Prevalence and predictors of depression and anxiety among caregivers of children with noncommunicable diseases in referral hospitals in Abia State Nigeria

Prevalence and predictors of depression and anxiety among caregivers of children with noncommunicable diseases in referral hospitals in Abia State Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence and predictors of depression and anxiety among caregivers of children with noncommunicable diseases in referral hospitals in Abia State Nigeria Eziyi Uche KALU, Ugo Uwadiako ENEBELI, Cherima Joel Yakubu, Ebelechukwu Lawrence Enebeli, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7914498/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Childhood non-communicable diseases (NCDs) pose a significant burden in low- and middle-income countries (LMICs), with a rising prevalence among children. Caregivers of affected children often experience mental health challenges, yet data from sub-Saharan Africa remain limited. This is the first childhood multi-NCD study providing insight into the burden of caregiving in Abia State, in the southeast of Africa’s most populous LMIC. Methods This hospital-based cross-sectional study enrolled 720 consenting caregivers of children with physician-diagnosed NCDs in three referral hospitals. Data were collected using a structured sociodemographic questionnaire, the Patient Health Questionnaire-9 (PHQ-9) for depression, and the Generalised Anxiety Disorder-7 (GAD-7) for anxiety. Descriptive statistics, chi-square tests, and multivariable logistic regression were performed using SPSS version 29. Results Caregivers were predominantly mothers (80.3%). Haematological disorders (23.1%) and malignancies (19.7%) were the most common NCDs among the children. The prevalence of depression (PHQ-9 ≥ 10) and anxiety (GAD-7 ≥ 10) among caregivers was 34.0% (95% CI: 30.4–37.6) and 25.6% (95% CI: 22.3–28.9), respectively. Rural residence (AOR 1.65, 95% CI: 1.32–2.06 for depression; AOR 2.32, 95% CI 1.78–3.02 for anxiety), low education (AOR 1.42, 95% CI: 1.12–1.80 for depression; AOR 1.43, 95% CI 1.09–1.88 for anxiety), and non-maternal caregivers, e.g., fathers or others (AOR 1.58, 95% CI: 1.18–2.11 for depression), were associated with higher odds of mental health issues. NCD type showed no significant independent association after adjustment. Conclusions Mental health burdens among caregivers of children with NCDs are substantial, exacerbated by rurality and socioeconomic factors. Hospital-integrated public health interventions targeting caregiver support are urgently needed to mitigate these intersections in LMICs, fostering resilient families and sustainable development. Childhood non-communicable diseases Chronically ill children Caregivers Mental health Depression Anxiety Nigeria LMIC 1 BACKGROUND Non-communicable diseases (NCDs) are non-infectious health conditions that cannot be transmitted between individuals ( 1 , 2 ). They represent a growing global health challenge, as the global burden of disease is rapidly transitioning from infectious diseases to NCDs ( 3 ). Over 2.1 billion children globally are affected by NCDs ( 4 , 5 ). NCDs are responsible for 75% of global mortality, and low- and middle-income countries (LMICs) are disproportionately impacted, with 73% of all LMIC deaths ( 6 ). A significant number of children die from NCDs like haematological disorders (particularly sickle cell disease) and cancers, particularly in sub-Saharan Africa, where access to healthcare is limited ( 7 ). In Nigeria, children 0–17 years old constitute 50% of the total population ( 8 ). NCDs account for around 30% of total mortality among Nigerian children, with paediatric NCDs emerging as an epidemic due to genetic predispositions (e.g., sickle cell disease) and environmental factors (e.g., air pollution worsening asthma) ( 9 ). Hospital records in Nigeria indicate that 20–32% of paediatric admissions are attributable to NCDs, including haematological, cancer, renal disorders, and neurological conditions ( 3 , 4 , 10 ), highlighting the need for facility-level data. Abia State, with an estimated population of 4,733,613 as of 2025 and diverse urban-rural dynamics, mirrors national and sub-national trends in health but lacks localised insights on childhood NCDs and caregiver mental health across its senatorial zones. The consequences of paediatric NCDs are so enormous; however, there are limited policies specific to childhood NCDs in many LMICs where, unfortunately, the bulk of young populations reside and where caregiving is traditionally the parents’ or caregivers’ burden to bear ( 11 ). Research indicates that these caretakers experience adverse effects on their physical health, including lower back discomfort, musculoskeletal pain, fatigue, and sleep disturbances ( 12 ). Beyond physical health, NCDs in children negatively impact the mental health of the carers, who are tasked with a considerable load from the processes for diagnosis, treatment, and daily care of the children. Consequently, in LMICs, carers, primarily mothers, have increased risks of depression, anxiety, and distress from financial difficulties, stigma, and insufficient support systems. Anxiety is the most common mental disorder globally (4.4%), followed by depression (4%), and both are more common in women ( 13 ). In LMICs, as much as 31–77% of carers of young children with NCDs report increased symptoms of depression or anxiety, with higher rates in Lesotho and Nigeria ( 14 , 15 ). These negative mental health impacts of caregiving can impair caregiving quality, perpetuating a cycle of poor child outcomes ( 12 ). Hospitals are healthcare facilities where some NCD patients receive outpatient and inpatient services to achieve the SDG 3.4 targets, which aim to reduce premature mortality from NCDs by one-third through prevention and treatment of mental health and well-being by 2030 ( 16 ). However, evidence from Nigeria is sparse on studies examining NCDs and their effect on caregivers, especially for Abia State, which has varying healthcare access; hence, this study. Research questions Therefore, the research questions are: What is the proportion of physician-diagnosed NCDs of children in referral hospitals in Abia State, Nigeria? What is the proportion of depression and anxiety among caregivers of children with physician-diagnosed NCDs in referral hospitals of Abia State, Nigeria? What is the relationship between the type/severity/duration of NCD in a child and occurrence of depression and anxiety in the child’s caregiver? What socio-demographic factors predict the occurrence of depression and anxiety among caregivers of children with NCDs in referral hospitals of Abia State, Nigeria? Study objectives This study aimed to determine: ( 1 ) the proportion of physician-diagnosed NCDs of children in referral hospitals in Abia State, Nigeria; ( 2 ) the proportion of depression and anxiety among carers of children with physician-diagnosed NCDs in referral hospitals of Abia State; ( 3 ) the relationship between the type/severity/duration of NCD in a child and occurrence of depression and anxiety in the child’s caregiver; ( 4 ) the socio-demographic factors predicting the occurrence of depression and anxiety among caregivers of children with NCDs in referral hospitals of Abia State, Nigeria. Hypotheses The null hypotheses for this study were that: There is no relationship between the type/severity/duration of NCD in a child and occurrence of depression and anxiety in the child’s caregiver. There are no socio-demographic factors predicting the occurrence of depression and anxiety among caregivers of children with NCDs in referral hospitals of Abia State, Nigeria. Understanding these intersections is crucial for holistic and effective public health strategies. 2 MATERIALS AND METHODS 2.1 Ethical statement and consent to participate The study received ethical approval from the Ethical and Research Committee of the Abia State Ministry of Health (AB/MH/PRS/ECS/T.1/1016) before the study commenced. Permission for the study was obtained from the medical directors of the health facilities, and freely given written informed consent was secured from caregivers prior to data collection. Confidentiality was ensured by anonymising the data and password-protecting the databases. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. 2.2 Study area Abia State is situated in the southeast geopolitical zone and is one of the 36 states of Nigeria, an LMIC in Sub-Saharan Africa. Abia State has three senatorial zones and 17 Local Government Areas (LGAs); the main urban areas are Umuahia (the state capital) and Aba (the major commercial centre), and 70% of the labour force is involved in agriculture ( 17 ). The state has an estimated total population of 4,733,613 persons as of 2025, based on the 2006 census and a growth rate of 2.7 ( 18 ). 2.3 Study design This is a hospital-based cross-sectional study conducted in paediatric inpatient wards and outpatient clinics of three referral hospitals in Abia State, Nigeria – at one referral hospital per senatorial zone. This included the General Hospital Ohafia (Abia North, rural), Children’s Hospital Umuahia (Abia Central, urban), and Comprehensive Hospital Ugwunagbo (Abia South, rural) in Abia State, Nigeria, surveyed from June to August 2025. 2.4 Study population The study population included 720 caregivers of children who presented at the paediatric outpatient clinics or were admitted into the paediatric inpatient wards for NCDs within the study period. The inclusion criteria were primary caregivers (self-identified as mainly responsible for care) of children aged 0–17 years with physician-diagnosed NCDs confirmed with their medical records (e.g., haematological disorders, malignancies, respiratory, cardiovascular, nutritional, digestive, endocrine, renal, neurological disorders) and who gave consent for the study. Exclusions: Caregivers of children with NCDs who did not give consent for the study, or caregivers of children who were not diagnosed with NCDs. 2.5 Sample size determination The sample size was calculated using Open Epi version 3 ( 19 ), assuming a 30% prevalence of caregiver depression from a study in southwestern Nigeria ( 10 ), a 5% margin of error, and a 95% confidence level, yielding 646. Factoring in a 10% non-response rate, the minimum sample size was 718. 2.6 Sampling technique The three senatorial zones in Abia State were included, with a sampling frame of all the public referral (secondary) hospitals in the state. One referral health facility was selected from each senatorial zone by simple random sampling, for a total of three referral hospitals included in the study. The final sample units were all consenting caregivers of children diagnosed with NCDs in the inpatient or outpatient settings of the selected hospitals and were recruited till the sample size was met. 2.7 Data collection The structured questionnaires were administered in English or Igbo after obtaining informed consent. The Igbo versions were translated and back-translated by bilingual experts to ensure linguistic and cultural equivalence, achieving a Cronbach’s α > 0.80. The study instrument was prepared on KoboCollect and underwent face validation by experts. It was pretested in 5% of the sample size in a non-participating health facility for the reliability and validity of the questions, and a Cronbach’s α of > 0.80 was obtained, which was acceptable. Data collection occurred in clinic waiting areas or wards, where caregivers received a tablet with the KoboCollect to complete the PHQ-9 and GAD-7 components or were interviewed by a researcher (depending on literacy level) over a 20–30-minute period. 