substance in the
past 03months and Ever use of a substance - In this study is defined as the use of at least one of
specified substance even once in a lifetime (WHO, 2018)
Comorbidity;- present of one or more medical diseased
Social support: individuals who scored ≥9 on the Oslo 3-item social support scale considered as
having social support and subscales were classified as 3-8 poor social support 9-11 moderate
social support and 12-14 strong social support (Dalgard.OS, 2013).

3.11 Data Quality Control

Quality of data will be assured through two days of training of data collectors on how to
interview. The data collection methods, tools and how to handle ethical issues will be also
discussed with the data collectors. The collected data from the participants will be reported to
the supervisor every day to enable him/her to take immediate action in case of inconsistencies or
problems that happened on the reported data. The supervisor will provide all items necessary for
the data collection on each data collection days, checking a filled questionnaire for completeness
and solving problems that will be happening during the data collection process
Each day during data collection, filled questioners will be cheek for completeness, accuracy, and
consistency. Pre-testing of the questionnaire will be undertaken before the actual data collection
will be taken place and corrections on the instruments will be made accordingly. To ensure the
quality of data and its competence, pretests of data collection tools will be carried out on 5% (20)
of HCW in Harar general hospital and modifications will be incorporated into the questionnaire.
The pre-test is also part of the data quality control and questionnaires used in the pre-test will be
not included in the analysis as part of the main study. Overall activity will be controlled by the
principal investigator, who will supervise carefully during data collection

3.12 Data processing, Analyses, and interpretation

Data will be checked for its completeness on the day it will be collected. Then it will be coded
and entered into Epi-Data version 3.1 and export to STATA Version 14.2 for analysis. The
finding will be presented using frequency distribution, summary measures, tables, figures, and
graphs. Data cleaning will be made by removing missing ideas and responses to questions about
relevant information. Descriptive analysis such as frequencies, proportions, median and means
will be used. Hosmer-Lemeshow's will be done to test for model fitness. Binary logistic
regression will be carried out to identify its associated factors. All variables with P-value ≤ 0.25
will be taken into consideration in the multivariable model to control for all possible
confounders. Multicollinearity tests will be carried out to see the correlation between
independent variables using standard error and one of the independent variables will be dropped
for those with a standard error of >2. Finally, the results of multivariable logistic regression
analysis will be presented in crude and adjusted odds ratios with 95% confidence intervals. The
level of statistical significance will be declared at P-value < 0.05.

3.13. Ethical Considerations

Ethical clearance will be obtained from Institutional Health Research Ethics Review Committee
(IHRERC) of the College of Health and Medical Sciences, Haramaya University. A formal letter
of support will be obtained from Haramaya University, College of Health and Medicine and
submitted to Hiwot Fana Specialized University Hospital and Jugal Hospital. Before the
questionnaire will be administered to any eligible participant, informed voluntary written and
signed consent will be obtained from heads of the hospitals and each study participant after the
study will be explained to them in detail by the data collectors. The right will be given to the
study participants to refuse or discontinue participation at any time they want and the chance to
ask anything about the study. For anonymity participant's name will not use at the time of data
collection and all other personnel information kept entirely anonymously and confidentiality will
be assured throughout the study period. Data collectors will put their signature for they could
obtain verbal consent for the interview from the respondents

3.14. Expected Outcome

Because of the novelty of the disease and easily availability of different triggering factors for
depression and anxiety like chat in the study area as well as the fatality rate of the COVID 19 the
prevalence of depression and anxiety will be able to expect to high and different factors will be
expected as an associated factors of depression and anxiety among health care workers.

3.15. Information Dissemination

The findings of the study will be submitted to Haramaya University (school of graduate studies)
and Jugol hospital and Hiwot Fana specialized hospital and Harari regional health bureau. The
research report will be also submitted to all relevant stakeholders through reports and
presentations. Finally, efforts will be made to publish results in national and international
journals for dissemination worldwide.

