1. Introduction {#sec1}
===============

Anxiety and depression are common mental illnesses. The total number of people living with anxiety and depression in the world is estimated to 322 million and 264 million, respectively \[[@B1]\]. In spite of this fact, anxiety and depression are common in diabetes, hypertension, and heart failure patients than the general population \[[@B2]\].

A systematic review and meta-analysis study reported that anxiety and depression were common among patients with chronic illness in both developed and developing countries \[[@B3]\]. Another systematic and meta-analysis conducted in Ethiopia indicates that depression is a common comorbid illness among patients with diabetes \[[@B4]\]. According to the national report of Australia Health, half of all Australians living with a chronic health condition experience depression or anxiety \[[@B5]\].

Anxiety and depression have a bidirectional relation with chronic illnesses \[[@B6], [@B7]\]. A review of anxiety disorders, hypertension, and cardiovascular risk indicated that hypertensive patients develop anxiety more likely \[[@B8]\]. Anxiety and depression causes chronic stimulation of sympathetic nervous system that results in insulin resistance and affects the function of the heart and blood vessels \[[@B6]\].

Having a chronic illness puts a person at greater risk of developing anxiety or depression. A study which is conducted in USA and China stated that both anxiety and depression are the major comorbidities in patients with chronic illnesses \[[@B9]\]. One recent study which is conducted in 15 nations reported that anxiety is highly prevalent in patients with chronic illness especially in diabetes patients \[[@B10]\]. However, anxiety and depression are remaining unrecognized and untreated.

Anxiety and depression have numerous negative health outcomes in patients with chronic illnesses. Medication nonadherence, rapid disease progression, and poor health outcomes were effects of untreated and unrecognized anxiety and depression \[[@B9]\]. Anxiety and depression are so overwhelming; they can interfere with a person\'s ability to function day to day and poor quality of life \[[@B11]\]. American Diabetes Association revealed that the mortality risk for diabetes patients is high in the presence of depression or anxiety or both \[[@B12]\].

There are different factors that affect the prevalence of anxiety and depression among patients with chronic illness. A systematic review and meta-analysis conducted in Ethiopia revealed that age, sex, and duration of disease were factors associated with depression \[[@B4]\]. Low educational level, body mass index, income, lack of social support, and residence of patients were the other factors associated with anxiety and depression \[[@B11], [@B13], [@B14]\].

Identifying factors associated with anxiety and depression is helpful for early screening and management. Nevertheless, factors associated with depression and anxiety in patients with diabetes, hypertension, and heart failure are not assessed adequately in developing countries including Ethiopia. Thus, this study was initiated to examine factors associated with anxiety and depression among patients with diabetes, hypertension, and heart failure in Dessie Referral Hospital, Northeast Ethiopia.

2. Methods {#sec2}
==========

2.1. Study Area and Period {#sec2.1}
--------------------------

The study was conducted at Dessie Referral Hospital which is found in Dessie town. Dessie town, which is an administrative town of South Wollo Zone, is 401 km far from Addis Ababa in the northeast direction. Dessie Referral Hospital, which is one of the frontline hospitals in Ethiopia, serves more than 3.5 million people as a referral hospital. It has about 749 workers. From this, 548 are health professionals and 201 are administrative staffs serving in the hospital. Out of those health professionals, 332 are nurses and 61 of them are diploma nurses. The study was conducted from February 22, 2019 to April 6, 2019.

2.2. Study Design {#sec2.2}
-----------------

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

2.3. Source Population {#sec2.3}
----------------------

All patients with diabetes, hypertension, and heart failure who are on follow-up in Dessie Referral Hospital were sources of population.

2.4. Study Population {#sec2.4}
---------------------

All patients with diabetes, hypertension, and heart failure who are on follow-up in Dessie Referral Hospital during the data collection period were the study populations.