2.8 Study instrument The study instrument included: Socio-demographic section : For the child: age, sex, and residence (urban/rural). For the caregiver: age in completed years, sex, relationship to the child, occupation, education (low: none/primary; high: secondary+), income, and the child’s NCD details, including type, duration, and perceived or clinically recorded severity. The Patient Health Questionnaire-9 (PHQ-9) The PHQ is a self-administered questionnaire for common mental disorders, and the PHQ-9 is the 9-item module on depression that scores nine symptoms’ frequency over the previous two weeks as “0” if the response is “not at all” and “3” if it is “nearly every day”. PHQ-9 has a total score of 0–27; a score of 10 has an 88% sensitivity and specificity for “major depression”, and it is reliable and valid for clinical and research criteria-based diagnoses of depressive disorders ( 20 ). Question 9 is a single screening question on suicide risk, and a “yes” answer to it was referred for evaluation ( 21 ). Other Nigerian studies have used the PHQ-9 ( 21 ). The test-retest reliability and the internal consistency (Cronbach’s alpha) of the PHQ-9 in this study were 0.87 and 0.84, respectively. The Generalised Anxiety Disorder-7 (GAD-7) The GAD-7 is a 7-item anxiety scale, a self-administered questionnaire with a 10-point score, which has an optimised sensitivity and specificity of 89% and 82%, respectively. The GAD-7 is valid and efficient for screening for generalised anxiety disorder at a ≥ 10 cutoff ( 22 ). The GAD-7 has been used in other studies in Nigeria ( 21 ). The test-retest reliability and the internal consistency (Cronbach’s alpha) of the GAD-7 in this study were 0.84 and 0.83, respectively. 2.9 Data management Data collected with KoboCollect were exported as Microsoft (MS) Excel files for initial cleaning and verification. The cleaned dataset was then imported from MS Excel to IBM SPSS version 29, where they were analysed. All data were anonymised by assigning unique IDs upon entry, and files were stored on password-protected, encrypted devices compliant with the Nigerian Data Protection Act 2023 ( 23 ). Only members of the research team had access to the data to ensure confidentiality. Dependent Variables : The caregiver’s mental health status (binary) was the primary outcome. Depression was assessed using the PHQ-9, and scores were dichotomised as 0 (no depression: <10) or 1 (depression: ≥10). Anxiety was assessed using the GAD-7, and scores were categorised as 0 (no anxiety: <10) or 1 (anxiety: ≥10). Independent Variables The independent variables encompassed socio-demographic and disease-related factors, which were coded for analyses. Socio-demographic: included age (of caregiver) and age (of child) categorised as < 30, 30–39, ≥ 40 and < 1, 1–5, 6–9, 10–17 years, respectively, for subgroup analyses. Sex of caregiver and child as binary (0 = male, 1 = female). Relationship to child: 0 = mother, 1 = non-mother. Education of caregiver: 0 = high, i.e., secondary/tertiary; 1 = low: none/primary. Residence: 0 = urban, 1 = rural. Monthly income: Ordinal (1=₦100,000). Disease-related: NCD type: Categorical (presence or absence of NCD types). Duration: continuous (years since diagnosis); categorised as 1 year. Severity: ordinal (1 = mild, 2 = moderate, 3 = severe). 2.10 Statistical analyses Statistical analyses were conducted using IBM SPSS Statistics version 29 (IBM Corp., Armonk, NY, USA). A significance level of p < 0.05 was adopted for all tests. Analyses were performed separately for depression and anxiety outcomes to account for potential differences in their determinants. Descriptive Statistics Participant characteristics were summarised using descriptive statistics. Continuous variables (e.g., caregiver age, child age, NCD duration) were reported as means with standard deviations (SD). Frequencies and percentages were used to present variables, e.g., NCD type and prevalence of NCD. Bivariate Analyses The chi-square tests were used to assess the association between the independent and dependent variables. The means of continuous variables were compared with independent t-tests. The output was in crude odds ratios (OR), the corresponding 95% confidence interval, and p-value significant at p < 0.05. Multivariable Analyses The multivariable logistic regression was used to assess independent associations while controlling for confounding variables. The significant variables from the bivariate analysis were included initially, and assessed while controlling for confounders, with the output in adjusted odds ratios (AOR), 95% confidence intervals, and significance at p < 0.05. 3 RESULTS 3.1 Sociodemographic characteristics of children with NCDs and their caregivers Caregivers were predominantly female (85.6%), with a mean age of 34.5 ± 7.9 years, and most were mothers (80.3%). 10.1% were fathers, 6.3% other relatives (e.g., grandparents, siblings), and 3.3% non-relatives. Nearly half (49.0%) had low education levels (none/primary), and low monthly income (<₦20,000) was reported by 32.2%. Half resided in urban areas (50.7%). Children had a mean age of 4.9 ± 2.5 years, with 55.6% male, and the majority aged 1–5 years (60.6%), as shown in Table 1 . Table 1 Sociodemographic characteristics of children with NCDs and their caregivers Characteristic Category Frequency Percentage Caregiver, n = 720 Age (years) < 30 30–39 ≥ 40 202 347 171 28.1 48.2 23.7 Sex Male Female 104 616 14.4 85.6 Relationship to child Mother Father Other relative Non-relative 578 73 45 24 80.3 10.1 6.3 3.3 Highest Educational level Low (None or Primary) High (Secondary+) 353 367 49.0 51.0 Average Household Income ≤ ₦20,000 ₦20,001-₦50,000 ₦50,001-₦100,000 >₦100,000 232 216 180 92 32.2 30.0 25.0 12.8 Residence Urban Rural 365 355 50.7 49.3 Mean age (years) ± SD 34.5 ± 7.9 Child, n = 720 Age group (year) < 1 1–5 6–9 10–17 144 436 108 32 20.0 60.6 15.0 4.4 Sex Male Female 400 320 55.6 44.4 Mean age (years) ± SD 4.9 ± 2.5 3.2 Children’s NCD Status Haematological disorders were the most prevalent NCD (23.1%), followed by malignancies (19.7%), renal disorders (15.4%), neurological disorders (10.6%), respiratory disorders (10.1%), cardiovascular disorders (9.9%), nutritional disorders (8.3%), digestive disorders (1.5%), and endocrine disorders (1.4%). Most cases had a duration of < 1 year (68.3%), with moderate severity predominant (52.3%). Among severe cases (n = 127, 17.6%), malignancies accounted for the highest proportion (22.0%), followed by haematological disorders (19.7%), as shown in Table 2 . Table 2 Children’s NCD status Characteristic Category n (%) NCD type Haematological disorders Malignancies disorders Renal disorders Neurological disorders Respiratory disorders Cardiovascular disorders Nutritional disorders Digestive disorders Endocrine disorders 166 (23.1) 142 (19.7) 111 (15.4) 76 (10.6) 73 (10.1) 71 (9.9) 60 (8.3) 11 (1.5) 10 (1.4) Duration of disease (years) 1 492 (68.3) 228 (31.7) Perceived/Clinical severity Mild Moderate Severe 217 (30.1) 376 (52.3) 127 (17.6) Severe cases by NCD type, n = 127 Malignancies Haematological Renal Neurological Respiratory Nutritional Cardiovascular Endocrine Digestive 28 (22.0) 25 (19.7) 19 (15.0) 13 (10.2) 13 (10.2) 12 (9.5) 10 (7.9) 4 (3.1) 3 (2.4) 3.3 Proportion of depression and anxiety among caregivers of children with NCDs in referral hospitals Overall, 34.0% and 25.6% of caregivers screened positive for depression and anxiety, respectively. Prevalence was significantly higher among rural residents (depression: 41.1%; anxiety: 35.5%) compared to urban (27.1% and 15.9%, respectively; both p < 0.001), and among caregivers with low education (depression: 46.7%; p < 0.001), compared to high education (21.8%). Non-maternal caregivers showed elevated depression rates (45.1%), compared to maternal caregivers (31.3%), p = 0.003 (Table 3 ). Of the 720 caregivers, 8 were referred to hospital mental health services due to PHQ-9 ≥ 10, GAD-7 ≥ 10, or reported suicidal ideation. Table 3 Proportion of depression and anxiety among caregivers of children with NCDs in referral hospitals Characteristic Category Total, n (%) Depression Anxiety Prevalence, n (%) p-value Prevalence, n (%) p-value Overall Yes No 245 (34.0) 475 (66.0) 245 (34.0) 475 (66.0) 184 (25.6) 536 (74.4) Residence Rural Urban 355 (49.3) 365 (50.7) 146 (41.1) 99 (27.1) < 0.001* 126 (35.5) 58 (15.9) < 0.001* Education Low High 353 (49.0) 367 (51.0) 165 (46.7) 80 (21.8) < 0.001* 95 (26.9) 89 (24.3) 0.089 Relationship to child Non-mother Mother 142 (19.7) 578 (80.3) 64 (45.1) 181 (31.3) 0.003* 40 (28.2) 144 (24.9) 0.065 * p < 0.05 3.4 Relationship between NCDs and Depression and Anxiety among Caregivers of Children with NCDs (Bivariate Associations) Rural residence was significantly associated with both depression (OR 1.88, 95% CI 1.37–2.57; p < 0.001) and anxiety (OR 2.91, 95% CI 2.04–4.15; p < 0.001). Low education predicted higher odds of depression (OR 3.15, 95% CI 2.28–4.35; p < 0.001), while shorter disease duration (< 1 year) was protective for both outcomes (depression OR 0.71, p = 0.036; anxiety OR 0.64, p = 0.012). Non-maternal caregivers had elevated depression risk (OR 1.80, p = 0.002); and caregiver and child sex showed no associations with neither depression nor anxiety (Table 4 ). Bivariate analysis showed higher depression (38.7%, OR 1.29, 95% CI 0.89–1.73, p = 0.196) and anxiety (29.2%, OR 1.22, 95% CI 0.85–1.75, p = 0.284) rates for caregivers of children with malignancies, but these differences were not significant. Table 4 Relationship between NCDs and Depression and Anxiety among Caregivers of Children with NCDs (Bivariate Associations) Characteristic Category Depression Anxiety Prevalence, n (%) OR (95% CI) p-value Prevalence, n (%) OR (95% CI) p-value Residence Rural Urban (ref) 146 (41.1) 99 (27.1) 1.88 (1.37–2.57) 1 < 0.001* 126 (35.5) 58 (15.9) 2.91 (2.04–4.15) 1 < 0.001* Education Low High (ref) 165 (46.7) 80 (21.8) 3.15 (2.28–4.35) 1 < 0.001* 95 (26.9) 89 (24.3) 1.37 (0.98–1.92) 1 0.089 Relationship to child Non-mother Mother (ref) 64 (45.1) 181 (31.3) 1.80 (1.24–2.62) 1 0.002* 40 (30.3) 144 (24.4) 1.35 (0.90–2.02) 1 0.065 NCD Duration 1 year (ref) 155 (31.5) 90 (39.5) 0.71 (0.51–0.98) 1 0.036* 112 (22.8) 72 (31.6) 0.64 (0.45–0.91) 1 0.012* NCD Type Malignancy Non-malignancy (ref) 55 (38.7) 190 (32.9) 1.29 (0.89–1.73) 0.196 41 (28.9) 143 (24.7) 1.22 (0.85–1.75) 1 0.284 Caregiver sex Male Female (ref) 33 (31.7) 212 (34.4) 1.08 (0.70–1.67) 0.719 25 (24.0) 159 (25.8) 1.22 (0.77–1.93) 1 0.406 Child sex Male Female (ref) 137 (34.3) 108 (33.8) 1.02 (0.75–1.39) 0.888 93 (23.3) 91 (28.4) 0.94 (0.67–1.31) 1 0.702 * p < 0.05 3.5 Sociodemographic Predictors of Depression and Anxiety in Caregivers of Children with NCDs (Multivariable Logistic Regression) After adjustment for sociodemographic and disease-related factors, rural residence independently predicted both depression (AOR 1.65, 95% CI 1.32–2.06; p < 0.001) and anxiety (AOR 2.32, 95% CI 1.78–3.02; p < 0.001). Low education remained a significant risk factor for depression (AOR 1.42, 95% CI 1.12–1.80; p = 0.003) and anxiety (AOR 1.43, 95% CI 1.09–1.88; p = 0.008). Non-maternal caregivers had higher odds of depression (AOR 1.58, 95% CI 1.18–2.11; p = 0.002), but not anxiety (AOR 1.15, p = 0.421) (Table 5 ). Table 5 Sociodemographic Predictors of Depression and Anxiety in Caregivers of Children with NCDs (Multivariable Logistic Regression) Characteristic Category Depression Anxiety Prevalence, n (%) AOR (95% CI) p-value Prevalence, n (%) AOR (95% CI) p-value Residence Rural Urban (ref) 146 (41.1) 99 (27.1) 1.65 (1.32–2.06) 1 < 0.001* 130 (35.5) 56 (15.9) 2.32 (1.78–3.02) 1 < 0.001* Education Low High (ref) 171 (46.7) 77 (21.8) 1.42 (1.12–1.80) 1 0.003* 105 (28.6) 80 (22.6) 1.43 (1.09–1.88) 1 0.008* Relationship to child Non-mother Mother (ref) 64 (45.1) 181 (31.3) 1.58 (1.18–2.11) 1 0.002* 43 (30.3) 141 (24.4) 1.15 (0.82–1.62) 1 0.421 * p < 0.05 4 DISCUSSIONS The first objective of this study was to determine the proportion of physician-diagnosed NCDs of children in referral hospitals. In this study, haematological disorders (23.1%) were the most common NCD, followed by malignancies (19.7%), renal disorders (15.4%), neurological disorders (10.6%), respiratory disorders (10.1%), cardiovascular disorders (9.9%), nutritional disorders (8.3%), digestive disorders (1.5%), and endocrine disorders (1.4%). The predominance of haematological disorders (23.1%) aligns closely with Emodi et al .’s findings in Enugu (23.3%) ( 3 ), though slight variations may reflect differences in hospital case mix. The study also reported 19.2% malignancies, and the renal, central nervous, and cardiovascular system NCDs accounted for 12.8%, 12.4%, and 10.9% among hospitalised children ( 3 ). In Benin, 33.9% haematological disorders predominated, followed by 29.2% neoplasms, 14.4% cardiovascular, 7.9% neurological, 6.1% renal, 5.1% digestive (5.1%), and endocrine (2.5%) ( 4 ). The predominance of haematological disorders (23.1%) as the most common NCD reflects the burden of sickle cell anaemia in Nigeria’s genetic epidemiology, where prevalence ranges from 1–3% nationally, contributing to 7–16% of child mortality in sub-Saharan Africa, and is driven by high carrier rates ( 24 ). The second objective was to determine the proportion of depression and anxiety among caregivers of children with physician-diagnosed NCDs in referral hospitals. This hospital-based cross-sectional study provides novel insights into the mental health burdens faced by caregivers of children with NCDs in Abia State, Nigeria, revealing a depression prevalence of 34.0% and an anxiety prevalence of 25.6% with the growing recognition of psychosocial strains in LMICs, where caregivers, who are often family members, navigate NCD management amid resource constraints. This study’s results on depression and anxiety are in agreement with a meta-analysis of the mental health of caregivers of children with epilepsy in 18 countries, which reported 31% depression and 34% anxiety prevalences ( 25 ), the slight differences probably being from our study’s wider NCDs range. On the other hand, our study’s findings are lower than in Ghana ( 26 ), with 66.2% depression and 56.2% anxiety among caregivers of mentally ill children, and the 70% depression among Iraqi caregivers of children that were ill with leukaemia ( 27 ). The differences with our study may again be due to single NCDs studied versus the multiple NCDs in our study. The index study found no independent association between the occurrence of caregiver anxiety and depression, and specific childhood NCD types like haematological disorders and malignancies after adjusting for confounders, and this conforms to an LMIC-wide analysis wherein systematic and not individual stressors were the precursors to anxiety and depression. These stressors included stigma, monetary considerations, and limitations in accessing healthcare, which were uniform across the different NCD types ( 28 ). The stressors do indeed cause heightened distress, but to all NCDs needing care, not necessarily specific to a type of NCD across LMICs ( 21 , 29 – 31 ). However, the scenario was different in high-income countries, where there were significantly higher rates of anxiety and depression with cancers due to acute issues surrounding their care ( 32 ). Factors like short disease duration (< 1 year in 68.3%) and moderate severity (52.3%) likely also contribute to generalised distress, implying that broad-spectrum interventions such as routine caregiver screening and peer support in Nigerian paediatric clinical settings should enhance family behavioural resilience, with future longitudinal research needed to explore causal pathways. The final objective was to determine the socio-demographic factors that predict the occurrence of depression and anxiety among caregivers of children with NCDs in referral hospitals. This study provides evidence that rural residence, low education, and non-maternal caregivers were significant risk factors for depression. And rural residence and low education predicted anxiety, similar to a study in rural communities in Kenya where the geographic isolation and poor access to healthcare services increased health risks for the children and compounded the caregiver’s anxiety ( 33 ). These poor access to healthcare as well as unrecognised caregiver mental health issues are additionally pointers to limitations and gaps in implementation of paediatric NCD policies in LMICs. These findings imply that community-based efforts targeting hard-to-reach areas are also imperative in the control of NCDs ( 34 , 35 ). The associated low education with caregiver distress in this study may be explained by low literacy in health and coping issues, as well as distress through low socioeconomic status associated with low education ( 36 ). Also, the heightened risk of depression among non-maternal caregivers seem to point to gender roles as fathers were a larger proportion of the non-maternal caregivers, and may face additional mental burden in performing roles societally gendered to mothers. This study’s strengths include its uniqueness in being at the forefront of caregiver mental health intersection with childhood NCDs in Abia State, Nigeria. Its rigorous and detailed methodology eases replicability for studies to elucidate caregiver burdens in LMICs. Its large sample size and multi-zonal selection make it representative of the population. And the ethical compliance and use of validated tools enhance its reliability. However, there are limitations that should be taken into account. It is a cross-sectional study and cannot establish causal relationships between caregiver mental health and the occurrence of NCDs in children. Again, the study’s dependence on self-reported mental health status may be prone to response or desirability bias, although using validated tools (like the PHQ-9 and the GAD-7) minimises this bias. The public health policy implications of these findings include that integrating routine screening for the mental health of caregivers of children with NCDs will enable their early diagnosis and management, in alignment with SDG 3.4. The use of peer support networks and incorporation of rural equity into mental health strategies will improve their effectiveness. It is recommended that future studies utilise longitudinal research to explore the efficacy of various interventions that could improve the mental health of caregivers in an era of expanding paediatric NCDs. 5 CONCLUSIONS This study is the first multi-NCD caregiver study in Abia, and among the few to examine the intersection of anxiety and depression in caregivers of children with a broad range of NCDs in Africa’s most populous country. Caregivers bear substantial mental health burdens from childhood NCDs, driven by socio-structural factors. Targeted hospital interventions can break this intersection, foster resilient families in LMICs, and support SDG 3.4 by highlighting caregiver well-being in NCD reduction. Abbreviations AOR Adjusted Odds Ratio CI Confidence Interval GAD-7 Generalised Anxiety Disorder-7 LGA Local Government Area LMIC Low- and Middle-income Country NCD Non-communicable Disease OR Odds Ratio (crude) PHQ-9 Patient Health Questionnaire-9 Declarations Funding Statement This study was self-funded by the authors. No external grants were received. Data Availability Statement The datasets for this study are available from the corresponding author upon reasonable request. Author Contributions Statement EIK: conceptualisation, data collection, data analysis, writing original draft, and funding. UUE: methodology, review, editing, writing final draft. YJC: data collection, data analysis, writing original draft. ELE: conceptualisation, writing original and final drafts. ANA: investigation, editing, supervision, review. Competing Interests Policy The authors declare there are no competing financial and/or non-financial interests in relation to the work described. Dual publication Not applicable. Authorship The corresponding author confirms that I have read the journal policies and am submitting the manuscript in accordance with those policies. Permission to Use Third-Party Material Not applicable. The authors created the images and figures, and they have never been published. Clinical Trial Number: Not applicable. Consent to Publish declaration: Not applicable. References Maphumulo SZ, Breukelman GJ, Shaw B, Shaw I. The prevalence of physiological non-communicable diseases risk factors among Black Africans in peri-urban community In South Africa. Clin Epidemiol Glob Health. 2025 Jul 1;34:102111. Onyeonoro UU, Ogah OS, Ukegbu AU, Chukwuonye II, Madukwe OO, Moses AO. Urban–rural differences in health-care-seeking pattern of residents of Abia State, Nigeria, and the implication in the control of NCDs. Health Serv Insights [Internet]. 2016 [cited 2025 Oct 12];9. 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J Gen Intern Med [Internet]. 2001 Sep [cited 2025 Oct 10];16(9):613. Available from: https://doi.org/10.1046/j.1525-1497.2001.016009606.x Ubom AEB, Adebayo O, Adeoye PA, Kanmodi KK, Salihu MO, Umar SS, et al. Health, well-being, and burnout amongst early career doctors in Nigeria. PLoS One [Internet]. 2023 May 23 [cited 2025 Feb 27];18(5):e0285983. Available from: https://doi.org/10.1371/journal.pone.0285983 Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med [Internet]. 2006 May 22 [cited 2025 Oct 10];166(10):1092–7. Available from: https://doi.org/10.1001/archinte.166.10.1092 Nigeria Data Protection Commission (NDPC). Nigeria Data Protection Act 2023. Abuja, FCT: NDPC; 2023. 