3.16. Limitation of the Study

There will be important limitations in interpreting the results of this study. The cross-sectional
study design limits causal inference as a result of uncertainty about the direction of the
associations. The study sample will be a homogeneous population; all the study area will be
registered in urban and more than half of the people live in urban and the results of this study
will not address those HCW who give service from other health facilities, as a result, might not
be generalized to other populations
 4. WORK PLAN
Table 2:- work plan for the study prevalence of depression, anxiety and factors associated with it
related to COVID 19 pandemic among HCW working at Harar public hospitals, eastern Ethiopia,
2021
Activity Responsib March April May June July Augus Septe Octob
ility t 2021 mber er
2021 2021 2021 2021 2021 2021 2021

Topic selection PI

Proposal preparation PI

Final proposal PI
submission

Ethical clearance, PI
Training of data
collectors

Pretest PI+DC

Data collection DC+SP

Data process & PI+ SP

analysis

First draft submission PI

Thesis defense PI

Submission of a final PI
paper

PI: principal investigator DC: data collector SP: super visor

 5. BUDGET BREAK DOWN

Table 3:- Budget break down for the study prevalence of depression, anxiety and factors
associated with it related to COVID 19 pandemic among HCW working at Harar public
hospitals, eastern Ethiopia, 2021

Table 3.1 Stationary budget

No Item Unit cost Quantity Total cost Total price

1 Pencil 5 birr 5 5x5 25

2 Pen 6 birr 6 6x6 36

3 Ruler 15 birr 5 15x5 15

4 Rubber 5 birr 1 5x1 75

5 Sharpener 15 birr 1 15x1 15

6 Marker 250 birr 1 250x1 250

7 Paper 3 birr 400 3x400 1200

8 Photocopy 3 birr 90 3x90 270

9 Printing 5 birr 90 5x90 450

10 Stapler 80 birr 2 80x2 160

11 Flash 200 birr 5 500x5 2500

12 Scotched tape 100 birr 1 100x1 100

13 Binder 40 birr 5 40x5 200

14 Calculator 120 birr 1 120x1 120

15 Notebook 30 birr 5 30x5 150

16 Total 419 birr 482 5566

Table 3.2 Personnel cost

Personal Payment No of person Multiple Total
factors (birr
per day x no of
working day x
no data
collector

