Psychological Distress During the COVID-19 Pandemic in Ethiopia: The Need for Equal Attention of Intervention


 Background: The COVID-19 pandemic led individuals to suffer from different levels of mental health problems such as psychological distress, anxiety, depression, denial, panic, and fear. This study aimed at determining the prevalence of psychological distress and associated factors among the Ethiopian population during the COVID-19 pandemic. Methods:A cross-sectional study was performed through an online survey using different online platforms. The questionnaire was created through Google Form and the survey link was administered by e-mail,LinkedIn,Telegram, and Facebook. Educated Ethiopian population who have access to the internet were invited to participate through an online survey and addressed to 929respondents. The psychological distress was assessed using the Kessler 10 item tool to measure psychological distress. Data were analyzed using SPSS andlogistic regression to examine mutually adjusted associations, expressed as adjusted odds ratios.A generalized additive model was also employed to identify additional predictors using R.Results:The prevalence of high psychological distress among the study population was 236(25.5%). Of all respondents, 421(45.1%) had low psychological distress, 274(29.4%) had moderate psychological distress, 164 (17.6%) had high psychological distress, and 72 (7.3%) had very high psychological distress.Psychological distress increased with being at young and middle-aged adults, getting information from social media, and not correctlypracticing infection prevention and control measures to prevent COVID-19 infection. Respondents with high perceived severity had increased psychological distress. On the contrary, those with the highest score of perceived response efficacy had low distress.Conclusion:Prevalence of psychological distress was substantial. Intervention of psychological distress is critically essential. The intervention target groupsare those whose information sourcesare from social media, young and middle-aged adults, and those who do not properly practice infection prevention and control measures to COVID-19 infection.


Introduction
Psychological distress is one of the major public health problems that may occur as a result of work environment [1] and different local and global incidents, like the COVID-19 pandemic. COVID-19 became a major concern for global health [2]. The disease is registered as the largest outbreak of atypical pneumonia since the severe acute respiratory syndrome (SARS) outbreak in 2003 [3]. On Jan 30, 2020, WHO declared the current novel COVID-19 as pandemic disease and a Public Health Emergency of International Concern posing a high risk to countries with vulnerable health systems [4].
The outbreak of COVID-19 in Ethiopia o cially recognized on 13 March 2020, after the Japanese arrived in Ethiopia from his Burkina Faso trip, tested positive for the novel COVID-19. From this time onwards, there is a surge of cases, with a peak of 494 new infections recorded as of May 24 and ve deaths had occurred, and as well as there are several exposed individuals who are under quarantine. The emergency committee has stated that the spread of COVID-19 pandemic may be interrupted by staying at home, quarantine, alongside city lockdown, school closure, early detection, prompt treatment, and the implementation of a robust system to trace contacts [5]. Such, health emergency measures to control the spread of the COVID-19 disease had a strong in uence on the psychological health of the population. Separation from loved ones, the loss of freedom, uncertainty over disease status, and boredom can, on occasion, create dramatic adverse effects on mental health (5). Feeling isolation can lead to poor sleep, psychological distress, anxiety, depressive symptoms, and impaired executive function. When executing tasks of the brain are impaired, individuals had more di cultly to focus, manage their emotions, fail to remember information, which leads to mental illness [6].
Furthermore, suicide has been reported [7], substantial anger generated, and complaints brought following the imposition of emergency health measures in outbreaks [8]. In the reviewed studies, the nancial loss as a result of emergency health measures created serious socioeconomic distress [9] and was found to be a risk factor for symptoms of psychological disorders [10]. The study revealed that the risk of contracting or carrying the virus could provoke substantial acute stress disorder, depression, post-traumatic stress disorder, insomnia, irritability, and emotional exhaustion [11].
Despite this, there is no information available regarding the psychological impact of the COVID-19 pandemic in Ethiopia. While many resources are devoted to biomedical research and medical treatment, psychological problems of the COVID-19 pandemic are mainly ignored in the world, particularly in Ethiopia. Although emergency health measures during the COVID-19 pandemic is adopted for protecting the physical health from infectious diseases, it is crucial to consider the mental health implications of such emergency health measures. Therefore, to address knowledge gaps, this study aimed at determining the prevalence of psychological distress and to identify associated factors among the Ethiopian population in response to the COVID-19 pandemic.

Study design and period
This cross-sectional study was performed through an online survey using different online platforms. The questionnaire was created through Google Form and the survey link was administered by e-mail, Telegram Facebook, LinkedIn, and Facebook page of Jimma University to assess psychological distress during COVID − 19 pandemic. The questionnaire was available online for two weeks, from April 22 to May 4 2020. During that time, we tracked the completion of questionnaires, observing the date and time of the survey end.

Study population
The literate Ethiopian population who have access to the internet were invited to participate in the study by responding to the online survey. In two weeks, 929 respondents completed the questionnaire.