1–47 p. Paul NI, Duru CO. Childhood non communicable diseases (NCDs) in two tertiary hospitals in South-South Nigeria. Archives of Current Research International [Internet]. 2020 Feb 28 [cited 2025 Oct 13];20(1):13–23. Available from: https://doi.org/10.9734/acri/2020/v20i130168 Li Y, Rao X, Yang C, Luo R, Cao D, Gan J. Prevalence of anxiety, depression, and posttraumatic stress disorder in caregivers of children with epilepsy: A meta-analysis. Epilepsy and Behavior [Internet]. 2025 Mar 1 [cited 2025 Oct 12];164:110301. Available from: https://doi.org/10.1016/j.yebeh.2025.110301 Ocansey PME, Kretchy IA, Aryeetey GC, Agyabeng K, Nonvignon J. Anxiety, depression, and stress in caregivers of children and adolescents with mental disorders in Ghana and implications for medication adherence. Ghana Med J [Internet]. 2021 Sep 1 [cited 2025 Oct 12];55(3):182. Available from: https://doi,org/10.4314/gmj.v55i3.1 Lutfi NM, Al Lami F. Prevalence and determinants of depression among caregivers of children with leukaemia in Iraq. East Mediterranean Health Journal [Internet]. 2019 [cited 2025 Oct 12];25(6):385–92. Available from: https://doi.org/10.26719/emhj.19.005 Kazibwe J, Tran PB, Annerstedt KS. The household financial burden of non-communicable diseases in low- and middle-income countries: a systematic review. Health Res Policy Syst [Internet]. 2021 Dec 1 [cited 2025 Oct 13];19(1):1–15. Available from: https://doi.org/10.1186/s12961-021-00732-y Kanmodi K, Yahya A, Umar S, Enebeli U, Adebayo O, Ilesanmi O, et al. Prevalence and determinants of medical errors among early career doctors in Nigeria. Ibom Medical Journal [Internet]. 2022 Jan 1 [cited 2025 Mar 12];15(1):8–17. Available from: https://doi.org/10.61386/imj.v15i1.227 Ogunsuji OO, Adebayo O, Kanmodi KK, Fagbule OF, Adeniyi AM, James NT, et al. Burnout: A predictor of oral health impact profile among Nigerian early career doctors. PLoS One [Internet]. 2023 Jul 21 [cited 2025 Feb 2];18(7):e0281024. Available from: https://doi.org/10.1371/journal.pone.0281024 Soneye OY, Ogundipe HD, Ayowole D, Umar SS, Osasona EO, Adebayo O, et al. Systematic review of work-life balance among early career doctors. Ibom Medical Journal [Internet]. 2023 Jan 1 [cited 2025 Feb 27];16(1):1–13. Available from: https://doi.org/10.61386/imj.v16i1.285 Farrag A, Ghazaly MH, Mohammed K, Volland R, Hero B, Berthold F. Comparing presentations and outcomes of children with cancer: a study between a lower-middle-income country and a high-income country. BMC Pediatr [Internet]. 2023 Dec 1 [cited 2025 Oct 13];23(1):443. Available from: https://doi.org/10.1186/s12887-023-04214-8 Laurenzi CA, Hunt X, Skeen S, Sundin P, Weiss RE, Kosi V, et al. Associations between caregiver mental health and young children’s behaviour in a rural Kenyan sample. Glob Health Action [Internet]. 2021 [cited 2025 Oct 13];14(1):1861909. Available from: https://doi.org/10.1080/16549716.2020.1861909 Karim A, De Savigny D, Awor P, Cobos Muñoz D, Mäusezahl D, Enebeli U, et al. The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions. BMJ Glob Health. 2022 Jun 30;7(6):e008493. Isiguzo C, Herrera S, Ufere J, Enebeli U, Oluoha C, Anyanti J, et al. Improving access to appropriate case management for common childhood illnesses in hard-to-reach areas of Abia State, Nigeria. J Glob Health Rep [Internet]. 2019 Nov 1 [cited 2025 Feb 4];3(2):e2019030. Available from: https://doi.org/10.29392/joghr.3.e2019030 Belapurkar P, Acharya S, Shukla S, Kumar S, Khurana K, Acharya N. Prevalence of Anxiety, Depression, and Perceived Stress Among Family Caregivers of Patients Diagnosed With Oral Cancer in a Tertiary Care Hospital in Central India: A Cross-Sectional Study. Cureus [Internet]. 2023 Oct 16 [cited 2025 Oct 13];15(10):e47100. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10646617/ Additional Declarations No competing interests reported. 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09:25:14","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":347368,"visible":true,"origin":"","legend":"\u003cp\u003eGraphical abstract designed on Canva by authors, picture generated with prompt on Gemini\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7914498/v1/9acf68a20d692d3cd09959c7.png"},{"id":95521616,"identity":"42b8e161-2d14-4088-9947-04b8beceeb52","added_by":"auto","created_at":"2025-11-10 09:25:14","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22670,"visible":true,"origin":"","legend":"","description":"","filename":"STUDYTOOL.docx","url":"https://assets-eu.researchsquare.com/files/rs-7914498/v1/cfe7d670a67b55e9215a8fb9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence and predictors of depression and anxiety among caregivers of children with noncommunicable diseases in referral hospitals in Abia State Nigeria","fulltext":[{"header":"1 BACKGROUND","content":"\u003cp\u003eNon-communicable diseases (NCDs) are non-infectious health conditions that cannot be transmitted between individuals (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). They represent a growing global health challenge, as the global burden of disease is rapidly transitioning from infectious diseases to NCDs (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Over 2.1\u0026nbsp;billion children globally are affected by NCDs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). NCDs are responsible for 75% of global mortality, and low- and middle-income countries (LMICs) are disproportionately impacted, with 73% of all LMIC deaths (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). A significant number of children die from NCDs like haematological disorders (particularly sickle cell disease) and cancers, particularly in sub-Saharan Africa, where access to healthcare is limited (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Nigeria, children 0\u0026ndash;17 years old constitute 50% of the total population (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). NCDs account for around 30% of total mortality among Nigerian children, with paediatric NCDs emerging as an epidemic due to genetic predispositions (e.g., sickle cell disease) and environmental factors (e.g., air pollution worsening asthma) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Hospital records in Nigeria indicate that 20\u0026ndash;32% of paediatric admissions are attributable to NCDs, including haematological, cancer, renal disorders, and neurological conditions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), highlighting the need for facility-level data. Abia State, with an estimated population of 4,733,613 as of 2025 and diverse urban-rural dynamics, mirrors national and sub-national trends in health but lacks localised insights on childhood NCDs and caregiver mental health across its senatorial zones.\u003c/p\u003e\u003cp\u003eThe consequences of paediatric NCDs are so enormous; however, there are limited policies specific to childhood NCDs in many LMICs where, unfortunately, the bulk of young populations reside and where caregiving is traditionally the parents\u0026rsquo; or caregivers\u0026rsquo; burden to bear (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Research indicates that these caretakers experience adverse effects on their physical health, including lower back discomfort, musculoskeletal pain, fatigue, and sleep disturbances (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Beyond physical health, NCDs in children negatively impact the mental health of the carers, who are tasked with a considerable load from the processes for diagnosis, treatment, and daily care of the children. Consequently, in LMICs, carers, primarily mothers, have increased risks of depression, anxiety, and distress from financial difficulties, stigma, and insufficient support systems.\u003c/p\u003e\u003cp\u003eAnxiety is the most common mental disorder globally (4.4%), followed by depression (4%), and both are more common in women (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In LMICs, as much as 31\u0026ndash;77% of carers of young children with NCDs report increased symptoms of depression or anxiety, with higher rates in Lesotho and Nigeria (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These negative mental health impacts of caregiving can impair caregiving quality, perpetuating a cycle of poor child outcomes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Hospitals are healthcare facilities where some NCD patients receive outpatient and inpatient services to achieve the SDG 3.4 targets, which aim to reduce premature mortality from NCDs by one-third through prevention and treatment of mental health and well-being by 2030 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, evidence from Nigeria is sparse on studies examining NCDs and their effect on caregivers, especially for Abia State, which has varying healthcare access; hence, this study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResearch questions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTherefore, the research questions are:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat is the proportion of physician-diagnosed NCDs of children in referral hospitals in Abia State, Nigeria?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat is the proportion of depression and anxiety among caregivers of children with physician-diagnosed NCDs in referral hospitals of Abia State, Nigeria?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat is the relationship between the type/severity/duration of NCD in a child and occurrence of depression and anxiety in the child\u0026rsquo;s caregiver?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat socio-demographic factors predict the occurrence of depression and anxiety among caregivers of children with NCDs in referral hospitals of Abia State, Nigeria?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy objectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study aimed to determine: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the proportion of physician-diagnosed NCDs of children in referral hospitals in Abia State, Nigeria; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the proportion of depression and anxiety among carers of children with physician-diagnosed NCDs in referral hospitals of Abia State; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) the relationship between the type/severity/duration of NCD in a child and occurrence of depression and anxiety in the child\u0026rsquo;s caregiver; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) the socio-demographic factors predicting the occurrence of depression and anxiety among caregivers of children with NCDs in referral hospitals of Abia State, Nigeria.\u003c/p\u003e\u003cp\u003e\u003cb\u003eHypotheses\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe null hypotheses for this study were that:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e There is no relationship between the type/severity/duration of NCD in a child and occurrence of depression and anxiety in the child\u0026rsquo;s caregiver.