Depression Prevalence and Associated Factors Among Adolescents with Sickle Cell Anemia in Dar es Salaam, Tanzania: A Cross-Sectional Study

Depression Prevalence and Associated Factors Among Adolescents with Sickle Cell Anemia in Dar es Salaam, Tanzania: A Cross-Sectional Study | 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 Depression Prevalence and Associated Factors Among Adolescents with Sickle Cell Anemia in Dar es Salaam, Tanzania: A Cross-Sectional Study Linda Paul Athman, Agnes Jonathan, Fatima Mussa, Honesta kipasika, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4693535/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2025 Read the published version in BMC Pediatrics → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Depression commonly arises among adolescents who have experienced long-standing psychosocial difficulties especially those facing chronic illnesses like Sickle Cell Anemia (SCA). SCA is a global health concern, and Tanzania is one of the countries with a high incidence, estimated at 8,000 to 11,000 births per year. This study aims to assess the magnitude and factors associated with depression among adolescents with SCA. Methodology: A cross-sectional analytical study conducted on adolescents aged 11-19 years attending sickle cell clinics in referral hospitals in Dar-es-salaam Tanzania, from October 2023-March 2024. A validated Patient Health Questionnaire (PHQ-9) tool was used to screen for depression. Univarite and multivariate regression model was used to determine factors associated with clinical depression.A P value of less than 0.05 was considered statistically significant. Results : Among 326 adolescents enrolled, the majority (64.7%) were 10-14 years of age. A total of 216 (54 %) had depression; when categorized into severity, 167 (38.7 %) had mild, 48 (14.7 %) had moderate and 1 (0.3%) had severe depression. Clinical depression, encompassing moderate to severe depression, was prevalent in 49 (15%) adolescents. Painful episodes were significantly associated with depression (aOR = 2.49) (95% CI: 1.17 - 5.29, p = 0.01). Conclusion : Depression is common among adolescents with SCA in our setting. Painful episodes experienced by these adolescents were significantly associated with depression. This study highlights the need for screening adolescents with SCA for depression and integration of mental health services in sickle cell clinics. Depression adolescents sickle cell anemia clinical depression Figures Figure 1 Figure 2 Figure 3 Figure 4 BACKGROUND Depression also known as major depressive disorder or clinical depression; is a mood disorder that affects how a person feels, thinks, and conducts daily activities. Globally, it has been estimated that 1 in every 7 (14%) 10-19-year-olds experience mental health conditions, majority being; depression, anxiety, and behavioral disorders. Depression occurs among 1.1% of adolescents with the age 10–14 years, and 2.8% of 15-19-year-olds. 1 It is predicted that, by 2030 depression alone is likely to be the 3rd leading cause of disease burden in low-income countries and 2nd highest in middle-income countries. 2 Sickle cell disease (SCD) is a global disease which occurs as a result of a genetic mutation that leads to abnormal hemoglobin molecules which polymerize when deoxidized. 3 , 4 Sickle cell Anemia (SCA), is an autosomal recessive hemoglobin S mutation (HbSS) which has been linked to significant mortality and morbidity in African and Mediterranean ancestry. 5 Tanzania is among the top 5 countries in Sub-Saharan Africa and the top leading in East Africa with the highest prevalence of SCD estimated at 8000-11,000 births per year. Almost half of SCA patients (47.4%) in Tanzania were in the age group of 5–17 years 6 . With improved care and advanced treatment modalities, there has been reduced mortality and thus increasing survival and transforming SCA into a chronic illness, accompanied with psychosocial and mental health burden. The occurrence of acute and chronic painful episodes, delayed puberty, recurrent hospital admissions and blood transfusion among others have been greatly linked to development of depressive symptoms in adolescents. Depression rates are found to be high in adolescents with SCA as compared to the general population of adolescence. 7 Despite the huge burden of SCA in Sub-Saharan Africa very few studies have been done to explore the burden of depression among adolescents with SCA. Depression magnitude among adolescents in Tanzania is unknown however we noted high prevalence 84% in some African countries like Congo 8 Studies done in Nigeria and other resource limited settings identified factors that may explain the presence of depression. These include; painful episodes, age, gender, level of education and socio-economic status. 