Measurements
The questionnaire consisted: socio-demographics characteristics, the practice of infection prevention techniques of COVID-19, and psychological distress. Demographic variables included age, gender, marital status, education, occupation, and current place of residency.
The Kessler 10 (K10)) tool was used to measure the psychological distress experienced by subjects during the last four weeks preceding the survey [12]. Respondents were instructed that the items constituted a list of ways they may have felt or behaved in the previous four weeks, and they scored on a scale of 1 to 5 depending on how frequently each symptom is experienced, where 1 = 'none of the time,' and 5 = 'all of the time'.
The K10 has ten items with a Likert rating scale ranging from 1 (not at all) to 4 (extremely). The full assessment scale contains ten items (scored from 0 to 50) with con rmed reliability and validity that measures psychological distress across diverse cultural settings. Thus, a minimum score of 10 indicates no psychological distress, and a maximum score of 50 indicates thet severe level of psychological distress. The nal K10 score was categorized into four levels: low psychological distress (10-15 score), moderate psychological distress (16-21 score), high psychological distress (22-29 score), and very high psychological distress (30-50 score) [13]. The Cronbach's alpha was 0.89 for this study indicates the acceptable internal consistency of the scale used to measure the psychosocial distress.
The total K10 scores of 22 or greater signi es high psychological distress (high + very high level of psychological distress). Where as scores of 21 or less indicate low psychological distress (low + moderate level of psychological distress). Scores from the K10 are indicative to the levels of intervention, with 'very high' psychological distress scores (> 30) associating to a case for a mental disorder, and high scores are strongly associated with a current diagnosis of anxiety and depression using the Composite International Diagnostics Interview (CIDI) [14].

Statistical analysis
The data were extracted, edited, and analysed using SPSS version 23 for Windows. Frequency tables were used to summarize sociodemographic characteristics and prevalence of psychological distress. Bivariate logistic regression was performed separately for each independent variable. Independent variables with a p-value < 0.25 were entered into the nal model for multivariable analysis. Variables in the mutually adjusted multivariable model with a twosided p-value < 0.05 were considered statistically signi cant. Also, dimension reduction was made to bring multiple similar variables into one component score using factor analysis. From our previous analysis (Birhanu et al.

Ethical clearance and consent to participate
The online survey was conducted after ethical clearance was obtained from the Ethical Review Board of the Jimma Institute of Health. Participants were informed to ll the online questionnaire voluntarily with a full right not to answer all or any of the questions. The online survey has no personal identi er, so that anonymity was maintained.
A total of 314 (33.6%) of the respondents were aged from 30-34 years old. More than half of the respondents, 494 (52.8%), had MSc or MA in educational quali cation. The majority of the respondents were ever married 609 (65.1%) and of residency in the Oromia region (531 (56.8%. Just under half of the respondents, 419 (44.8%) were orthodox Christina by religious followers. More than half of the participants, 505 (54%) were university employees, whilst only 15 (1.6%) of respondents had no job (see Table 1).

Means And Source Of Information
Respondents were asked to tick the top two information sources about the pandemic. The majority of respondents (72.5%) got different information about COVID-19 from television, followed by mobile (cellular) data internet (54.4), which is the only mobile service provider in the country. Figure 1 demonstrates the number of respondents using different sources of coronavirus information.
The Prevalence Of Psychological Distress  The distribution of different variables against the four categories of the psychological status of the respondents indicated that those who trust information sources are under very high psychological distress. Those respondents who were knowledgeable about coronavirus transmission and prevention have either moderate or no psychological distress (Fig. 2).

Multivariable Analysis
The multivariate logistic regression revealed that the odds of psychological distress was higher among participants age of 25-29 (AOR: 3.21 Those who disagree on having the resource (water, soup) to wash their hands (AOR: 2.62; 95%CI: 1.20-5.70) were also found to have higher odds of psychological distress. It was also revealed that participants who disagree on having the skill to follow recommended handwashing practices to prevent COVID-19 infection were found to have higher odds of psychological distress when compared to their counterparts (AOR 5.39, 95%CI: 1.17-24.87) (see Table 3). In addition to the logistic regression, generalized additive model (GAM) was used to predict the psychological distress among the Ethiopian communities. The GAM model demonstrated that psychological distress was signi cantly (pvalue < 0.01) predicted by level of trust on information, practice on coronavirus prevention, perceived severity, perceived collective e cacy, and perceived vulnerability of the participants. Interestingly, those who are practicing coronavirus infection prevention activities, such as social distancing, handwashing, staying at home, and avoiding crowded places, had signi cantly less psychological distress. We also have identi ed that, hhen perceived collective e cacy increases, psychosocial distress decrease. Conversely, those who had the highest score of information trust and the highest score perceived vulnerability about coronavirus had the highest score of psychological distress (Fig. 3).