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eThere are no socio-demographic factors predicting the occurrence of depression and anxiety among caregivers of children with NCDs in referral hospitals of Abia State, Nigeria.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eUnderstanding these intersections is crucial for holistic and effective public health strategies.\u003c/p\u003e"},{"header":"2 MATERIALS AND METHODS","content":"\u003cp\u003e\u003cb\u003e2.1 Ethical statement and consent to participate\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The study received ethical approval from the Ethical and Research Committee of the Abia State Ministry of Health (AB/MH/PRS/ECS/T.1/1016) before the study commenced. Permission for the study was obtained from the medical directors of the health facilities, and freely given written informed consent was secured from caregivers prior to data collection. Confidentiality was ensured by anonymising the data and password-protecting the databases. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study area\u003c/h2\u003e\u003cp\u003eAbia State is situated in the southeast geopolitical zone and is one of the 36 states of Nigeria, an LMIC in Sub-Saharan Africa. Abia State has three senatorial zones and 17 Local Government Areas (LGAs); the main urban areas are Umuahia (the state capital) and Aba (the major commercial centre), and 70% of the labour force is involved in agriculture (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The state has an estimated total population of 4,733,613 persons as of 2025, based on the 2006 census and a growth rate of 2.7 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Study design\u003c/h2\u003e\u003cp\u003eThis is a hospital-based cross-sectional study conducted in paediatric inpatient wards and outpatient clinics of three referral hospitals in Abia State, Nigeria \u0026ndash; at one referral hospital per senatorial zone. This included the General Hospital Ohafia (Abia North, rural), Children\u0026rsquo;s Hospital Umuahia (Abia Central, urban), and Comprehensive Hospital Ugwunagbo (Abia South, rural) in Abia State, Nigeria, surveyed from June to August 2025.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Study population\u003c/h2\u003e\u003cp\u003eThe study population included 720 caregivers of children who presented at the paediatric outpatient clinics or were admitted into the paediatric inpatient wards for NCDs within the study period. The inclusion criteria were primary caregivers (self-identified as mainly responsible for care) of children aged 0\u0026ndash;17 years with physician-diagnosed NCDs confirmed with their medical records (e.g., haematological disorders, malignancies, respiratory, cardiovascular, nutritional, digestive, endocrine, renal, neurological disorders) and who gave consent for the study. Exclusions: Caregivers of children with NCDs who did not give consent for the study, or caregivers of children who were not diagnosed with NCDs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Sample size determination\u003c/h2\u003e\u003cp\u003eThe sample size was calculated using Open Epi version 3 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), assuming a 30% prevalence of caregiver depression from a study in southwestern Nigeria (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), a 5% margin of error, and a 95% confidence level, yielding 646. Factoring in a 10% non-response rate, the minimum sample size was 718.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Sampling technique\u003c/h2\u003e\u003cp\u003eThe three senatorial zones in Abia State were included, with a sampling frame of all the public referral (secondary) hospitals in the state. One referral health facility was selected from each senatorial zone by simple random sampling, for a total of three referral hospitals included in the study. The final sample units were all consenting caregivers of children diagnosed with NCDs in the inpatient or outpatient settings of the selected hospitals and were recruited till the sample size was met.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.7 Data collection\u003c/h2\u003e\u003cp\u003eThe structured questionnaires were administered in English or Igbo after obtaining informed consent. The Igbo versions were translated and back-translated by bilingual experts to ensure linguistic and cultural equivalence, achieving a Cronbach\u0026rsquo;s α\u0026thinsp;\u0026gt;\u0026thinsp;0.80. The study instrument was prepared on KoboCollect and underwent face validation by experts. It was pretested in 5% of the sample size in a non-participating health facility for the reliability and validity of the questions, and a Cronbach\u0026rsquo;s α of \u0026gt;\u0026thinsp;0.80 was obtained, which was acceptable. Data collection occurred in clinic waiting areas or wards, where caregivers received a tablet with the KoboCollect to complete the PHQ-9 and GAD-7 components or were interviewed by a researcher (depending on literacy level) over a 20\u0026ndash;30-minute period.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.8 Study instrument\u003c/h2\u003e\u003cp\u003eThe study instrument included:\u003c/p\u003e\u003cp\u003e\u003cb\u003eSocio-demographic section\u003c/b\u003e: For the child: age, sex, and residence (urban/rural). For the caregiver: age in completed years, sex, relationship to the child, occupation, education (low: none/primary; high: secondary+), income, and the child\u0026rsquo;s NCD details, including type, duration, and perceived or clinically recorded severity.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eThe Patient Health Questionnaire-9 (PHQ-9)\u003c/strong\u003e\u003cp\u003eThe PHQ is a self-administered questionnaire for common mental disorders, and the PHQ-9 is the 9-item module on depression that scores nine symptoms\u0026rsquo; frequency over the previous two weeks as \u0026ldquo;0\u0026rdquo; if the response is \u0026ldquo;not at all\u0026rdquo; and \u0026ldquo;3\u0026rdquo; if it is \u0026ldquo;nearly every day\u0026rdquo;. PHQ-9 has a total score of 0\u0026ndash;27; a score of 10 has an 88% sensitivity and specificity for \u0026ldquo;major depression\u0026rdquo;, and it is reliable and valid for clinical and research criteria-based diagnoses of depressive disorders (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Question 9 is a single screening question on suicide risk, and a \u0026ldquo;yes\u0026rdquo; answer to it was referred for evaluation (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Other Nigerian studies have used the PHQ-9 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The test-retest reliability and the internal consistency (Cronbach\u0026rsquo;s alpha) of the PHQ-9 in this study were 0.87 and 0.84, respectively.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eThe Generalised Anxiety Disorder-7 (GAD-7)\u003c/strong\u003e\u003cp\u003eThe GAD-7 is a 7-item anxiety scale, a self-administered questionnaire with a 10-point score, which has an optimised sensitivity and specificity of 89% and 82%, respectively. The GAD-7 is valid and efficient for screening for generalised anxiety disorder at a\u0026thinsp;\u0026ge;\u0026thinsp;10 cutoff (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The GAD-7 has been used in other studies in Nigeria (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The test-retest reliability and the internal consistency (Cronbach\u0026rsquo;s alpha) of the GAD-7 in this study were 0.84 and 0.83, respectively.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.9 Data management\u003c/h2\u003e\u003cp\u003eData collected with KoboCollect were exported as Microsoft (MS) Excel files for initial cleaning and verification. The cleaned dataset was then imported from MS Excel to IBM SPSS version 29, where they were analysed. All data were anonymised by assigning unique IDs upon entry, and files were stored on password-protected, encrypted devices compliant with the Nigerian Data Protection Act 2023 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Only members of the research team had access to the data to ensure confidentiality.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDependent Variables\u003c/b\u003e: The caregiver\u0026rsquo;s mental health status (binary) was the primary outcome. Depression was assessed using the PHQ-9, and scores were dichotomised as 0 (no depression: \u0026lt;10) or 1 (depression: \u0026ge;10). Anxiety was assessed using the GAD-7, and scores were categorised as 0 (no anxiety: \u0026lt;10) or 1 (anxiety: \u0026ge;10).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIndependent Variables\u003c/strong\u003e\u003cp\u003eThe independent variables encompassed socio-demographic and disease-related factors, which were coded for analyses.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSocio-demographic: included age (of caregiver) and age (of child) categorised as \u0026lt;\u0026thinsp;30, 30\u0026ndash;39, \u0026ge;\u0026thinsp;40 and \u0026lt;\u0026thinsp;1, 1\u0026ndash;5, 6\u0026ndash;9, 10\u0026ndash;17 years, respectively, for subgroup analyses. Sex of caregiver and child as binary (0\u0026thinsp;=\u0026thinsp;male, 1\u0026thinsp;=\u0026thinsp;female). Relationship to child: 0\u0026thinsp;=\u0026thinsp;mother, 1\u0026thinsp;=\u0026thinsp;non-mother. Education of caregiver: 0\u0026thinsp;=\u0026thinsp;high, i.e., secondary/tertiary; 1\u0026thinsp;=\u0026thinsp;low: none/primary. Residence: 0\u0026thinsp;=\u0026thinsp;urban, 1\u0026thinsp;=\u0026thinsp;rural. Monthly income: Ordinal (1=\u0026lt;₦20,000; 2=₦20,000\u0026ndash;50,000; 3=₦50,001-100,000; 4=\u0026gt;₦100,000).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDisease-related: NCD type: Categorical (presence or absence of NCD types). Duration: continuous (years since diagnosis); categorised as \u0026lt;\u0026thinsp;1 year or \u0026gt;\u0026thinsp;1 year. Severity: ordinal (1\u0026thinsp;=\u0026thinsp;mild, 2\u0026thinsp;=\u0026thinsp;moderate, 3\u0026thinsp;=\u0026thinsp;severe).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.10 Statistical analyses\u003c/h2\u003e\u003cp\u003eStatistical analyses were conducted using IBM SPSS Statistics version 29 (IBM Corp., Armonk, NY, USA). A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was adopted for all tests. Analyses were performed separately for depression and anxiety outcomes to account for potential differences in their determinants.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDescriptive Statistics\u003c/strong\u003e\u003cp\u003eParticipant characteristics were summarised using descriptive statistics. Continuous variables (e.g., caregiver age, child age, NCD duration) were reported as means with standard deviations (SD). Frequencies and percentages were used to present variables, e.g., NCD type and prevalence of NCD.