2.5. Inclusion and Exclusion Criteria {#sec2.5}
-------------------------------------

### 2.5.1. Inclusion Criteria {#sec2.5.1}

On follow-up patients who are diagnosed either with hypertension or diabetes or heart failure and who are 18 years and above were included

### 2.5.2. Exclusion Criteria {#sec2.5.2}

Patients unable to communicate were excluded

### 2.5.3. Sample Size Determination {#sec2.5.3}

The sample size for the first objective was calculated by using the single-population proportion formula with 95% confidence level, 5% margin of error, and proportion of depression among patients with heart failure. Proportion, which is 51.1% %, was taken from a study conducted on depression among heart failure patients in three public hospitals of Northwest Ethiopia \[[@B15]\]. It was calculated as follows: $$\begin{matrix}
{N = \frac{\left( Z_{a/2} \right)^{2}\left( P \right)\left( {1 - P} \right)}{D^{2}},} \\
\end{matrix}$$where *N* is the sample size, *Z*~*a*/2~ = 1.96 (standardized normal distribution curve value for the 95% confidence interval), *P* = 0.8165 (proportion of depression among patients with heart failure) and *D* = 0.05 (degree of margin of error): $$\begin{matrix}
{N = \frac{\left( 1.96 \right)^{2}\left( 0.51 \right)\left( 0.49 \right)}{\left( 0.05 \right)^{2}},} \\
{N = 384.5,} \\
{\left. N = \right.\sim 385.} \\
\end{matrix}$$

Therefore, by adding a 5% nonresponse rate of 385, the total sample size was 404.

### 2.5.4. Sampling Technique and Procedure {#sec2.5.4}

The study utilized a stratified random sampling technique. Initially, patients with a chronic illness were stratified into diabetes mellitus (DM), hypertension, and heart failure based on their diagnosis. After that, the total sample size was allocated for each stratum based on their proportion. Then, study participants were selected by systematic sampling in every *k*^th^ value which is 6 from each stratum. The *k* value was calculated from the proportion of sample in each stratum to the total population. The first patient was selected by simple random sampling from patients who are coming for follow-up during the data collection period. After that, data were collected in every 6^th^ patient from each stratum until the total sample size is achieved.

### 2.5.5. Variables {#sec2.5.5}

Dependent variables were anxiety and depression, and independent variables were sociodemographic variables (sex, age, educational level, marital status, resident, occupation, monthly income, family size, weight, height, and BMI), disease characteristics (duration of disease since diagnosis, number of medication), perception towards prognosis of illness, substance and alcohol use (coffee and tea use, smoking, chat chewing, uses of hashish and shisha, and alcohol drinking), and physical activity.

2.6. Data Collection Tool and Procedures {#sec2.6}
----------------------------------------

### 2.6.1. Data Collection Tool {#sec2.6.1}

The data were collected by using a structured questionnaire which is adapted from previous research. It has 3 parts. The first part asked about the sociodemographic status of the study participants. The second part measured the level of anxiety and depression with generalized anxiety disorder and patient health questionnaire, respectively. In this study, internal reliability for GAD-7 questionnaires and PHQ-2 questionnaires were 0.76 and 0.8, respectively. The third part focused on factors such as physical activity, substance use, alcohol use, and support from anyone. Physical activity was screened by the International Physical Activity Questionnaire (IPAQ-7) which is a standardized tool for measurement of physical activity for patients with chronic illnesses. All parts of the questionnaire were prepared in English version initially and translated into Amharic then back to English to check their consistency. Additionally, weight (in kilogram) and height (in meter) for nonpregnant and edematous patient were measured by data collectors during data collection.

### 2.6.2. Data Collection Procedures {#sec2.6.2}

After preparing the questionnaire, 4 BSc nurses for data collection and 1 BSc nurse as a supervisor were recruited. A two-day training was given for each of them on the meaning of every items of the questionnaire and the techniques of data collection such as ways of greeting, ways of taking consent, ways of data quality monitoring during height and weight measurement, and ways of addressing ambiguous items. Data were collected by face-to-face interview after patients finish their visit.