Discussion
The purpose of this study was to explore the psychological distress among the Educated Ethiopian population during the COVID-19 pandemic and identify the associated factors. In Ethiopia, 25.5% of participants had high psychological distress during the COVID-19 pandemic (45.1%, had low psychological distress, 29.4% had moderate psychological distress, 17.6% had high psychological distress, and 7.3% had very high psychological distress). These rates of prevalence are considerably lower than those reported from China (35% of the respondents experienced high psychological distress) [15].
Our rates are comparable to ndings from Italy with a prevalence of 29.3% experiencing high psychological distress [16]. However, the use of different tools to assess this psychological distress and the different samples in the studies made a statistical comparison di cult. Though, it is possible to observe that our results showed considerable psychological distress during the COVID-19 pandemic.
Multivariable analysis revealed that those who get information from social media were more likely to had psychological distress. This nding is in agreement with the previous study, where social media exposures were associated with anxiety [17].
The possible reason might be during COVID-19 pandemic, misinformation, myths about COVID-19 pandemic have bombarded through social media, which strengthened groundless stress about COVID-19 among the population[18]. Trusting information coming from different sources might expose people for metal stress. Hence the use of information only trusted and authorized source could alleviate the problem. Besides, a lot of people state their negative feelings, such as fear, worry, nervousness, anxiety on social media, which can lead to transfer emotional states to others via emotional contagion, leading people to have similar emotions without their awareness [19]. So caution is necessary concerning getting information about COVID-19 on social media and better to use information delivered by WHO's 'infodemics' team [2].
Our nding revealed that participants who do not wash their hands frequently with soap and water, not having the resource (water and soap) to wash their hands, and those who have no the skill to follow recommended handwashing practices, had higher odds of psychological distress. The absence of hand hygiene resources and not washing their hands inadequately could have made individuals fear to contract the COVID-19 infection, which is associated with high psychological distress. This emphasizes the importance of compliance with infection prevention and control practices of the WHO-5 hand hygiene campaign-consisting of ve components, namely system change, training and education, observation and feedback, reminders, and a safety climate-found it to be effective in improving hand hygiene in the community, and found that compliance was further improved by adding behavioral interventions such as goal setting, reward incentives, and accountability [20,21].
Furthermore, during the COVID-19 pandemic, when the need for hand hygiene supply is considerably increased, sustaining the required supplies is critically essential to maintain frequent hand hygiene. These ndings should inform strategies designed to increase supplies needed for infection prevention and control and to in uence the behavioral factors of compliance with hand hygiene practices.
We found a signi cant association between age and psychological distress. This is consistent with a study conducted in Australia during the in uenza epidemic [22]. The possible reason may be that young and middle-aged adults were most at risk and were coping less well with the consequences (23) and they are also less likely to be resilient or skilful, mostly when it comes to handling a di culty. Also, there are varying observations about how age affects psychological distress with a lack of consistent results across studies. This has been largely attributed to different patterns of exposure to risk factors across age groups in various studies [23,24].
Psychological crisis intervention plan should be developed in a cultural context and health education for the Ethiopian population on awareness creation and how to reduce the psychological impact of COVID-19 induced distress. Besides, psychological counselors/counseling psychologists should regularly visit people with psychological distress to listen to their stories for their stress and provide support. Therefore, it is a timely need for pertinent stakeholders to support the Ethiopian public health care system to introduce novel approaches to generate nancially sustainable programs for the prevention of psychological distress among the Ethiopian population through a group of well-trained psychologists.
Our study has limitations. We collect the data after two months of COVID-19 outbreak. Therefore, the period of exposure to the COVID-19 was short. We could only study the acute psychological impact and might not be generalized to sub-acute and long-term psychological complications if the outbreak continues. This study was a cross-sectional study not able to determine cause-and-effect relationships between these variables.

Limitation
This study covers only communities who were able to read and write in English and had internet access.

Conclusion
This study indicates that, in the literate community of Ethiopian, the prevalence of high psychological distress was substantial. Those who have alternative information sources and trust the information need special attention and intervention. Promoting communities to practice preventive measures also could enhance their con dence of not contracting the disease so as psychological distress can be reduced. In conclusion, there is a need to develop an intervention plan for this psychological distress in population, mainly targeting those who got information from social media, young and middle-aged adults, and those who do not adequately practice infection prevention and control measures to prevent COVID-19 infection.

Declarations
The authors declare no con ict of interest.

Funding
This study received no funding from any funding source.

Contributors
AA, YY, ZB, YK, and DF contributed to the inception, surveydesign of the study, analysis, interpretation, and manuscript writing. MM, JA, AK contributed to analysis, interpretation, and reviewing the manuscript.

Declaration of interests
We declare no competing interests.