Prevalence and associated Factors of Anxiety among Type 2 Diabetes Mellitus Patients on Follow Up at Ambo General Hospital, Oromia Regional State, Ethiopia, Institutional Based Cross Sectional Study

Diabetes Mellitus (DM) is a common health problem with serious medical and economic consequences. Between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries [1]. Anxiety is a vague, subjective, non-specific feeling of uneasiness, apprehension, tension, (excessive nervousness) fears, and a sense of impending doom, irrational avoidance of objects or situation and anxiety attack [2]. The anxiety disorders make up one of the most common groups of psychiatric disorders and the National co-morbidity study reported that one of four persons met the diagnostic criteria for at least one anxiety disorder and that there is a 12-month prevalence rate of 17.7% [3].

Anxiety has been found to be associated with a negative impact on diabetes mellitus patients [4]. Presence of anxiety symptoms significantly impairs the Health Related Quality of Life among those with diabetes mellitus patients [5]. 

Studies conducted in different countries on prevalence of anxiety among type 2 Diabetes mellitus patients shows that 68.0% in Unit kingdom [6], 55.10% in Mexican [7], 29% in North India [8], 35.3% in Qatar [9], 44.9% in Romanian [10], 88.3% in Hospital of Lithuanian [11], 56.1% in China [12], 67% in Bardar Abbas, Southern Iran [13], 69.6% in Tehran Iran [14], 30.5% and 31,4% in Malaysia [15,16], 57.9% in Pakistan [17] and 58.7% in Guinea [18].

Being women, older, single, with a low educational level, more diabetes complications, anxiety symptoms, greater than five years duration and currently use of alcohol and smoking were significant associated factors anxiety among type 2 diabetes mellitus patients [14-17].

Moreover, anxiety is independently associated with increased chronic complication among patients with type 2 diabetes mellitus. Anxiety has been found to be associated with a negative impact among patients with type 2 diabetes mellitus. Despite their known effect on the population, there is no data available in the study area. Therefore, this study was planned to determine the prevalence and associated factors of anxiety among patients with type 2 diabetes mellitus at Ambo General Hospital, Oromia Regional State, Ethiopia.

The study was a cross sectional design, conducted from April to May, 2016 in Ambo General Hospital, Oromia regional state, Western Ethiopia. All adult patients (age ≥ 18) with type 2 diabetes mellitus who had regular follow were included in the sample. Critically ill patients were excluded from the study. Among 993 DM patients who had regular follow-up at diabetes clinics, 423 type 2 DM patients were recruited for the study. Study participants were included using systematic random sampling technique.

Data were collected by trained psychiatry nurses using pretested interviewer administered questionnaire. The data collection instrument had different components. The first part includes socio-demographic characteristics (age, Sex, education, occupation, marital status and others). The instrument was adopted and translated to Afan Oromo language and back to English and highly reliable in the study (Cronbach’s α = 0.89). An outcome variable (presence of anxiety) was collected by Hospital Anxiety & Depression scale (HADS-A). HADS-A is a 7-item questionnaire, commonly used to screen for symptoms of anxiety and depression 7-item sub-scales for anxiety. It was validated in Ethiopia and its internal consistency was 0.78 for anxiety subscales and 0.87 for full scale. The scales use a cut off score for anxiety of greater than or equal to 8 [19].

Data were analyzed using SPSS version 20. Bivariate analysis was done to see the association of each independent variable with the outcome variable. Potential confounders (important) variables were entered into binary logistic regression model to identify the effect of each independent variable with the outcome variables. A p-value of less than 0.05 was considered statistically significant, and adjusted odds ratio with 95 % CI was calculated to determine association.

Ethical clearance was obtained from the Research and Ethics Review Committee of the Ambo University College of medicine and health science. Permission letter was obtained from Ambo Hospital administration office. Written informed consent was obtained from each study participant and they were informed about their rights to interrupt the interview at any time. Confidentiality was maintained at all levels of the study. Type 2 DM patients who were found to have moderate to severe anxiety were referred to psychiatry clinics for further investigations.

A total of 423 participants were recruited for the study which makes the response rate 100%. The mean (± SD) age of the respondents was 45.21 (±15.72) years. Among the respondents, 244 (57.7%) were female, 287 (67.8%) were married, 171 (40.4%) were farmers, 132 (31.2%) were attended primary education, and 116 (27%) the median monthly income of the participants was 2151 (Table 1).