Patients were interviewed with 7 questions to assess their level of physical activity. The total score of questions was categorized into three levels: inactive, those individuals who do not meet the criteria for minimally active or health-enhancing physical activity (HEPA); minimally active, 3 or more days of vigorous activity of at least 20 minutes per day or 5 or more days of moderate-intensity activity or walking of at least 30 minutes per day or 5 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities achieving a minimum of at least 600 metabolic equivalent (MET) (min/week); and health-enhancing physical activity, vigorous-intensity activity on at least 3 days achieving a minimum of at least 1500 metabolic equivalent (MET) (minutes/week) or 7 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities achieving a minimum of at least 3000 MET (minutes/week).

Height and weight were measured for nonpregnant and edematous patients during the data collection period by data collectors. To avoid a repeated interview for patients with repeated visit, data collectors asked and verified whether the patient is interviewed or not before data collection. The supervisor and principal investigator monitored closely the data collection process.

### 2.6.3. Data Quality Assurance {#sec2.6.3}

The quality of data was assured by training the data collectors and supervisor, carefully designing the questionnaire, monitoring the data collection process, and checking the completeness of data during data collection time. In addition to these, all questionnaires were pretested on 10% of the sample size (40 respondents) at Hidar 11 Primary Hospital to address confusing items and to increase the quality of data. During the pretest, some respondents were confused on the duration of anxiety questions and physical activity questions. To address this confusing issue, data collectors tried to remind the duration in each section of the questionnaire at the time of data collection.

### 2.6.4. Data Processing and Analysis Procedure {#sec2.6.4}

After data collection, completely collected data were entered in to EpiData version 3.1 and exported to Statistical Package and Service Product (SPSS) version 25 for analysis. During analysis, the study participants who scored 9 and above in the Generalized Anxiety Disorder item 7 (GAD-7) questionnaire were categorized as having anxiety, and study participants who scored 3 and above in the Patient Health Questionnaire item 2 (PHQ-2) questionnaire were categorized as positive for depression disorder. The results of the study was presented by using texts, tables, and figures, and the binary logistic regression model was enrolled by considering 95% confidence level and a *P* value of 0.05. Multivariable binary logistic regression was done by taking variables that have a *P* value of ≤ 0.2 from bivariable logistic regression to identify factors associated with anxiety and depression.

3. Result {#sec3}
=========

3.1. Sociodemographic and Economic Characteristics {#sec3.1}
--------------------------------------------------

From a total of 405 respondents, 384 respondents participated with a 94.8% response rate. Among these, 179 (46.6%) were female, 152 (39.6%) were illiterate (unable to read and write), 241 (62.8%) were married, and 138 (35.9%) were farmers. The median age of respondents was 45 (IQR = 30), and 53 (13.8%) of the respondents were 65 and above years of age. From the total respondents, 151 (39.3%) of them lived in rural areas. Although 149 (38.8%) of the respondents had a family size of more than four, above one-fifth of the total respondents 84 (21.9%) did not get any support from others. BMI was calculated for 371 nonpregnant and edematous respondents, and among these, above one-fifth of them were overweight (BMI ≥ 25 kg/m^2^) ([Table 1](#tab1){ref-type="table"}).

3.2. Disease Characteristics {#sec3.2}
----------------------------

From the total study participants, 39 (10.2%) had poor perception towards the prognosis of their illness. For 64 (16.7%) study participants, the duration of disease since diagnosis was above 6 years. From the total study participants, 26 (6.8%) took 5 and above drugs daily in the past one month ([Table 2](#tab2){ref-type="table"}).

3.3. Substance and Alcohol Use {#sec3.3}
------------------------------

From the total study participants, majority 311 (81%) of them drank coffee and/or tea in the past one month. Only 4 (1%) respondents smoke cigarettes in the past month, and twenty-eight (7.3%) drank any type of alcohol in the past one month. From the sum score of alcohol drinking, smoking cigarette, chat chewing, and using shisha, and others, 32 (8.3%) of them took at least one substance in the past month ([Table 3](#tab3){ref-type="table"}).