Data collector 100 EB 4 100x4x30 12,000

Supervisor 150 1 150 x30 4500

Secretary 10 birr per page 1 1x5x3x40 1200

Subtotal 17,700

Table 3.3 Communication and Transportation

Items Unit cost Quantity Multiple costs Total

Mobile card 50 4 50x4x5 1000

Transport 10 30 30x5x10 1500

Coffee or tea 50 15 50x15x5 3750

Subtotal 6250

Table 3.4 Budget Summary

Description Amount/birr

Stationary cost 5566

Personal cost 17700

Communication 6250

Total 29,516

Source of budget: - Self sponsor

 6. REFERENCES
AKISKAL. S (2005) Mood disorders: Historical introduction and conceptual overview. In: Sadock BJ,
Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 1.
Baltimore: Lippincott Williams & Wilkins; 2015:1559.
ASSEFA, B. (2020) Prevalence and Factors Associated with Depression and Anxiety ofhealth
professionals working at Hospitalized Patients with COVID-19 in St.peter Specialized Hospital
Treatment Centers. journal of psychiatry 23;15.
BAHARI R (2019) The psychological impact of diabetic limb problems Int Med J Malaysia., 14(2), 3-7.
BJELLAND.I, D. A., HAUG.T, AND, NECKELMANN,D, (2012) the vallidation of hiospital anxiety and
depression scall. journal of psychosom Res, 52 (79-78).
CHEKOLE.Y, Y. M., MEKONNEN.S, AND, MEKURIAW,B, (2020) Perceived Stress and Its Associated
Factors during COVID-19 among Healthcare Providers in Ethiopia: A Cross-Sectional Study.
Hindawi Advances in Public Health
20
7 pages.
CHERNG. L, A. M., HATTA.S,MANSOR. S, AND, JAAFAR,R, (2021) Depression, anxiety, and the COVID-
19 pandemic: Severity of symptoms and associated factors among Health care workers at the
university hospital after the end of the movement lockdown. plose one, 101, 139-98.
CS (2007) central stastical agency 2007 report.
DAGNEI. H, A. A., ALEMU. K, AZALE.T, YITAYIH.S,DAGNEW.B, ALEMAYEHU.A, ANDUALEM.Z,
SISAYI.M,TADESSE.M, CHEKOL.M, MAMO.E, AND, SIMEGN,W, (2021) Anxiety and associated
factors among Ethiopian health professionals at early stage of COVID-19 pandemic in Ethiopia.
PLoS ONE 16(6), 11-39.
DALGARD.OS (2013) the 3-items social support scale., 3-8.
ELL K., K. W., CABASSA LJ., XIE B., LEE P-J., A. & KAPETANOVIC S. (2019) Depression and anxiety among
Low-Income Hispanics health workers related to COVID 19 : Design Elements of a Socio-
Culturally Adapted Collaborative Care Model Randomized Controlled Trial. Int J Psychiatry
Med., 39(2) 113 131.
GETACHEW R., B. M., KALE B., WORKI K., A. AND G/EGIZABHER. Y, (2019) Depressive disorder and its
associated factors among HCW in Debre Berhan Town, North Showa, Ethiopia.
HABTEWOLD TD., A. S., A. & HAILE YG. (2019) Sociodemographic, clinical, and psychosocial factors
associated with depression among health care workers working at outpatients department in
Black Lion.
HRHB (2013) Hrarari regional health bureau 2013 E.C annual report, harar.
IMAN A. BASHETII.D, Q. N., MHAIDAT, HALA.N, AND, MHAIDAT, (2021) Prevalence of anxiety and
depression during COVID-19 pandemic among healthcare students in Jordan and its effect on
their learning process: A national survey. plose one, 31, 23-39.
JIANBO.L, S. M., AND,WANG,Y, (2019) Factors Associated With Mental Health Outcomes Among
Health Care Workers Exposed to Coronavirus Disease 2019. jornal of psychiatry 51, 32-35.
KEVIN.P, Y. D., DIANA.L, KOLCZ.P, DAVID.M, JEREMY.F, AND,KENNETH,R, (2020) Health Care Workers’
Mental Health and Quality of Life During COVID-19: Results From a Mid-Pandemic, National
Survey. Psychiatric Services 72, 122-128.
KHADEMIAN. F, D. S., KOOHJAN.Z, AND, KHADEMIAN,Z, (2021) An investigation of depression,
anxiety, and stress and its relating factors during COVID- 19 pandemic in Iran. BMC public
health 21, 275-77.
KHALAF. O, M. A., KHALIL, AND, ABDELMAKSOUD,R, (2020) Coping with depression and anxiety in
Egyptian physicians during COVID-19 pandemic. Middle East Current Psychiatry, 27, 27-63.
KHATUN. F, P. M., RASHID.M, ALAM.S, KAMRUNNAHAR.M,TALUKDER.A, RAZU.S, WARD,P, AND,
ALI,M, (2021) mental health of physicianss during COVID-19 outbreak in bangladsh:-aweb
based cross-sectional study. public health 21, 101-73.
