Prevalence and determinants of common mental illness among adult residents of Harari Regional State, Eastern Ethiopia

Introduction Common mental disorders include depression, anxiety and somatoform disorders are a public health problem in developed as well as developing countries. It represents a psychiatric morbidity with significant prevalence, affecting all stages of life and cause suffering to the individuals, their family and communities. Despite this fact, little information about the prevalence of common mental illness is available from low and middle-income countries including Ethiopia. The aim of this study was to determine the magnitude of common mental disorders and its associated factors among adult residents of Harari Region. Methods Comparative cross-sectional, quantitative community-based survey was conducted From February 1, 2016 to March 30, 2016 in Harari Regional State using multi-stage sampling technique. A total of 968 residents was selected using two stage sampling technique. Of this 901 were participated in the study. Validated and Pretested Self reported questionnaire (SQR_20) was used to determine the maginitude of common mental disorders. Data was entered and analyzed using Epi-info version 3.5.1 and SPSS-17 for windows statistical packages. Univirate, Bi-variate and multivariate logistic regression analysis with 95% CI was employed in order to infer associations. Results The prevalence of common mental illnesses among adults in our study area was 14.9%. The most common neurotic symptoms in this study were often head ache (23.2%), sleep badly (16%) and poor appetite (13.8%). Substance use like Khat chewing (48.2%), tobacco use (38.2%) and alcohol use (10.5%) was highly prevalent health problem among study participant. In multivariate logistic regression analysis, respondents age between 25-34 years, 35-44 years, 45-54 years and above 55years were 6.4 times (AOR 6.377; 95% CI: 2.280-17.835), 5.9 times (AOR 5.900; 95% CI: 2.243-14.859), 5.6 times (AOR 5.648; 95% CI: 2.200-14.50) and 4.1 times (AOR 4.110; 95% CI: 1.363-12.393) more likely having common mental illnesses than those age between 15-24 years, respectively. The occurrence of common mental illness was twice (AOR: 2.162; 95% CI 1.254-3.728) higher among respondents earn less than the average monthly income than those earn more than average monthly income. The odds of developing common mental illnesses were 6.6 times (AOR 6.653; 95% CI: 1.640-6.992) higher among adults with medically confirmed physical disability than those without physical disability. Similarly, adults who chewed Khat were 2.3 times (AOR 2.305; 95% CI: 1.484-3.579) more likely having common mental illnesses than those who did not chew Khat. Adults with emotional stress were twice (AOR 2.063; 95% CI: 1.176-3.619) higher chance to have common mental illnesses than adults without emotional stress. Conclusion This study had reveals that common mental disorders are major public health problems. Advancing age, low average family monthly income, Khat chewing and emotional stress were independent predictors of common mental illnesses. Whereas sex, place of residence, educational status, marital status, occupation, family size, financial stress, taking alcohol, tobacco use and family history of mental illnesses were not statistically associated with common mental illnesses.


Introduction
Mental illness is a public health problem in developed as well as developing countries [1]. Globally, neuropsychiatric conditions account for 9.8% burden of the diseases [2,3]. Atleast one in four people are affected by amental health problem at some point in their lives [4]. Mental and behavioural disorders are found in every countries at all stages of life [5]. The burden of chronic non communicable disease is emerging as a major public health challenge worldwide, especially in developing countries where these diseases have been assumed to be less common [6]. Five of the ten leading causes of disability and premature death worldwide are related with psychiatric conditions. Globally, about 25% of the population will develop mental illness at some stage in their lives, and 12% to the global Burden of disease is from the low-income countries [7]. Depression is the third leading cause of disease burden worldwide; representing 4.3% of total disability adjusted life years and predicted to become the second leading cause of the global disease burden by the year 2020 [8]. In Ethiopia, mental health problems accounts for 12.45% of the burden of diseases, 12% of the people are suffering from mental health problems [9,10]. The poor or inexistent mental health care, both in terms of the offer of services and development of policies on health protection and promotion is due to lack of information about the mental health status. Currently no available published study on community based common mental disorders in Harari Region. Therefore, the present researchers believe that this problem which affects the living condition of the society is really a gap that needs to be addressed. This study was, therefore, intended to determine the magnitude of common mental disorders and its associated factors among adult residents of Harari Region.