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eBivariate Analyses\u003c/strong\u003e\u003cp\u003eThe chi-square tests were used to assess the association between the independent and dependent variables. The means of continuous variables were compared with independent t-tests. The output was in crude odds ratios (OR), the corresponding 95% confidence interval, and p-value significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMultivariable Analyses\u003c/strong\u003e\u003cp\u003eThe multivariable logistic regression was used to assess independent associations while controlling for confounding variables. The significant variables from the bivariate analysis were included initially, and assessed while controlling for confounders, with the output in adjusted odds ratios (AOR), 95% confidence intervals, and significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3 RESULTS","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Sociodemographic characteristics of children with NCDs and their caregivers\u003c/h2\u003e\u003cp\u003eCaregivers were predominantly female (85.6%), with a mean age of 34.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 years, and most were mothers (80.3%). 10.1% were fathers, 6.3% other relatives (e.g., grandparents, siblings), and 3.3% non-relatives. Nearly half (49.0%) had low education levels (none/primary), and low monthly income (\u0026lt;₦20,000) was reported by 32.2%. Half resided in urban areas (50.7%). Children had a mean age of 4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 years, with 55.6% male, and the majority aged 1\u0026ndash;5 years (60.6%), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic characteristics of children with NCDs and their caregivers\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaregiver, n\u0026thinsp;=\u0026thinsp;720\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\u003cp\u003e\u0026ge;\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e202\u003c/p\u003e\u003cp\u003e347\u003c/p\u003e\u003cp\u003e171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.1\u003c/p\u003e\u003cp\u003e48.2\u003c/p\u003e\u003cp\u003e23.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104\u003c/p\u003e\u003cp\u003e616\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003cp\u003e85.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship to child\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMother\u003c/p\u003e\u003cp\u003eFather\u003c/p\u003e\u003cp\u003eOther relative\u003c/p\u003e\u003cp\u003eNon-relative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e578\u003c/p\u003e\u003cp\u003e73\u003c/p\u003e\u003cp\u003e45\u003c/p\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.3\u003c/p\u003e\u003cp\u003e10.1\u003c/p\u003e\u003cp\u003e6.3\u003c/p\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHighest Educational level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow (None or Primary)\u003c/p\u003e\u003cp\u003eHigh (Secondary+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e353\u003c/p\u003e\u003cp\u003e367\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49.0\u003c/p\u003e\u003cp\u003e51.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAverage Household Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le; ₦20,000\u003c/p\u003e\u003cp\u003e₦20,001-₦50,000\u003c/p\u003e\u003cp\u003e₦50,001-₦100,000\u003c/p\u003e\u003cp\u003e\u0026gt;₦100,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e232\u003c/p\u003e\u003cp\u003e216\u003c/p\u003e\u003cp\u003e180\u003c/p\u003e\u003cp\u003e92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32.2\u003c/p\u003e\u003cp\u003e30.0\u003c/p\u003e\u003cp\u003e25.0\u003c/p\u003e\u003cp\u003e12.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e365\u003c/p\u003e\u003cp\u003e355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.7\u003c/p\u003e\u003cp\u003e49.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean age (years)\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChild, n\u0026thinsp;=\u0026thinsp;720\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge group (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e\u003cp\u003e1\u0026ndash;5\u003c/p\u003e\u003cp\u003e6\u0026ndash;9\u003c/p\u003e\u003cp\u003e10\u0026ndash;17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e144\u003c/p\u003e\u003cp\u003e436\u003c/p\u003e\u003cp\u003e108\u003c/p\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003cp\u003e60.6\u003c/p\u003e\u003cp\u003e15.0\u003c/p\u003e\u003cp\u003e4.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e400\u003c/p\u003e\u003cp\u003e320\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55.6\u003c/p\u003e\u003cp\u003e44.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean age (years)\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Children\u0026rsquo;s NCD Status\u003c/h2\u003e\u003cp\u003eHaematological disorders were the most prevalent NCD (23.1%), followed by malignancies (19.7%), renal disorders (15.4%), neurological disorders (10.6%), respiratory disorders (10.1%), cardiovascular disorders (9.9%), nutritional disorders (8.3%), digestive disorders (1.5%), and endocrine disorders (1.4%). Most cases had a duration of \u0026lt;\u0026thinsp;1 year (68.3%), with moderate severity predominant (52.3%). Among severe cases (n\u0026thinsp;=\u0026thinsp;127, 17.6%), malignancies accounted for the highest proportion (22.0%), followed by haematological disorders (19.7%), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChildren\u0026rsquo;s NCD status\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNCD type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHaematological disorders\u003c/p\u003e\u003cp\u003eMalignancies disorders\u003c/p\u003e\u003cp\u003eRenal disorders\u003c/p\u003e\u003cp\u003eNeurological disorders\u003c/p\u003e\u003cp\u003eRespiratory disorders\u003c/p\u003e\u003cp\u003eCardiovascular disorders\u003c/p\u003e\u003cp\u003eNutritional disorders\u003c/p\u003e\u003cp\u003eDigestive disorders\u003c/p\u003e\u003cp\u003eEndocrine disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e166 (23.1)\u003c/p\u003e\u003cp\u003e142 (19.7)\u003c/p\u003e\u003cp\u003e111 (15.4)\u003c/p\u003e\u003cp\u003e76 (10.6)\u003c/p\u003e\u003cp\u003e73 (10.1)\u003c/p\u003e\u003cp\u003e71 (9.9)\u003c/p\u003e\u003cp\u003e60 (8.3)\u003c/p\u003e\u003cp\u003e11 (1.5)\u003c/p\u003e\u003cp\u003e10 (1.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of disease (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e492 (68.3)\u003c/p\u003e\u003cp\u003e228 (31.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived/Clinical severity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003cp\u003eModerate\u003c/p\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e217 (30.1)\u003c/p\u003e\u003cp\u003e376 (52.3)\u003c/p\u003e\u003cp\u003e127 (17.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere cases by NCD type, n\u0026thinsp;=\u0026thinsp;127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMalignancies\u003c/p\u003e\u003cp\u003eHaematological\u003c/p\u003e\u003cp\u003eRenal\u003c/p\u003e\u003cp\u003eNeurological\u003c/p\u003e\u003cp\u003eRespiratory\u003c/p\u003e\u003cp\u003eNutritional\u003c/p\u003e\u003cp\u003eCardiovascular\u003c/p\u003e\u003cp\u003eEndocrine\u003c/p\u003e\u003cp\u003eDigestive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (22.0)\u003c/p\u003e\u003cp\u003e25 (19.7)\u003c/p\u003e\u003cp\u003e19 (15.0)\u003c/p\u003e\u003cp\u003e13 (10.2)\u003c/p\u003e\u003cp\u003e13 (10.2)\u003c/p\u003e\u003cp\u003e12 (9.5)\u003c/p\u003e\u003cp\u003e10 (7.9)\u003c/p\u003e\u003cp\u003e4 (3.1)\u003c/p\u003e\u003cp\u003e3 (2.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Proportion of depression and anxiety among caregivers of children with NCDs in referral hospitals\u003c/h2\u003e\u003cp\u003eOverall, 34.0% and 25.6% of caregivers screened positive for depression and anxiety, respectively. Prevalence was significantly higher among rural residents (depression: 41.1%; anxiety: 35.5%) compared to urban (27.1% and 15.9%, respectively; both p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and among caregivers with low education (depression: 46.7%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), compared to high education (21.8%). Non-maternal caregivers showed elevated depression rates (45.1%), compared to maternal caregivers (31.3%), p\u0026thinsp;=\u0026thinsp;0.003 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Of the 720 caregivers, 8 were referred to hospital mental health services due to PHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;10, GAD-7\u0026thinsp;\u0026ge;\u0026thinsp;10, or reported suicidal ideation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eProportion of depression and anxiety among caregivers of children with NCDs in referral hospitals\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal, n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrevalence, n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePrevalence, n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e245 (34.0)\u003c/p\u003e\u003cp\u003e475 (66.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e245 (34.0)\u003c/p\u003e\u003cp\u003e475 (66.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e184 (25.6)\u003c/p\u003e\u003cp\u003e536 (74.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e355 (49.3)\u003c/p\u003e\u003cp\u003e365 (50.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e146 (41.1)\u003c/p\u003e\u003cp\u003e99 (27.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e126 (35.5)\u003c/p\u003e\u003cp\u003e58 (15.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e353 (49.0)\u003c/p\u003e\u003cp\u003e367 (51.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e165 (46.7)\u003c/p\u003e\u003cp\u003e80 (21.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95 (26.9)\u003c/p\u003e\u003cp\u003e89 (24.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.089\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship to child\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-mother\u003c/p\u003e\u003cp\u003eMother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142 (19.7)\u003c/p\u003e\u003cp\u003e578 (80.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64 (45.1)\u003c/p\u003e\u003cp\u003e181 (31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.003*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40 (28.2)\u003c/p\u003e\u003cp\u003e144 (24.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Relationship between NCDs and Depression and Anxiety among Caregivers of Children with NCDs (Bivariate Associations)\u003c/h2\u003e\u003cp\u003eRural residence was significantly associated with both depression (OR 1.88, 95% CI 1.37\u0026ndash;2.57; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and anxiety (OR 2.91, 95% CI 2.04\u0026ndash;4.15; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Low education predicted higher odds of depression (OR 3.15, 95% CI 2.28\u0026ndash;4.35; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while shorter disease duration (\u0026lt;\u0026thinsp;1 year) was protective for both outcomes (depression OR 0.71, p\u0026thinsp;=\u0026thinsp;0.036; anxiety OR 0.64, p\u0026thinsp;=\u0026thinsp;0.012). Non-maternal caregivers had elevated depression risk (OR 1.80, p\u0026thinsp;=\u0026thinsp;0.002); and caregiver and child sex showed no associations with neither depression nor anxiety (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Bivariate analysis showed higher depression (38.7%, OR 1.29, 95% CI 0.89\u0026ndash;1.73, p\u0026thinsp;=\u0026thinsp;0.196) and anxiety (29.2%, OR 1.22, 95% CI 0.85\u0026ndash;1.75, p\u0026thinsp;=\u0026thinsp;0.284) rates for caregivers of children with malignancies, but these differences were not significant.