Study design, setting and period
An institution-based cross-sectional study was conducted from November to January, 2019, at Dessie referral hospital. The hospital is found in the Amhara region located 401 km far from Addis Ababa, the capital city of Ethiopia. The hospital is serving more than five million people of the town and nearby districts. In addition to the general services, the hospital also provides antiretroviral therapy services for more than 6, 763 HIV/AIDS (6279 adults and 484 pediatric) patients since the service started.
Population and samples
Patients aged 18 years and above and took ART treatment for at least 6 months and attending ART clinic during the data collection period were the study population.
The sample size was determined by using single proportion formula with the assumptions of prevalence (P) of depression among HIVAIDS positive adults (38.94%) obtained from a study conducted in Debrebrhan [14] hospital, 95% confidence level, margin of error 5%, and 10% non-response rate and the final sample size became 403. Finally, the study participants selected by using systematic random sampling technique among ART clinic visitors.
Data collection procedure
Before initiation of the data collection process questionnaire was prepared in English by reviewing different literatures then translated to local language Amharic to keep its consistencies. The data collection tool has socio demographic, clinical, stigma, psychosocial and depression measurement questions. Depression was measured using the nine-item standardized Patient Health Questionnaire (PHQ-9) depressive symptoms scale. It has a Likert scale with the following response options: 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day. It has 0–27 scoring as minimal (1–4), mild (5–9), moderate (10–14), moderately severe (15–19) and severe depressive symptoms (20–27). This is one of the most widely used scales and has been also used in Ethiopia, it is reliable, valid, sensitive and specific to measure depression [15].
Data were collected by interview administered questionnaire to recall for depressive symptoms within 2 weeks, other socio-demographic and clinical characteristics harvested through patient document review. To ensure the validity of the study pretest of the tool and 2 days training was given for two data collectors and one supervisor about the objective of the study and how to make and interview with HIV/AIDS patients.
Depression: Participants who were interviewed and scored five and above using patient health questioner 9 (PHQ-9) were considered as depressed [15].
Good adherence: If the average adherence level (95% or more adherence = missing ≤ 2 doses of 30 doses or ≤ 3 doses of 60 doses) and try to assess by asking the missed doses with in the past 3 days, within 1 week and within 1 month [16].
Fair adherence : (85–94% or 4–8 doses missed per month) [16].
Poor adherence: (less than 85% or ≥ 9 doses missed per month) [16].
Perceived stigma: Participants who scored above the median score ≥ 24 were perceived stigma and who scored below the median score (< 24) were not perceived stigma measured by using the HIV stigma scale [17].
Social support: The OSS-3 scores ranged from 3 to 14 with a score of 3–8 = poor support; 9–11 = moderate support; and 12–14 = strong support [18].
Body Mass Index: based on Nutritional assessment classification underweight < 18.5 kg/m2, Normal = 18.5–24.9 kg/m2, over weight ≥ 25 kg/m2 [19].
Data processing and analysis
The data was cleaned and entered into Epi info version 7 then exported to STATA Version 14 for data management and analysis. Descriptive statistics like percentage, median (IQR) were used to summarize socio-demographic and clinical characteristics and presented in the form of text, table and graphs. Binary logistic regression model was fitted to identify factors associated with depression on HIV/AIDS patients. Crude and adjusted odds ratio with 95% CI computed to see the presence and strength of association between independent variables and depression. Variables having a p-value of 0.05 and less in the multivariable logistic model considered as significantly associated with depression. Model fitness was checked by using Hosmer and Lemeshow goodness of fit test.
Ethical consideration
Ethical clearance was obtained from the University of Gondar College of medicine and health sciences ethical review committee before data collection process. An official permission letter was also written to Dessie referral hospital. Respondents were informed about the purpose of the study and verbal consent was obtained from each respondent. Moreover, all the study participants were informed that they have a full right to decline from the study and they were also assured for an attainment of confidentiality for the information obtained from them. Patients who had depression during data collection were linked to psychiatry clinic for further treatment and intervention.