Study area:
The study was conducted in Harari People Regional Babile in Northeast, Fedis in south east and Haramaya in the West side respectively. Harar also lies within fertile coffee growing districts and agricultural fields, producing various products particularly chat, fruits/ vegetables, and several kinds of grains [11].
Based onMOH, Health and Health Related Indicator, the total population of the region is estimated to be 203,834 in 2003 EC and this makes Harari Region least populous region in the country.
About 54% of the population lives in the urban area while the remaining 46% live in rural area. The people of Harari region earn their livelihood from trade, agriculture and employment by government and the private sector [12]. According to the currently adopted administrative structure, Harari Region is divided in to 19 kebeles (in urban area) and 17 peasant association (in rural areas). In the current system the district is responsible for management of Primary Health Care Unit (Health centre and Health post), while the management of Hospitals and Training Institution are under the RHB. The RHB is organized in to different departments and services, each with specific roles and responsibilities. At district level, there is one health coordinator and two experts. At the health post, level there is one nurse and two female HEWs. With regard to the number of facilities, the region has relatively a higher degree of Health Service Coverage (100%) as compared to the national level [11].

Study design and period:
A community-based comparative cross-sectional survey was carried out among adults in five randomly selected woredas using multi-stage sampling technique.
This study was conducted from February to March, 2016.
Sample size determination and sampling procedure: The sample size was determined by two proportion formula considering the study which was conducted in Oyo state of Nigeria [13]. The proportion of the psychiatric morbidities among urban and rural area were 18.4% and 28.4%, respectively.With a precision of 95% and the desired power of 80%. Including 15% loss to follow-up and design effect of 1.5, the final sample size for each of urban and rural area were 484 (a total of 968 households were included in the study). Multistage sampling technique was used to obtain a representative sample of the communities in Harari regional state as follows.

Stage 1:
A sampling frame of all the woredas in Harari regional state was drawn and stratified into urban and rural areas. Two rural and three urban woredas were obtained by simple random  survey questionnaire were pre-tested in two randomly selected kebeles (one from urban and one from rural) which was not be involved in the actual data collectionand the necessary modifications and correction was made to ensure its consistency. Using the questionnaire data were collected by twenty (20) trained HEW with experience in data collection and fluent speakers of afanoromo and Amharic languages. The interview was made by house-to-house visit in the presence of strong supervision.

Data quality control:
To assure the data quality high emphasis was given in designing data collection instrument. The questionnaires were pre tested on 10% of the sample size in two randomly selected kebeles (one from urban and one from rural) which was not involved in the actual data collection to check consistency and length of time each questioners took, sampling method and techniques, as well as the skill of data collectors two weeks prior to the main data collection time. Training was provided for data collectors and supervisors on the objective of the study, the source of bias, method of data collection. Before data collection the questioners were checked its simplicity, clarity and understandability. Checking and re-checking of the data were employed to identify whether the data were completely filled or not by double data entry. Daily supervision of data collection process was implemented. To assess the consistency, 25% of the collected data were checked in a daily based.  Table 1).

Magnitude of common mental illnesses: A locally validated
self-reported questionnaire-20 (SRQ-20) was used as screening tool to assess presence of common mental disorders among respondents. This SRQ-20 consists of 20 yes/no questions which can assess of neurotic symptoms (anxiety, depression, psychosomatic).
Each yes/no response of each respondent was first summing up.
Finally those respondents scored more than or equal to six were categorized as having common Mental illness and those scored less than 6 categorized as free from common mental illness. The respondents' score of those neurotic symptoms were ranged from 0 to 20. More than half (57.9%) of the respondents were reported that they had no any of those symptoms while 11 (1.2%) reported they had all of neurotic symptoms. In this study 134 participants were respond as having ≥ six neurotic symptoms, that make the prevalence of common mental illnesses 14.9% ( Table 2). The most common neurotic symptoms in this study were often head ache (23.2%), sleep badly (16%) and poor appetite (13.8%). In contrary, the least complained symptoms were uncomfortable feeling in the stomach (7.8%), easily freighted (10%) and having shaking hands (10%) ( Table 3).