 

	Variables	Frequency	Percentage
	<30	41	9.7
Age	30-39	62	14.7
	40-49	100	23.6
	50-59	74	17.5
	≥60	146	34.5
Sex	Male	179	42.3
	Female	244	57.7
Religion	Orthodox	204	48.2
	Protestant	182	43.0
	Muslim	37	8.7
	Others	12	2.8
	Oromo	361	85.3
	Amhara	44	10.4
	Gurage	10	2.4
	Tigre	6	1.4
	Others	2	0.5
Educational status	No formal education	94	22.2
	Primary school	132	31.6
	Secondary School	83	19.6
	Diploma and above	114	27.0
Marital status	Married	287	67.8
	Single	61	14.4
	Divorced	28	6.6
	Widowed	47	11.1
Occupational status	Employed	112	26.5
	Merchant	83	19.6
	Farmer	104	24.6
	House wife	80	18.9
	Others	44	10.4
Family monthly income	≤500	105	24.8
	500-1200	95	22.5
	1201­-2151	116	27.4
	>2151	107	25.3

Table 1: Distribution of type 2 DM patients at Ambo General Hospital, Oromia Regional State, Ethiopia, 2016.

Two hundred eight nine (68.3%) of the respondents reported less than or equal to five years duration of diabetes diagnosis, 98 (23.2%) of the study population had at least one chronic complication of diabetes mellitus and 74 (17.5%) of the respondents had at least one other additional chronic disease and 43 (10.2%) of participants were reported history of current alcohol users (Table 2).

 

	Variables	Frequency	Percentage
Duration of illness	≤5 years	289	68.3
	>5 years	134	31.7
Chronic complication of diabetes	Yes	98	23.2
	No	325	76.8
Additional chronic disease	Yes	74	17.5
	No	349	82.5
History of substance users (alcohol, khat & cigarette)	Yes	243	57.4
	No	180	42.6
Currently substance users (alcohol, khat & cigarette)	Yes	55	13
	No	368	87

Table 2: Description of clinical, psychosocial and substance use factors among patients with type 2 diabetes mellitus at Ambo General Hospital, Oromia Regional State, Ethiopia, 2016.

The prevalence of anxiety among Type 2 DM patients was 44.2%.

Binary logistic regression analysis revealed that being female, greater than five years duration of diabetes mellitus diagnosis, chronic complication of diabetes mellitus and other additional chronic disease were statistically significant with anxiety (Table 3).

 

*P value is significant at P<0.05 

**P value is significant at P<0.01
***P value is significant at P<0.001

This study revealed that the prevalence of anxiety was 44.2%. The finding was similar with other studies carried out in Romania 44.9 % [10]. On the other hand, the current study finding was higher than the study done in Mexican 55.10% [7], in United kingdom 68% [6], in hospital of Lithuanmia 88.3% [11],in China 56.1% [12], in Bardar Abbas, Southern Iran 67% [13], in Tehran Iran 69,6% [14], in Pakistan 57.9% [17], and in Guinea 58.7% [18]and lower than the study was done in North India 29% [8],in Qatar 35.3% [9] and in Malaysia 30.5% and 31.4% [15,16]. The variation might be due to the difference in study design, data collection tool, sample size and difference in study participants.

One of the factors significantly associated with anxiety was being female. The finding is similar with the study conducted in Hospital of Lithuanian University of Health Sciences, Romania, China, Bardar Abbas, Sothern Iran Tehran Iran, Malaysia and Guinea [10,12,13,16,18], Being type 2 DM diagnosed greater than five years significantly associated similar with study done in Hospital of Lithuanian University of Health Sciences, Tehran Iran, Qatar,in Malaysia and in Pakistan [11,14-17].

This is similar with a study conducted in in Mexican, in china, in Malaysia and Pakistan [7,12,15-17]. Previous study has proven that presence of complication and other complication of chronic disease are highly associated with anxiety.

The prevalence of anxiety 44.2% among Type 2 DM patients was high. Anxiety had statistically significant association with being female sex, chronic complication, greater than five duration of type 2 DM diagnosis and additional other chronic disease. Oromia Health Bureau should develop guidelines to screen and treat anxiety among Type 2 DM patients. Further research on risk factors of anxiety should be conducted to strengthen and broaden the current findings.