3.4. Physical Activity {#sec3.4}
----------------------

Physical activity was assessed for only 332 study participants since others were excluded from the analysis during data cleaning because of incomplete data. Among these respondents, the level of physical activity for one-third 110 (33.1%) of them was inactive and minimally active ([Figure 1](#fig1){ref-type="fig"}).

3.5. Prevalence of Anxiety {#sec3.5}
--------------------------

From the total study participants, 123 (32%) had anxiety. Among the total hypertensive patients, 34.8% had anxiety. The prevalence of anxiety based on disease condition is presented in [Figure 2](#fig2){ref-type="fig"}.

3.6. Prevalence of Depression {#sec3.6}
-----------------------------

In this study, among the total of 384 study participants, only 5.73% had depression. From the total heart failure patients, 11.1% had depression. The prevalence of depression based on the disease condition is presented in [Figure 3](#fig3){ref-type="fig"}.

3.7. Factors Associated with Anxiety {#sec3.7}
------------------------------------

Variables which have an association with anxiety at *P* value ≤ 0.2 in bivariable logistic regression were educational status, marital status, occupation, residence, perception towards prognosis of illness, physical activity, body mass index, monthly income, supported by someone, and substance use (chat, cigarette, shisha, hashish, and alcohol). These were entered in multivariable logistic regression to identify factors associated with anxiety. However, in multivariable logistic regression, only educational level, marital status, monthly income, perception towards prognosis of illness, and substance use were associated with anxiety at *P* value \< 0.05. According to the result, patients who did not read and write develop anxiety 7.89 times more likely compared with those whose educational status is diploma and above (AOR: 7.89; 95% CI: 3.08-20.26; *P* = 0.001). Patients who took substances like chat, cigarette, shisha, hashish, and alcohol develop anxiety 2.56 times more likely compared with their counterparts (AOR: 2.56; 95% CI: 1.05--6.23; *P* = 0.038) ([Table 4](#tab4){ref-type="table"}).

3.8. Factors Associated with Depression {#sec3.8}
---------------------------------------

Variables which have an association with depression at *P* value ≤ 0.2 in bivariable logistic regression were sex, marital status, occupation, residence, perception towards prognosis of illness, physical activity, body mass index, number of drugs, and monthly income. These were entered in multivariable logistic regression to identify factors associated with depression. However, in multivariable logistic regression, only marital status and physical activity were associated with depression at *P* value \< 0.05. According to the result, patients whose level of physical activity is inactive develop depression 24 times more likely than patients who did a health-enhancing physical activity (AOR: 24.03; 95% CI: 6.01--96.08; *P* = 0.001). Patients whose marital status is widowed develop depression 5 times more likely compared with patients who are married (AOR: 4.75; 95% CI: 1.25--18.05; *P* = 0.001) ([Table 5](#tab5){ref-type="table"}).

4. Discussion {#sec4}
=============

Anxiety and depression are common in patients with diabetes, hypertension, and heart failure. Despite this fact, there is lack of attention to screening and early treatment. Identifying risk factors is helpful for early screening and treatment. Thus, this study was carried out to assess factors associated with anxiety and depression among patients with diabetes, hypertension, and heart failure in Dessie Referral Hospital.

In this study, the prevalence of anxiety among patients with diabetes, hypertension, and heart failure was 32% (95% CI: 27.3%-36.7%). This finding is consistent with the finding of studies conducted in Korea (30%) \[[@B16]\] and Brazil (33.7%) \[[@B17]\]. This is lower than the finding of a study conducted in three Asian countries (Cambodia, Myanmar, and Vietnam) (17%) \[[@B18]\]. However, this finding was lower than studies conducted in Saudi Arabia (45%) \[[@B19]\]. The reason for this discrepancy could be the difference in study period, source population, and socioeconomic difference. In addition, the use of different tools could be the other reason for the discrepancy.