Discussion
Mental illness is a public health problem that causes suffering to the individuals, their family and communities in developed as well as developing countries [1,14]. The global burden of disease report revealed that common mental disorders account for 9.8% of the global burden of diseases [2,3]. Worldwide it is estimated that lifetime prevalence ranges from 12. illnesses. This finding of higher prevalence of common mental illnesses among rural adults than urban was also observed in Nigeria study (18.4% in the urban areas and 28.4% in the rural areas) [13].
In current study advancing age was associated with increased likelihood of developing or having common mental illnesses. This finding was similar with several previous studies conducted in Brazil [14], Kenya [15], in Addis Ababa [17] and Butajira [25]. Like study conducted in in Addis Ababa [17], marital status of respondents did not show statistically significant associated with common mental illnesses. But some previous studies reported that marital status had significantly association with common mental illnesses [15,26].
This difference might be due to difference in study population, study design and data collection tools. The first study was cohort study conducted on Indianwomen aged 18 to 50 yearsusing RCIS. Unlike many previous studies, educational status and employment status or occupation of respondent did not show statistical significant association with common mental illnesses [13-15, 18, 20, 27, 28].
As stated by Scott and Glyn, financial strain is a main predictor of future psychiatric morbidity [29]. In our study average family income was strongly associated with common mental illnesses.
Adults with low average family income had two times higher chance of having mental illnesses than adults earned more than average monthly income. This association was also reported by many of the previous studies conducted in Nigeria [13], England, Wales, and Scotland [20], Brazil [14], Indian [26], two urban areas of Tanzania [15] and Butajira district rural Ethiopia [25]. In our study it was observed that about half (48.2%) of adults chewed khat. This is because Khat chewing is one of common habit practiced among peoples living in the study area. In the other word, 64.2% of adults with common mental illnesses and 45.4% of adults without common mental illnesses were chewing Khat in the last 3 months.
This difference was statistically significant that those adults who chewed Khat had 2.3 times higher chance of having common mental illnesses than those who did not chew khat. But alcohol taking and tobacco use did not show statistical association with common mental illnesses in this study. In contrary to this, other studies conducted in Brazil [14] and Indian [26] reported statistical significant relationship between tobacco use and common mental illnesses. About 3% of adults with common mental illnesses and 0.7% of adults without common mental illnesses had medically confirmed physical disability. This difference in proportion physical disability among adults with and without common mental illnesses was statistically significant. Adults with physical disability were almost 7 times higher chance of having common mental illnesses than adults without physical disability. This finding was also consistent with previous studies [13-15, 24, 26].

Conclusion
This study significant proportion (one out of seven) of adults in

Competing interests
The authors declare no competing interest.

Authors' contributions
Gari Hunduma participated in proposal writing, data collection, analysis, interpretation and critical review of the manuscript.
Mulugeta Girma participated in proposal writing, data collection, analysis, interpretation and critical review of the manuscript.
Tesfaye Digaffe participated in proposal writing, data collection, analysis, interpretation and critical review of the manuscript. Fitsum Weldegebreal, participated in data collection, data analysis, interpretation and critical review of the manuscript. Assefa Tola participated data analysis, interpretation and critical review of the manuscript. They also read and approved the final manuscript.

Acknowledgments
We acknowledge Haramaya University research and publication office for budget allocation. The regional health bureau also acknowledged for accepting this research work to be done in the region. Our thanks also extend to Institutional Health Research and Ethics Review Committee of the Haramaya University for facilitating the ethical clearance.