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The Magnitude of Psychological Problem and Associated Factor in Response to COVID-19 Pandemic Among Communities Living in Addis Ababa, Ethiopia, March 2020: A Cross-Sectional Study Design

Purpose COVID-19 pandemic is a World Health Organization day-to-day work and has a significant crisis on the physical and mental health of humans. However, little is known about the mental health crisis of the pandemic in Sub-Saharan countries. Therefore, this study aimed to determine the magnitude of psychological problems and associated factors among communities living in Addis Ababa, Ethiopia. Methods A community-based cross-sectional study design was conducted from March 10 to 30, 2020. Data were collected from 420 respondents selected using a consecutive sampling technique. An online self-administered and Depression, Anxiety, and Stress Scale (DASS-21) survey during the initial phase of the pandemic was conducted to assess the presence of psychological problems for the last two weeks in response to the infection. Results The magnitude of the psychological problem from moderate to severe levels was 66.4%. The predictor variables of the outcome were female gender, above the secondary level of education, monthly income below 3000 ETB, and more than three family size at 95% CI, P<0.05. Conclusion At the time of the initial COVID-19 pandemic in Ethiopia, nearly two-thirds of the respondents reported moderate to severe levels of psychological problems. Therefore, working on those identified factors would be vital to promote the mental resilience of a community towards the pandemic.


Introduction
The 2019 coronavirus disease (COVID-19) pandemic has first occurred in Wuhan city of China. 1 It has a wide coverage and death report as compared to the 2012 first Middle East respiratory syndrome (MERS) outbreak in Saudi Arabia. 2 The distribution of the virus at a global level is about 6,175,207 cases (224,172 deaths), in Africa 74,663 cases (973 deaths), and Ethiopia 2336 cases (32 deaths). 3 The pandemic is the global public health emergency due to its rapid transmission, the increment of the confirmed case, and death. 4 It is highly contagious and transmits to humans through respiratory droplets, human body contact, surface contact, and symptoms were fever, cough, fatigue, breathing difficulty. 5 The incubation period of the virus was from 2 to 11 days, and this helps for a quarantine period of duration for suspected cases. 6 Individuals with other chronic medical conditions or age greater than 65 years were highly vulnerable to be infected and showed poor treatment outcome. 7 The prevention strategies of the virus were to limit physical contact to the extent of home lockdown, avoid public meetings, minimize the number of passengers during transportation, and talk with keeping one-meter social distance, use of a facemask, and frequent hand washing with soaps and water. 8 The most common mental and psychosocial disturbances seen during the previous outbreaks occurred in a different part of the world were hopelessness, anger, loss of interest, fear of death, the difficulty of initiating and maintaining sleep, loss of appetite, and anxiety. [9][10][11] The current pandemic causes suicide, stress, confusion, anger, fear, frustration, boredom, financial loss, and stigma among confirmed cases and communities living in the world. 12 During this pandemic period, having mental and psychological problems leads to poor self-hygiene, appetite, sleep, immunity status, and commitment to obey commands recommended by health professionals that all enhance the susceptibility for infection. 13,14 After the occurrence of the pandemic, in Italy, 38%, 15 china 53.8%, 16 Australia 78%, 17 France 38.6% 18 and India 25.3% 19 of the respondents were developed mild to moderate psychological distress including anxiety, stress and depression.
The contributing factors for experiencing mental and psychological problems in response to the pandemic were female gender, older age, medical comorbidity, poor social support, more family size, low-income status, and educational level. [15][16][17][18] To manage the mental health impacts of the pandemic, scholar recommends to limit the sources of stress, break the isolation with online communication media, regular sleep, and diet patterns, focus on the benefit of separation, ask professional for outpatient and inpatient mental health service. 20,21 The mental health impact of this pandemic in developing countries might be significant due to limited resources, unintegrated health-care systems, and a lack of skilled health-care providers. Despite this fact, there are no adequate studies conducted in this regard. Therefore, this study aimed to determine the magnitude of psychological problems in response to the pandemic and its associated factor among communities living in Addis Ababa, the Capital city of Ethiopia. The results of this study will serve to generate appropriate mental health crisis management guidelines for the promotion of the psychosocial wellbeing of a community in response to the pandemic.

Study Design, Setting and Period
This study was a community-based cross-sectional study design conducted from March 10-30 at Addis Ababa, Capital city of Ethiopia, and the first Ethiopian city in which COVID-19 confirmed cases reported. Currently, six million peoples were living in the city.

Study Participants
The source of the population for this study was all social media users (Facebook and telegram) living in the town, Addis Ababa, and all users during the study period were study populations. The exclusion criteria of the study were all users less than 18 years of age.

Sample Size and Sampling Technique
The sample size was calculated using the single proportion formula by considering p value of the previous study done in china on the same pandemic 53.8%. 16 The single proportion formula of cross-sectional study design (n = required sample size n= Z (α/2) 2 pq/d2) was used.

Data Quality Control
The English version of the questioner first translated into Amharic, the official language of the study area, and then back-translated to English to check the consistency of the English version questioner. The data collectors used the Amharic version of the questioner for data collection.
The investigator conducted a pretest among 21 respondents before one week of the actual data collection. The researcher trained both the data collectors and supervisors for about four days about the purpose of the study. The supervisors checked all the data collectors at an online survey cite about the completeness of the questioner and discarded the incomplete before data entry.