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRelationship between NCDs and Depression and Anxiety among Caregivers of Children with NCDs (Bivariate Associations)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrevalence, n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePrevalence, n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003cp\u003eUrban (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e146 (41.1)\u003c/p\u003e\u003cp\u003e99 (27.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.88 (1.37\u0026ndash;2.57)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e126 (35.5)\u003c/p\u003e\u003cp\u003e58 (15.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.91 (2.04\u0026ndash;4.15)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003cp\u003eHigh (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e165 (46.7)\u003c/p\u003e\u003cp\u003e80 (21.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.15 (2.28\u0026ndash;4.35)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95 (26.9)\u003c/p\u003e\u003cp\u003e89 (24.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.37 (0.98\u0026ndash;1.92)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.089\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship to child\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-mother\u003c/p\u003e\u003cp\u003eMother (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64 (45.1)\u003c/p\u003e\u003cp\u003e181 (31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.80 (1.24\u0026ndash;2.62)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40 (30.3)\u003c/p\u003e\u003cp\u003e144 (24.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.35 (0.90\u0026ndash;2.02)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNCD Duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1 year (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e155 (31.5)\u003c/p\u003e\u003cp\u003e90 (39.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.71 (0.51\u0026ndash;0.98)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.036*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e112 (22.8)\u003c/p\u003e\u003cp\u003e72 (31.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.64 (0.45\u0026ndash;0.91)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.012*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNCD Type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMalignancy\u003c/p\u003e\u003cp\u003eNon-malignancy (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (38.7)\u003c/p\u003e\u003cp\u003e190 (32.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.29 (0.89\u0026ndash;1.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e41 (28.9)\u003c/p\u003e\u003cp\u003e143 (24.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.22 (0.85\u0026ndash;1.75)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.284\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaregiver sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003cp\u003eFemale (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (31.7)\u003c/p\u003e\u003cp\u003e212 (34.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.08 (0.70\u0026ndash;1.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.719\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25 (24.0)\u003c/p\u003e\u003cp\u003e159 (25.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.22 (0.77\u0026ndash;1.93)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.406\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChild sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003cp\u003eFemale (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e137 (34.3)\u003c/p\u003e\u003cp\u003e108 (33.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.02 (0.75\u0026ndash;1.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.888\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e93 (23.3)\u003c/p\u003e\u003cp\u003e91 (28.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.94 (0.67\u0026ndash;1.31)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.702\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Sociodemographic Predictors of Depression and Anxiety in Caregivers of Children with NCDs (Multivariable Logistic Regression)\u003c/h2\u003e\u003cp\u003eAfter adjustment for sociodemographic and disease-related factors, rural residence independently predicted both depression (AOR 1.65, 95% CI 1.32\u0026ndash;2.06; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and anxiety (AOR 2.32, 95% CI 1.78\u0026ndash;3.02; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Low education remained a significant risk factor for depression (AOR 1.42, 95% CI 1.12\u0026ndash;1.80; p\u0026thinsp;=\u0026thinsp;0.003) and anxiety (AOR 1.43, 95% CI 1.09\u0026ndash;1.88; p\u0026thinsp;=\u0026thinsp;0.008). Non-maternal caregivers had higher odds of depression (AOR 1.58, 95% CI 1.18\u0026ndash;2.11; p\u0026thinsp;=\u0026thinsp;0.002), but not anxiety (AOR 1.15, p\u0026thinsp;=\u0026thinsp;0.421) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic Predictors of Depression and Anxiety in Caregivers of Children with NCDs (Multivariable Logistic Regression)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrevalence, n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePrevalence, n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003cp\u003eUrban (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e146 (41.1)\u003c/p\u003e\u003cp\u003e99 (27.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.65 (1.32\u0026ndash;2.06)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e130 (35.5)\u003c/p\u003e\u003cp\u003e56 (15.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.32 (1.78\u0026ndash;3.02)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003cp\u003eHigh (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e171 (46.7)\u003c/p\u003e\u003cp\u003e77 (21.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.42 (1.12\u0026ndash;1.80)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.003*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e105 (28.6)\u003c/p\u003e\u003cp\u003e80 (22.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.43 (1.09\u0026ndash;1.88)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.008*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship to child\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-mother\u003c/p\u003e\u003cp\u003eMother (ref)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64 (45.1)\u003c/p\u003e\u003cp\u003e181 (31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.58 (1.18\u0026ndash;2.11)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e43 (30.3)\u003c/p\u003e\u003cp\u003e141 (24.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.15 (0.82\u0026ndash;1.62)\u003c/p\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.421\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4 DISCUSSIONS","content":"\u003cp\u003eThe first objective of this study was to determine the proportion of physician-diagnosed NCDs of children in referral hospitals. In this study, haematological disorders (23.1%) were the most common NCD, followed by malignancies (19.7%), renal disorders (15.4%), neurological disorders (10.6%), respiratory disorders (10.1%), cardiovascular disorders (9.9%), nutritional disorders (8.3%), digestive disorders (1.5%), and endocrine disorders (1.4%). The predominance of haematological disorders (23.1%) aligns closely with Emodi \u003cem\u003eet al\u003c/em\u003e.\u0026rsquo;s findings in Enugu (23.3%) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), though slight variations may reflect differences in hospital case mix. The study also reported 19.2% malignancies, and the renal, central nervous, and cardiovascular system NCDs accounted for 12.8%, 12.4%, and 10.9% among hospitalised children (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In Benin, 33.9% haematological disorders predominated, followed by 29.2% neoplasms, 14.4% cardiovascular, 7.9% neurological, 6.1% renal, 5.1% digestive (5.1%), and endocrine (2.5%) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The predominance of haematological disorders (23.1%) as the most common NCD reflects the burden of sickle cell anaemia in Nigeria\u0026rsquo;s genetic epidemiology, where prevalence ranges from 1\u0026ndash;3% nationally, contributing to 7\u0026ndash;16% of child mortality in sub-Saharan Africa, and is driven by high carrier rates (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe second objective was to determine the proportion of depression and anxiety among caregivers of children with physician-diagnosed NCDs in referral hospitals. This hospital-based cross-sectional study provides novel insights into the mental health burdens faced by caregivers of children with NCDs in Abia State, Nigeria, revealing a depression prevalence of 34.0% and an anxiety prevalence of 25.6% with the growing recognition of psychosocial strains in LMICs, where caregivers, who are often family members, navigate NCD management amid resource constraints. This study\u0026rsquo;s results on depression and anxiety are in agreement with a meta-analysis of the mental health of caregivers of children with epilepsy in 18 countries, which reported 31% depression and 34% anxiety prevalences (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), the slight differences probably being from our study\u0026rsquo;s wider NCDs range. On the other hand, our study\u0026rsquo;s findings are lower than in Ghana (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), with 66.2% depression and 56.2% anxiety among caregivers of mentally ill children, and the 70% depression among Iraqi caregivers of children that were ill with leukaemia (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The differences with our study may again be due to single NCDs studied versus the multiple NCDs in our study.\u003c/p\u003e\u003cp\u003eThe index study found no independent association between the occurrence of caregiver anxiety and depression, and specific childhood NCD types like haematological disorders and malignancies after adjusting for confounders, and this conforms to an LMIC-wide analysis wherein systematic and not individual stressors were the precursors to anxiety and depression. These stressors included stigma, monetary considerations, and limitations in accessing healthcare, which were uniform across the different NCD types (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The stressors do indeed cause heightened distress, but to all NCDs needing care, not necessarily specific to a type of NCD across LMICs (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, the scenario was different in high-income countries, where there were significantly higher rates of anxiety and depression with cancers due to acute issues surrounding their care (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFactors like short disease duration (\u0026lt;\u0026thinsp;1 year in 68.3%) and moderate severity (52.3%) likely also contribute to generalised distress, implying that broad-spectrum interventions such as routine caregiver screening and peer support in Nigerian paediatric clinical settings should enhance family behavioural resilience, with future longitudinal research needed to explore causal pathways.