KNYCHALA MA., J. M., MINIZ CK., FARIA PN., A. & JORGE PT (2019) High-risk alcohol use and anxiety
and depression symptoms in adolescents and among health care workers related to covid 19:
a cross-sectional study. . Diabetol Metab Syndr., 7(1), 24.
MAK IWC, C. C., PAN PC, ET AL (2009) Long-Term psychiatric morbidities among SARS survivors Gen
Hosp Psychiatry 31, 318–26.
MAUTONG.H, R. J., VILLA. G, CADENA.J, MOLINA. D, ROMÁN.C, AND, CHERREZ,I, (2021) Assessment of
depression, anxiety and stress levels in the Ecuadorian health workers during social isolation
due to the COVID-19 outbreak: a cross-sectional study. BMC Psychiatry, 21, 212.
MCEVOY PM, G. R., SLADE T. (2017) Epidemiology of anxiety disorders in the general population:
fndings of the 2017 international survey of mental health and Wellbeing. Journal of
Psychiatry., 45(11), 957–967.
MING.Y, X. M., WANG.W, XIAO.F, JING.L, SHAO.K, RAN.R, YUAN.L,AND,QIAO,Y, (2020) Psychological
impact of COVID-19 on medical care workers in China. BMC jornal 9,, 27-30.
MOHAMED.H, ATTIA.N, MOHAMMED.R, A. & ELSAID, A. (2021) Stress, anxiety and depression among
healthcare workers facing COVID-19 pandemic in Egypt: a cross-sectional online-based study.
BMJ, 10.
MULFNGER N, S. A., STUBER F, ET AL (2019) Cluster-Randomised trial evaluating a complex
intervention to improve mental health and wellbeing of employees working in hospital – a
protocol for the SEEGEN
trial. BMC Public Health 2019;19:1694.
PORTER.C, F. M., HITTMEYER.A, SCOTT.D,JIMÉNEZ.A,ELLANKI.R,WOLDEHANNA.T,5 LE THUC DUC,
MICHELLE G, AND, STEIN,A, (2021) mpact of the COVID-19 pandemic on anxiety and
depression symptoms of young people in the global south: evidence from a four-country
cohort study. BMJ, 11, 11-37.
SALARI. N, H. A., JALALI.R, RAYGANI.R, RASOULPOOR.S, MOHAMMADI. M, RASOULPOOR. S, AND, K,
(2020) Prevalence of stress, anxiety, depression among health care workers during the COVID-
19 pandemic: a systematic review and meta-analysis. jornal of globalazetion and health 16:57,
20-58.
TAM.W, P. P., LAM.C,AND, CHIU,HF, (2013) Severe acute respiratory syndrome (SARS) in Hong Kong in
2013: stress and psychological impact among frontline healthcare workers. Psychol Med.
(7):1197–1204.
TESHOME.A, G. M., SHEGAZE.M,TEKABE.B, GETIE.A, ASEFA.G,GETAHUN.D,AND, KANKO,T, (2020)
Generalized Anxiety Disorder and Its Associated Factors Among Health Care Workers Fighting
COVID-19 in Southern Ethiopia. Psychology Research and Behavior Management, 13.
WANG, C., HORBY, P. W., HAYDEN, G. & GAO, G. F. (2019) A novel coronavirus outbreak of global
health concern. Lancet 395, 470-473 (2020).
WANG D, H. B., HU C, ET AL. (2019) Clinical characteristics of 138 hospitalized patients with 2019 novel
coronavirus–on health care workers in Wuhan, China. . JAMA 2020;323:1061–9.
WHO (2018) Alcohol, Smoking and Substance involvement Screening Test (ASSIST v 3.) to assess the
substnace behaviour of the participants
WHO (2019) World Health Organization. Coronavirus Disease 2019 (World Health Organization, 2020).
WHO (2021) world health organazetion COVID-19 corona virus pandemic update on june 18,2021
WHO. (2011) The WHO STEPwise approach to noncommunicable disease risk factor surveillance
(STEPS).
XIANG Y-T, Y. Y., LI W, ET AL (2020) Timely mental health care for the 2019 novel coronavirus outbreak
is urgently needed. The Lancet Psychiatry 2020;7:228–9.
ZHENG W (2019) Mental health and a novel coronavirus (2019-nCoV) in China. J Affect Disord
2020;269:201–2.
ZHOU.Y, D. H., ZHANG.Y, ZHANG.B, GUO.Y, CHEUNG.T, HALL.B, SHI.T, XIANG.Y, AND, TANG,Y, (2021)
Prevalence of poor psychiatric status and sleep quality among frontline healthcare workers
during and after the COVID-19 outbreak: a longitudinal study. Translational Psychiatry, 11,
112-138.
ZHU.N, Z. D., AND, WANG,W, (2019) A novel coronavirus from patients with pneumonia in China,
2019. N Engl J Med Overseas Ed;382:727-33.
ZIGMOND.AS, A., SNAITH,RP, (1983) the hospital anxiety and depression scale. Acta Psychiatry
scandinavica 67(6):361-370.