This study revealed that the prevalence of depression among patients with diabetes, hypertension, and heart failure was 5.73% (95% CI: 3.4%-8.3%). This finding is in line with the magnitude of depression among pregnant women in a study conducted at Malaysia (6.9%) \[[@B20]\]. However, this is lower than studies conducted in three public hospitals of Northwest Ethiopia (51%) \[[@B15]\], Addis Ababa (21%) \[[@B21]\], the pooled prevalence of depression among patients with diabetes in Ethiopia (39.73%) \[[@B22]\], Saudi Arabia (37.4%) \[[@B19]\], China (31.4%) \[[@B23]\], and the three Asian countries (39.1%) \[[@B18]\]. The possible justification for this discrepancy might be the difference in tool, source population, and socioeconomic difference. For example, in a study conducted in three public hospitals of Northwest Ethiopia, only patients with heart failure were included. In addition, a study conducted at Addis Ababa included asthmatic patients. In this study, patients with heart failure, hypertension, and diabetes were included.

In this study, anxiety had a significant association with low educational level. Patients who do not read and write develop anxiety 7.89 times more likely compared with those whose educational status is diploma and above (AOR: 7.89; 95% CI: 3.08-20.26; *P* = 0.001). The possible justification for this finding might be related with poor health perception and management in patients with low educational level. This finding is consistent with the report of study conducted in Pakistan among diabetes patients \[[@B14]\].

This study revealed that patients whose level of physical activity is inactive develop depression 24 times more likely than patients who did a health-enhancing physical activity (AOR: 24.03; 95% CI: 6.01--96.08; *P* = 0.001). The possible justification for this might be because of the stimulation of the hypothalamus and the production of endorphins during exercise. When endorphins are produced, they resemble the opiates and produce analgesia and sense of wellbeing. This is in line with the finding of a study conducted in Pakistan \[[@B24]\].

Marital status was statistically associated with depression. According to the finding, patients who were single reported depression 4 times more likely compared with married patients (AOR: 4.02; 95% CI: 1.05--15.41, *P* = 0.001). The possible justification for this might be the lack of social support for single patients. This finding was consistent with the finding of a study conducted in Addis Ababa \[[@B21]\], Saudi Arabia \[[@B19]\], and Spain \[[@B25]\].

The association between substance use and depression was not seen. This is consistent with the report of a study conducted in Addis Ababa \[[@B21]\]. However, the association between substance use and depression was reported in different studies \[[@B15], [@B26]\]. Unlike depression, substance use is statistically associated with anxiety. Patients who took substances like chat, cigarette, hashish, and alcohol develop anxiety 2.56 times more likely compared with their counterparts (AOR: 2.56; 95% CI: 1.05-6.23; *P* = 0.038). This might be because of withdrawal effect.

5. Limitation of Study {#sec5}
======================

This study has limitations although it has different methodological strengths. However, having a cross-sectional study design is the limitation of this study. This study assessed anxiety and depression for only diabetes, hypertension, and heart failure patients. It cannot be generalized for other chronic illnesses.

6. Conclusion and Recommendations {#sec6}
=================================

Lower educational level, being single, higher monthly income, and poor perception to prognosis of illness were factors associated with anxiety among patients with diabetes, hypertension, and heart failure. On the other hand, being single and inactive to physical activity were factors associated with depression among patients with diabetes, hypertension, and heart failure. Any patient with diabetes, hypertension, and heart failure should be screened, recognized, and treated for anxiety and depression. Patients with low educational level and monthly income should be screened early for anxiety. Health care providers provide advice to patients with diabetes, hypertension, and heart failure about physical activity to prevent depression. Researchers should investigate more regarding the factors affecting depression and anxiety among patients with other chronic illnesses. Policy makers should develop a guideline for the screening and treatment of anxiety and depression.