\u003c/p\u003e\u003cp\u003eThe final objective was to determine the socio-demographic factors that predict the occurrence of depression and anxiety among caregivers of children with NCDs in referral hospitals. This study provides evidence that rural residence, low education, and non-maternal caregivers were significant risk factors for depression. And rural residence and low education predicted anxiety, similar to a study in rural communities in Kenya where the geographic isolation and poor access to healthcare services increased health risks for the children and compounded the caregiver\u0026rsquo;s anxiety (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). These poor access to healthcare as well as unrecognised caregiver mental health issues are additionally pointers to limitations and gaps in implementation of paediatric NCD policies in LMICs.\u003c/p\u003e\u003cp\u003eThese findings imply that community-based efforts targeting hard-to-reach areas are also imperative in the control of NCDs (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The associated low education with caregiver distress in this study may be explained by low literacy in health and coping issues, as well as distress through low socioeconomic status associated with low education (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Also, the heightened risk of depression among non-maternal caregivers seem to point to gender roles as fathers were a larger proportion of the non-maternal caregivers, and may face additional mental burden in performing roles societally gendered to mothers.\u003c/p\u003e\u003cp\u003eThis study\u0026rsquo;s strengths include its uniqueness in being at the forefront of caregiver mental health intersection with childhood NCDs in Abia State, Nigeria. Its rigorous and detailed methodology eases replicability for studies to elucidate caregiver burdens in LMICs. Its large sample size and multi-zonal selection make it representative of the population. And the ethical compliance and use of validated tools enhance its reliability. However, there are limitations that should be taken into account. It is a cross-sectional study and cannot establish causal relationships between caregiver mental health and the occurrence of NCDs in children. Again, the study\u0026rsquo;s dependence on self-reported mental health status may be prone to response or desirability bias, although using validated tools (like the PHQ-9 and the GAD-7) minimises this bias.\u003c/p\u003e\u003cp\u003eThe public health policy implications of these findings include that integrating routine screening for the mental health of caregivers of children with NCDs will enable their early diagnosis and management, in alignment with SDG 3.4. The use of peer support networks and incorporation of rural equity into mental health strategies will improve their effectiveness. It is recommended that future studies utilise longitudinal research to explore the efficacy of various interventions that could improve the mental health of caregivers in an era of expanding paediatric NCDs.\u003c/p\u003e"},{"header":"5 CONCLUSIONS","content":"\u003cp\u003eThis study is the first multi-NCD caregiver study in Abia, and among the few to examine the intersection of anxiety and depression in caregivers of children with a broad range of NCDs in Africa\u0026rsquo;s most populous country. Caregivers bear substantial mental health burdens from childhood NCDs, driven by socio-structural factors. Targeted hospital interventions can break this intersection, foster resilient families in LMICs, and support SDG 3.4 by highlighting caregiver well-being in NCD reduction.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAOR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Adjusted Odds Ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Confidence Interval\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGAD-7\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Generalised Anxiety Disorder-7\u003c/p\u003e\n\u003cp\u003eLGA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Local Government Area\u003c/p\u003e\n\u003cp\u003eLMIC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Low- and Middle-income Country\u003c/p\u003e\n\u003cp\u003eNCD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-communicable Disease\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Odds Ratio (crude)\u003c/p\u003e\n\u003cp\u003ePHQ-9\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Patient Health Questionnaire-9\u0026nbsp;\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was self-funded by the authors. No external grants were received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets for this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEIK: conceptualisation, data collection, data analysis, writing original draft, and funding. UUE: methodology, review, editing, writing final draft. YJC: data collection, data analysis, writing original draft. ELE: conceptualisation, writing original and final drafts. ANA: investigation, editing, supervision, review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests Policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare there are no competing financial and/or non-financial interests in relation to the work described.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDual publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe corresponding author confirms that I have read the journal policies and am submitting the manuscript in accordance with those policies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermission to Use Third-Party Material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. The authors created the images and figures, and they have never been published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\n\u003cli\u003eMaphumulo SZ, Breukelman GJ, Shaw B, Shaw I. The prevalence of physiological non-communicable diseases risk factors among Black Africans in peri-urban community In South Africa. Clin Epidemiol Glob Health. 2025 Jul 1;34:102111. \u003c/li\u003e\n\u003cli\u003eOnyeonoro UU, Ogah OS, Ukegbu AU, Chukwuonye II, Madukwe OO, Moses AO. Urban\u0026ndash;rural differences in health-care-seeking pattern of residents of Abia State, Nigeria, and the implication in the control of NCDs. Health Serv Insights [Internet]. 2016 [cited 2025 Oct 12];9. 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Glob Health Action [Internet]. 2021 [cited 2025 Oct 13];14(1):1861909. Available from: https://doi.org/10.1080/16549716.2020.1861909\u003c/li\u003e\n\u003cli\u003eKarim A, De Savigny D, Awor P, Cobos Mu\u0026ntilde;oz D, M\u0026auml;usezahl D, Enebeli U, et al. The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions. BMJ Glob Health. 2022 Jun 30;7(6):e008493. \u003c/li\u003e\n\u003cli\u003eIsiguzo C, Herrera S, Ufere J, Enebeli U, Oluoha C, Anyanti J, et al. Improving access to appropriate case management for common childhood illnesses in hard-to-reach areas of Abia State, Nigeria. J Glob Health Rep [Internet]. 2019 Nov 1 [cited 2025 Feb 4];3(2):e2019030. Available from: https://doi.org/10.29392/joghr.3.e2019030\u003c/li\u003e\n\u003cli\u003eBelapurkar P, Acharya S, Shukla S, Kumar S, Khurana K, Acharya N. 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Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10646617/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Childhood non-communicable diseases, Chronically ill children, Caregivers, Mental health, Depression, Anxiety, Nigeria, LMIC","lastPublishedDoi":"10.21203/rs.3.rs-7914498/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7914498/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChildhood non-communicable diseases (NCDs) pose a significant burden in low- and middle-income countries (LMICs), with a rising prevalence among children. Caregivers of affected children often experience mental health challenges, yet data from sub-Saharan Africa remain limited. This is the first childhood multi-NCD study providing insight into the burden of caregiving in Abia State, in the southeast of Africa’s most populous LMIC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis hospital-based cross-sectional study enrolled 720 consenting caregivers of children with physician-diagnosed NCDs in three referral hospitals. Data were collected using a structured sociodemographic questionnaire, the Patient Health Questionnaire-9 (PHQ-9) for depression, and the Generalised Anxiety Disorder-7 (GAD-7) for anxiety. Descriptive statistics, chi-square tests, and multivariable logistic regression were performed using SPSS version 29.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCaregivers were predominantly mothers (80.3%). Haematological disorders (23.1%) and malignancies (19.7%) were the most common NCDs among the children. The prevalence of depression (PHQ-9 ≥ 10) and anxiety (GAD-7 ≥ 10) among caregivers was 34.0% (95% CI: 30.4–37.6) and 25.6% (95% CI: 22.3–28.9), respectively. Rural residence (AOR 1.65, 95% CI: 1.32–2.06 for depression; AOR 2.32, 95% CI 1.78–3.02 for anxiety), low education (AOR 1.42, 95% CI: 1.12–1.80 for depression; AOR 1.43, 95% CI 1.09–1.88 for anxiety), and non-maternal caregivers, e.g., fathers or others (AOR 1.58, 95% CI: 1.18–2.11 for depression), were associated with higher odds of mental health issues. NCD type showed no significant independent association after adjustment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMental health burdens among caregivers of children with NCDs are substantial, exacerbated by rurality and socioeconomic factors. Hospital-integrated public health interventions targeting caregiver support are urgently needed to mitigate these intersections in LMICs, fostering resilient families and sustainable development.\u003c/p\u003e","manuscriptTitle":"Prevalence and predictors of depression and anxiety among caregivers of children with noncommunicable diseases in referral hospitals in Abia State Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 09:25:10","doi":"10.21203/rs.3.rs-7914498/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e9e3cc7-4bdf-46c7-b639-5c64dbd09691","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T10:26:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 09:25:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7914498","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7914498","identity":"rs-7914498","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}