7 APPENDIXES:

7.1Appendex I: - Information Sheet and Informed Consent Form Heads of the jugal
hospital and HFSUH

My name is Fnuel Tesfye attending my MPH study at Haramaya University. I am here to

conduct a study at your hospital. I conduct this study under Haramaya University, College of
Health and Medical Sciences, for partial fulfillment of master of public health in General Public
health. It will also have paramount importance for your hospital to know the problem under
study and act accordingly. So I kindly request you to give me time to explain the study
importance, ethical issues and how the study will be conducted. First I would like to thank you
for your time and help.

The study/project title:

Prevalence and Factors Associated with depression and anxiety related to COVID -19 among
HCW working at at Hiwot Fana Specialized University hospital and Jugola Hospital Harar,
Eastern Ethiopia,2021

Purpose/Aim of the study:

Knowing the magnitude of depression, anxiety and its associated factors are paramount
importance for hospital health office to plan strategies that can address preventive message
towards prevention and control of consequence of depression and anxiety on HCW. Moreover,
the main aim of this study is to write a thesis as a partial requirement for the fulfillment of a
Master’s Program in General Public Health for the principal investigator.

Procedure and duration:

My data collectors will be interviewing HCW using a questionnaire to provide me with pertinent
data that is helpful for the study. There are 64 questions to answer where my data collector will
fill the questionnaire by interviewing them. The interview on each participants takes about 25-30
minutes

Risks and benefits:

The risk of conducting this study is very minimal but taking a few minutes from participants'
time. There would not be any direct payment for participating in this study. But the findings from
this research may reveal important information for the local health planners concerning the
prevalence of depression, anxiety and its consequence.

Confidentiality:
The information that we collect during this study will be kept confidential, any personal
information (name or any other identification) will not be recorded in questioner or in recording
material rather coding will be employed and all the information taken from participants will be
kept safely and confidentially.

Rights:

Participation in my study is fully voluntary. The participants have the right to declare to
participate or not in the study. If they decide to participate, they have the right to withdraw from
the study at any time and this will not label them for any loss of benefits that you otherwise are
entitled. They do not have to answer any question that they do not want to answer.

Contact address

Contact address: If you have any questions about the study, the procedure or anything else
related to the study, please contact through the following address:

Principal investigator: Fnuel Tesfaye

E-mail: ---------

Mobile phone: +251-921020092

Institutional Health Research Ethics Review Committee (IHRERC) Haramaya University: Office
phone: 0254660708: P.O.BOX: 235, Harar 39

Declaration of informed voluntary consent:-

I have read the participant information sheet. I have clearly understood the purpose of the
research, the procedures, the risks and benefits, issues of confidentiality, the rights of participants
and the contact address for any requirements. I have been allowed to ask questions for things that
may have been unclear. I was informed that the participants have the right to withdraw from the
study at any time or not to answer any question that they do not want. I am also informed that the
hospital has the right to stop the study from being conducted in the hospital if any misdeeds and
unethical procedures are reported during the data collection process in the hospital's premises.
Also, I understand that the hospital has the right to use the result of the study as public property.
Therefore; I declare my voluntary consent on behalf of ------------ hospital management to allow
this study to be conducted in the institution with my initials (signature).

Name and signature of the Head of the hospital: __________________________

Signature of data collector: __________________________

Thank you for your cooperation!

7.2 Appendix II: - participant information sheet and informed voluntary consent form
for adult participants

My name is -------------------------------------------- I am working as a data collector for the study

being conducted in this community by Fnuel Tesfaye who is studying for his Master’s degree at
Haramaya University, the College of Health and Medical Sciences. I kindly request you to lend
me your attention to explain to you about the study and being selected as the study participant

The study/project title:

Prevalence and Factors Associated with depression and anxiety related to COVID -19 among
HCW working at at Hiwot Fana Specialized University hospital and Jugola Hospital Harar,
Eastern Ethiopia,2021

Purpose/Aim of the study:

The findings of this study can be of paramount importance for the woreda health office to plan
intervention programs to decrease the prevalence of depression, anxiety and prevent
consequences in your HCWs; thereby improve the health of people and the health of HCW in
general. Moreover, this study aims to write a thesis as a partial requirement for the fulfillment of
a Master's Program in general public health for the principal investigator

Procedure and duration:

I will be interviewing you using a questionnaire to provide me with pertinent data that is helpful
for the study. There are 64 questions to answer where I will fill the questionnaire by interviewing
you. The interview will take about 25-30 minutes, so I kindly request you to spare me this time
for the interview

Risks and benefits:

The risk of being participating in this study is very minimal, but only taking a few minutes from
your time. There would not be any direct payment for participating in this study. But the findings
from this research may reveal important information for the local health planners

Confidentiality:

The information you will provide us will be confidential. There will be no information that will
identify you in particular. The findings of the study will be general for the study community and
will not reflect anything particular of individual persons or housing. The questionnaire will be
coded to exclude showing names. No reference will be made in oral or written reports that could
link participants to the research

Rights:
Participation in this study is fully voluntary. You have the right to declare to participate or not in
this study. If you decide to participate, you have the right to withdraw from the study at any time
and this will not label you for any loss of benefits that you otherwise are entitled. You do not
have to answer any question that you do not want to answer.