We want to forward our heartfelt thanks to the study participants and data collectors for their commitment and cooperation during data collection period. We would also like to thank Dessie Referral Hospital and Wollo University for their support.

Data Availability
=================

The data used to support the findings of this study are available from the corresponding author upon request.

Ethical Approval
================

Before data collection period, ethical clearance and approval was obtained from Wollo University College of Health Science Research and Ethical Committee (Com/Nurs/135/11). A supportive letter was given to the Dessie Referral Hospital and permission was obtained from hospital manager to implement the study.

Consent
=======

Prior to interviewing the respondents, the aim and objectives of the study were clearly explained to the participants and oral informed consent was obtained. Additionally, participants were informed about the right to ask questions and stop response in anywhere. Confidentiality and anonymity were ensured throughout the execution of the study.

Conflicts of Interest
=====================

The authors declared that they have no conflict of interest.

Authors\' Contributions
=======================

Afework Edmealem conceived and designed the study and performed analysis and interpretation of data. Dr. Caridad Sanchez Olis advised and supervised the design conception, analysis and interpretation of data, and made critical comments at each step of research. All authors read and approved the final Manuscript. Confidentiality and anonymity were ensured throughout the execution of the study.

![Level of physical activity among patients with diabetes, hypertension and heart failure at Dessie Referral Hospital, 2019.](BN2020-3609873.001){#fig1}

![Prevalence of anxiety among patients with diabetes, hypertension and heart failure in Dessie Referral Hospital, Northeast Ethiopia, 2019.](BN2020-3609873.002){#fig2}

![Prevalence of depression among patients with diabetes, hypertension, and heart failure at Dessie Referral Hospital, 2019.](BN2020-3609873.003){#fig3}

###### 

Sociodemographic status of patients with diabetes, hypertension, and heart failure at Dessie Referral Hospital, 2019 (*N* = 384).

  Variable                                   Category                   Frequency   Percentage
  ------------------------------------------ -------------------------- ----------- ------------
  Sex                                        Female                     179         46.6
  Male                                       205                        53.4        
                                                                                    
  Age                                        18-24                      52          13.6
  25-29                                      38                         9.9         
  30-34                                      30                         7.8         
  35-44                                      65                         16.9        
  45-64                                      146                        38.0        
  ≥65                                        53                         13.8        
                                                                                    
  Educational level                          Unable to read and write   152         39.6
  Able to read and write (informal school)   32                         8.3         
  Grade 1-8                                  53                         13.8        
  Grade 9-12                                 54                         14.1        
  Certificate                                12                         3.1         
  Diploma and above                          81                         21.1        
                                                                                    
  Marital status                             Single                     68          17.7
  Married                                    241                        62.8        
  Widow                                      53                         13.8        
  Divorced                                   22                         5.7         
                                                                                    
  Residence                                  Urban                      233         60.7
  Rural                                      151                        39.3        
                                                                                    
  Occupation                                 Farmer                     138         35.9
  Merchant                                   125                        32.5        
  Student                                    26                         6.8         
  Gov\'t or non gov\'t employee              84                         21.9        
  Others (retired, no permanent job)         11                         2.9         
                                                                                    
  Monthly income (ETB)                       ≤1000                      113         29.4
  1001-2000                                  84                         21.9        
  2001-3500                                  96                         25          
  \>3500                                     91                         23.7        
                                                                                    
  Family size                                ≤4                         235         61.2
  \>4                                        149                        38.8        
                                                                                    
  Any support                                Yes                        300         78.1
  No                                         84                         21.9        
                                                                                    
  BMI                                        Underweight                38          10.3
  Normal                                     255                        68.7        
  Overweight                                 78                         21          

Note: monthly income was categorized based on quartile range; family size was based on mean; BMI was based on WHO weight classification for Ethiopia.

###### 

Disease characteristics and individual factors among patients with diabetes, hypertension, and heart failure at Dessie Referral Hospital, 2019 (*N* = 384).