Statistical Analysis
The data coded, entered, and checked on Epi-Data Version 3.4 and exported to SPSS (Statistical Package for Social Science) version 24 for analysis. A Bivariate logistic regression analysis at a p-value of ≤0.25 used to identify the association of each independent variable with the outcome variables. Bivariate logistic regression at p-value ≤0.25, used to identify variables candidate for multiple logistic regression analysis. Multivariable logistic regression analysis at p-value ≤0.05, used to control the possible effect of confounders and identify independent predictors of the outcome variable. Hosmer and Lemeshow goodness of fit test was used to check the model fitness.

Socio-Demographic Characteristics
One-third of the respondents have a single marital status, and nearly two-thirds of the respondents have more than a secondary level of education. The mean age onset and monthly income of the respondents were 27 years and 3000 ETB, respectively (Table 1).

Knowledge, Attitude, and Practice About Coronavirus
All respondents heard about the coronavirus, and their source of information was Facebook, TV, radio, Telegram, families, and friends. Nearly two-thirds of respondents were thinking, as coronavirus is very dangerous. One-third of the respondents reported as they used preventive measures such as washing their hands, wearing a facemask, and keeping a social distance ( Table 2).

Prevalence of Psychological Problem
Nearly two-thirds (66.4%) of the respondents had moderate to severe levels of a psychological problem, 36% anxiety, 12.4% depression, and 18% stress ( Figure 1).

Factors Associated with Psychological Problems
During multivariate logistic regression analysis, the independent predictor variables were Gender, educational status, monthly income, family size, contact with the person came abroad, and history of chills and fever at p< 0.05 (Table 3).

Discussion
This study found that 66.4% of the respondents were experienced moderate to severe form psychological problems, including stress, anxiety, and depression in response to COVID-19 pandemic. This result was very high and implicated, as there is a need for immediate mental health crisis intervention. This study finding was higher than the study done in Italy, 38%, 15 china 53.8%, 16 Australia 78%, 17 France 38.6%, 18 and India 25.3%. 19 It might be due to the difference in socioeconomic, cultural, and environmental factors such as literacy, norms, attitudes, and resources contribute to coping with the psychological crisis of the pandemic.
This study found that being female gender was the independent predictor for the psychological problem in response to the pandemic. This finding was consistent with other studies done in Italy, 15 France, 18 and china. 16 Naturally, females have a low level of tolerance for stressful situations. In Ethiopia, females have a high responsibility for the health of the family.
The current research found that having more than a secondary level of education had two times more to develop the psychological problem as compared to those who had primary level education. This result was inconsistent with the studies done in Russia 25 and China. 26 It might be due to a chance to work outside the home through contact with different people and high expectations from the community and government in controlling and preventing the pandemic with limited resources.
This study found that monthly income less than 3000 ETB had two times the odds of having psychological problems. This finding was similar to a study done in Saudi Arabia. 27 Among low-income respondents, the socioeconomic impact of a virus might be much significant to the extent of unable to buy safety measures of prevention, such as facemask, soaps, and sanitizers. In-addition during this pandemic period, they were not able to fulfill their basic needs of day-to-day life.
The current study found that having more than three family size at home was associated with psychological problems in response to the pandemic, and this is in     19 The number of family member contribute to contracting the virus due to the high chance of contact with different people. This study revealed that respondents with the past two weeks of chills, fever, cough, and dizziness over the past two weeks had three times increased the odds of having psychological problems in response to the pandemic. This finding was similar to the study done in China. 16 A similar presentation of the current symptoms with coronavirus symptoms leads to misinterpretation of being infected with the virus.
The odds of developing psychological problem among those who had recent contact with peoples who came abroad were two times higher than as compared to those who no history of contact with foreign peoples. This result supported by the studies done in Italy. 15 In Ethiopia, the first confirmed case was a man who came from Japan, and thus contacting foreign peoples and came from abroad would result in a high chance of worry about getting the infection.

Limitation of the Study
It was a cross-sectional study design, challenging to conclude regarding causality and alternative explanations of the findings. The data collection method of this study was an onlineadministered questioner that is prone to information bias.

Conclusions
Most of the respondents (66.4%) had a psychological problem, and the modifiable factors of this study were monthly income below 3000 ETB, current symptoms of chills, fever, cough, and dizziness and having recent contact with people who came from abroad.
Therefore, government and private health sector organizations were highly responsible for preventing and controlling the mental health crisis of the pandemic through transmitting up-to-date and specific information through different social media about the prevention of the virus, what to do if the symptoms occur to themselves, family and community. There should be a continuous supply of precautionary preventive equipment, including facemask, water, soap, alcohol, and sanitizer for those who had more than three family members and low income. The mental health professional should give on-call, outpatient, and inpatient mental health services for clients who developmental and psychological problems in response to the epidemic.
The pandemic task force groups of the country might use these findings to formulate an emergency mental health intervention guideline to promote the psychological resilience of a community in response to the COVID-19 pandemic.