Contact address:

If there are any questions or enquires any time about the study or the procedures, please contact:

Phone number

Mobile phone: +251-921020092

Email: ----------@gmail.com

Contact address of the responsible Institutional Health Research Ethics Review Committee
(IHRERC) at office phone 0254662011 or P.O.Box 235, Harar, Ethiopia].

Declaration of informed voluntary consent:

I have read/ was read to me/ the participant information sheet. I have clearly understood the
purpose of the research, the procedures, the risks and benefits, issues of confidentiality, the rights
of participating and the contact address for any queries. I have been allowed to ask questions for
things that may have been unclear. I was informed that I have the right to withdraw from the
study at any time or not to answer any question that I do not want. Therefore, I declare my
voluntary consent to participate in this study with my initials (signature)

Name and signature of participant:___________________ ___________ Date _________

Name and signature of Data Collector:_____________ ___________ Date _________

Thank you for your cooperation
 7.3. Appendix III: English Version Questionnaire on the prevalence of depression, anxiety
and factors associated with it related to COVID 19- among HCW working at Harar public
hospital in eastern Ethiopia, 2021
Name of the Hospital: _____________________
Interview code: ___________________________
Interviewer Name: _________________________

Part I: Socio-demographic information on the prevalence of depression, anxiety and factors

associated with it related to COVID-19 among HCW working at Harar public hospital in eastern
Ethiopia, 2021

Code Question Respondents possible answer Response Skip

Q101 What is your age? ( in a --------------------in years

completed year )

Q102 Sex 1. Male

2. Female

Q103 What is your Residence? 1. Urban

2. Rural

Q104 What is your marital status? 1. Single

2. Married
3. Divorced
4. Widowed
5. Separated

Q105 What is your educational 1. Cannot read and write

status? 2. Read and write only
3. Primarily school ( 1-8)
4. Secondary school (1-9)
5. Collage /university
Q106 What is your occupational 1. Farmer
status? 2. Governmental employer
3. Privet worker
4. Merchant
5. Other (___ specify)____

Q107 What is your religion? Muslim

Orthodox

Protestant

Catholic

Other (specify) ________

Q108 What is your ethnicity? 1. Oromo

2. Amara
3. Harari
4. Tigray
5. Other ( specify)______

Q109 What is your living 1. With family

circumstance? 2. Alone
3. Other (specify)_______

Q Current location of job

110

Q111 What is your average house _______________in ETB

hold monthly income?
 Q112 Number of family including ________________
you in the house

Part II:- question related to clinical factors

S. No VARIABLES RESPONSE

Q201 Do you have any medical chronic 1. Yes

innless 2. No

Q202 If yes in Q C201, what type of medical 1. DM

illness you have ? 2. Hypertension
3. HIV/AIDS
4. TB
5. Others ( please specify it ---------)

Q203 If Yes in Q201 what is the duration ? 1. Less than 1 year

2. 1-5 years
3. Greater than or equals 5 years

Q204 If yes in Q201 do you used medication 1. Yes

for your medical illness regularly? 2. No

Q205 If yes in Q Q204 there any 1. Yes

complication related your medication 2. No
that you used

Q206 Do you have any sleep problem 1. Yes

related to COVID-19 2. No
Q207 Do you have any psychiatric 1. Yes
disorder 2. No

Q208 Presence of Comorbidities 1. Yes

2. No

Q209 If yes in Q208 which you have? 1. Hypertension

2. Renal disease
3. Neuropathy
4. Others (specify)____________

Q2010 Have you ever been told by a doctor or other 1. Yes

health worker that you have a Depressive 2. No
disorder or anxiet ? (

Q2011 Family history of depression or anxiety 1. Yes

2. No

Q2012 If yes “Q2011” specify the relationship of

the family member

Part III. Questionnaire related Social Support of the study on the prevalence of depression and
anxiety and its associated factors related to COVID-19 among HCW working at Harar public
hospital eastern Ethiopia

Instruction: - The following three questions which are also known as OSLO tool asks about
how you experience your social relationships. The inquiry is about your immediate personal
experience. Please tell me the one option that represents your experience.