  Variable                                  Category        Frequency   Percent (%)
  ----------------------------------------- --------------- ----------- -------------
  Perception towards prognosis of illness   Good            240         62.5%
  Fair                                      105             27.3%       
  Poor                                      39              10.2%       
                                                                        
  Duration of disease after diagnosis       Below 3 years   163         42.4%
  3 to 6 years                              157             40.9%       
  Above 6 years                             64              16.7%       
                                                                        
  Number of drugs taken daily               Below 5 drugs   358         93.2%
  5 and above drugs                         26              6.8%        

###### 

Substance and alcohol use among patients with diabetes, hypertension, and heart failure at Dessie Referral Hospital, 2019 (*N* = 384).

  Variable                                                                                  Category   Frequency   Percent (%)
  ----------------------------------------------------------------------------------------- ---------- ----------- -------------
  Coffee and/or tea                                                                         Yes        311         81
  No                                                                                        73         19          
                                                                                                                   
  Cigarette smoking                                                                         Yes        4           1
  No                                                                                        380        99          
                                                                                                                   
  Alcohol drinking                                                                          Yes        28          7.3
  No                                                                                        356        92.7        
                                                                                                                   
  Chat chewing                                                                              Yes        1           0.3
  No                                                                                        383        99.7        
                                                                                                                   
  Using shisha and other substances                                                         Yes        0           0
  No                                                                                        384        100         
                                                                                                                   
  Sum of substance uses (alcohol drinking, chat chewing, cigarette smoking, shisha, etc.)   Yes        32          8.3
  No                                                                                        352        91.7        

###### 

Bivariable and multivariable logistic regression output on the association between anxiety and factors, 2019 (*N* = 384).

  Variable                             Category                   Anxiety   COR                   AOR                   *P* value          
  ------------------------------------ -------------------------- --------- --------------------- --------------------- ------------------ -------
  Educational level                    Unable to read and write   86        66                    1                     1                  0.001
  Able to read and write               23                         9         0.51 (0.22-1.17)      7.91 (3.08-20.26)                        
  Grade 1-8                            41                         12        0.38 (0.18-0.78)^∗^   3.81 (1.18-12.32)                        
  Grade 9-12                           36                         18        0.65 (0.34-1.24)      1.18 (0.39-3.54)                         
  Certificate                          7                          5         0.93 (0.28-3.06)      3.53 (1.30-9.57)                         
  Diploma and above                    68                         13        0.24 (0.12-0.48)^∗^   3.83 (0.82-17.93)                        
                                                                                                                                           
  Marital status                       Single                     41        27                    1.67 (0.95-2.93)      2.82 (1.35-5.91)   0.032
  Married                              173                        68        1                     1                                        
  Widowed                              33                         20        1.54 (0.82-2.87)      0.80 (0.35-1.85)                         
  Divorced                             14                         8         1.45 (0.58-3.62)      0.74 (0.23-2.40)                         
                                                                                                                                           
  Residence                            Urban                      173       60                    0.48 (0.31-0.75)^∗^                      
  Rural                                88                         63        1                                                              
                                                                                                                                           
  Occupation                           Farmer                     83        55                    1                                        
  Merchant                             85                         40        0.71 (0.42-1.17)                                               
  Student                              16                         10        0.94 (0.39-2.23)                                               
  Employee                             69                         15        0.32 (0.17-0.63)^∗^                                            
  Others                               8                          3         0.56 (0.14-2.22)                                               
                                                                                                                                           
  Monthly income                       ≤1000                      65        48                    1                     1                  0.001
  1001-2000                            54                         30        0.75 (0.42-1.34)      0.57 (0.28-1.17)                         
  2001- 3500                           76                         20        0.35 (0.19-0.66)^∗^   0.25 (0.12-0.54)                         
  \>3500                               66                         25        0.51(0.28-0.92)       1.25 (0.53-2.93)                         
                                                                                                                                           
  Perception to prognosis of illness   Good                       176       64                    1                     1                  0.022
  Fair                                 63                         42        1.83 (1.13-2.97)^∗^   2.28 (1.27-4.10)                         
  Poor                                 22                         17        2.12 (1.06-4.25)^∗^   1.41 (0.61-3.23)                         
                                                                                                                                           
  Substance use                        Yes                        17        14                    1.99 (0.96-4.13)      2.56 (1.05-6.23)   0.038
  No                                   244                        108       1                     1                                        
                                                                                                                                           
  Physical activity                    Inactive                   12        11                    1.72 (0.72-4.09)                         
  Minimally active                     62                         25        0.75 (0.44-1.30)                                               
  HEPA                                 145                        77        1                                                              
                                                                                                                                           
  BMI                                  Undernutrition             23        25                    1.30 (0.64-2.62)                         
  Normal                               170                        85        1                                                              
  Overweight                           59                         19        0.64 (0.36-1.14)                                               

Notes: Hosmer and Lemeshow test = 0.954; ^∗^Significant variables at *P* value \< 0.05 in bivariable logistic regression.

###### 

Bivariable and multivariable logistic regression output on the association between depression and factors, 2019 (*N* = 384).

  Variable                             Category         Depression   COR                    AOR                    *P* value           
  ------------------------------------ ---------------- ------------ ---------------------- ---------------------- ------------------- --
  Sex                                  Female           165          14                     2.08 (0.85-5.10)                           
  Male                                 197              8            1                                                                 
                                                                                                                                       
  Marital status                       Single           62           6                      3.23 (1.04-9.97)^∗^    4.02 (1.05-15.41)   
  Married                              234              7            1                      1                      0.001               
  Widowed                              45               8            5.94 (2.05-17.21)^∗^   4.75 (1.25-18.05)                          
  Divorced                             21               1            1.59 (0.18-13.56)                                                 
                                                                                                                                       
  Residence                            Urban            225          8                      0.34 (0.14-0.85)                           
  Rural                                137              14           1                                                                 
                                                                                                                                       
  Occupation                           Farmer           128          10                     1                                          
  Merchant                             116              9            0.99 (0.39-2.52)                                                  
  Student                              24               2            1.06 (0.22-5.17)                                                  
  Employee                             84               0                                                                              
  Others (retired, no job)             10               1            1.28 (0.14-11.03)^∗^                                              
                                                                                                                                       
  Monthly income                       ≤1000            101          12                     1                                          
  1001-2000                            78               6            0.64(0.23-1.80)                                                   
  2001--3500                           94               2            0.18(0.03-0.82)^∗^                                                
  \>3500                               89               2            0.18(0.04-0.87)^∗^                                                
                                                                                                                                       
  Perception to prognosis of illness   Good             232          8                      1                                          
  Fair                                 96               9            2.71 (1.01-7.25)^∗^                                               
  Poor                                 34               5            4.26 (1.31-13.79)^∗^                                              
                                                                                                                                       
  Substance use                        Yes              331          21                     0.5 (0.06-3.90)                            
  No                                   31               1            1                                                                 
                                                                                                                                       
  Physical activity                    Inactive         16           7                      18.98 (5.41-66.6)^∗^   2.13 (0.58-7.83)    
  Minimally active                     81               6            3.21 (0.95-10.82)^∗^   24.03 (6.01-96.0)                          
  HEPA                                 217              5            1                      1                      0.001               
                                                                                                                                       
  BMI                                  Undernutrition   33           5                      2.82 (0.94-8.42)                           
  Normal                               242              13           1                                                                 
  Overweight                           75               3            0.74 (0.20-2.68)                                                  
                                                                                                                                       
  Number of drugs                      \<5 drugs        339          19                     1                                          
  ≥5 drugs                             23               3            2.32 (0.64-8.44)                                                  

Notes: Hosmer and Lemeshow test = 0.709; ^∗^Significant variables at *P* value \< 0.05 in bivariable logistic regression.

[^1]: Academic Editor: Luigi Trojano