Code Questions Respondents possible answer

Q301 How many people are so close to you None 1 or 2 3-5 More than 5
that you can count on them if you have
serious personal problems?

1 2 3 4

Q302 How much concern do people show in No Little Uncertai Some A lot of
what you are doing? concern concern n concern concern
and and and and interest
interest interest interest

Q303 How easy is it to get practical help from Very difficult Possible Easy Very easy
neighbors if you should need it? difficult

1 2 3 4 5

Part - IV: questions related to the substance use of the study on the prevalence of depression,
anxiety and factors associate with is related to COVID-19 among HCW working at Harar public
hospital eastern Ethiopia

Instruction: - The following questions going to ask you some questions about substance use

Code

Tobacco use

Questions Participant Response Skip

possible response

Q401 Do you currently smoke any tobacco products, such as 1. Yes If no skip
cigarettes, cigars or pipes? 2. No to Q405
Q402 Do you currently smoke tobacco products daily? 1. Yes
2. No

Q403 How old were you when you first started smoking? _______in years

Q404 During the past 12 months, have you tried to stop smoking? 1. Yes
2. No

Q405 In the past, did you ever smoke any tobacco products? 1. Yes
2. No

Alcohol Consumption

Q406 Have you ever consumed any alcohol such as beer, wine, 1. Yes If no skip
and/or local alcohols (Areke, Tela. Tej, …)? 2. No to Q407

Q407 Have you consumed any alcohol within the past 12 1. Yes If no skip
months? 2. No to Q411

Q408 Have you consumed any alcohol within the past 30 days? 1. Yes
2. No

Q410 During the past 30 days, how frequently have you had at 1. Daily
Least one standard alcoholic drink? 2. 5-6 days per
week
3. 3-4 days per
week
4. 1-2 days per
week
5. 1-3 days per
week
6. Less than
once a month
 7. Never

Khat use

Q411 Have you ever used in the past 12-month Khat? (non – 1. Yes
medical use only) 2. No

Q412 In the past three months, have you ever used Khat? (non – 1. Yes
medical use only) 2. No

Shisha

Q413 In your lifetime, have you ever used Shisha? (non –medical 1. Yes
use only) 2. No

Q414 In the past three months, have you ever used Shisha? (non 1. Yes
– medical use only) 2. No

Q15 Do you use illicit drugs like cocaine, amphetamine, 1. Yes

marijuana? 2. No
 Part -V: Questions regarding asses depression and anxiety of the study on the prevalence of
depression, anxiety and factors associated with it related to COVID-19 among HCW working at
Harar public hospital eastern Ethiopia

Instruction: - Over the last two weeks, how often have you been bothered by any of the
following problems related to the current COVID 19 pandemic

Tick the box beside the reply that is closest to how you have been feeling in the past week. Don’t
take too long over you replies: your immediate is best.

Code Questions of Anxiety Not at all Sometimes Very often Nearly all
the time

Q501 I feel tense or 'wound up' 0 1 2 3

Q502 I still enjoy the things I used to enjoy 0 1 2 3

Q503 I get a sort of frightened feeling as if something 0 1 2 3

awful is about to happen:

Q504 I can laugh and see the funny side of things 0 1 2 3

Q505 Worrying thoughts go through my mind 0 1 2 3

Q506 I feel cheerful 0 1 2 3

Q507 I can sit at ease and feel relaxed 0 1 2 3

Question for Depression

Q508 I feel as if I am slowed down 0 1 2 3

Q509 I get a sort of frightened feeling like 'butterflies' 0 1 2 3

in the stomach

Q5010 I have lost interest in my appearance 0 1 2 3

Q5011 I feel restless as I have to be on the move 0 1 2 3

Q5012 I look forward with enjoyment to things 0 1 2 3

Q5013 I get sudden feelings of panic 0 1 2 3

Q5014 I can enjoy a good book or radio or TV program: 0 1 2 3

END

Thanks