8 – 9 Similar studies have been conducted for adult patients with SCA. 10 Data from this study provides the magnitude and severity of depression in adolescents with SCA. It further enlightens on factors associated with depression among adolescents with SCA. METHODOLOGY Study design and setting: A cross-sectional analytical study conducted among adolescents attending sickle cell clinics found in Dar es Salaam form October 2023 to March 2024. Dar es Salaam is one among the largest and fastest growing cities in Tanzania with estimated population of 7.4 million residents as per 2022 census and experience a rapid growth rate of about 5.6% per year. It comprises of 4 referral hospitals including a national referral hospital and three Regional Referral Hospitals (RRH) Mwananyamala RRH, Amana RRH and Temeke RRH. Study participants: Adolescents aged 11–19 years, confirmed with SCA by Hb electrophoresis or HPLC were included. Among these; adolescents who declined assent and consent, those with painful crisis at that time and those with additional comorbid illness which could further contribute to depression were excluded. Sample size and selection The sample size (N) was calculated using the formula for proportion. Where; N = minimum sample size required, P = 86% - mean prevalence of depression in adolescence with SCA in Congo.(19); E = Maximum allowable error of the study, which is 5%; Z = Standard normal distribution that corresponds to 95% level of confidence, which is 2.85. Therefore, the minimum sample size required was 320 participants. Convenience sampling was used to obtain participants and a total of 326 participants were recruited. Data collection methods Data was collected by the principal investigator with the help of 3 research assistants (medical personnel’s). The research assistants were pre-trained on the entire data collection process and had good understanding of the study. The study was conducted using pre-structured and pre-tested questionnaire to assess the prevalence, severity and factors associated with depression. The questionnaire had three sections including socio-demographic data, severity of SCA and Patient Health Questionnaire (PHQ-9) tools. The interviews took place during the time at which clients waited to see the attending doctor or after they were done with their visit. This did not affect their access to necessary services during their clinic visit. The researcher administered the questionnaire due to the sensitivity of data and ease of obtaining data from participants who can’t read or write. Data collection tools: Structured questionnaire was used to obtain socio-demographic data and clinical profile of study participants. Sickle cell disease severity scores adapted from a study by ezenwosu et al was analyzed as follows. Items in the previous 12 months (number of hospitalizations, number of blood transfusions, and number of painful crises) were scored according to the frequency of their occurrence (0–3). Items in present state- splenic and liver enlargement were scored by severity (0 = 10cm) while lifetime complications of SCA; leg ulcers, stroke, priapism, respiratory complications, arthritis, osteomyelitis, sickle cell nephropathy and gallstones (0 = absent, 1 = present). Total score was 21, whereby; a score ≤ 6 (mild), score 7–12 (moderate), and score > 12 (severe). 9 Patient Health Questionnaire (PHQ-9) tool was used to screen for depression. 11 The severity of depression was obtained from the PHQ-9 tool scores whereas the total score from the 9 items ranged from 0 to 27. Clinical depression or major depressive disorder was suggested if PHQ-9 score ≥ 10 or if of the 9 items, 5 or more are checked as, “at least more than half the days” or each item 1 or 2 was checked as, “at least more than half the days”. A score of 0–4 (none-minimal depression), 5–9 (mild depression), 10–14 (moderate depression), 15–19 (moderately severe depression), 20–27 (severe depression). Data analysis: Data was entered in SPSS V23 and data cleaning was done. For numerical variables, mean and standard deviation were used. Categorical variables were described using frequencies and proportions with difference in proportions analyzed using the chi squared or Fishers exact test, as appropriate. Univariate and multivariate analysis were used for the associated factors. A P value of less than 0.05 was considered statistically significant. RESULTS Participant’s socio-demographic characteristics Participant’s socio-demographic characteristics as elaborated on Table 1 revealed that the majority (64.7%) of participants were 10–14 years of age, with the mean age of 13.9 ± 2.4 SD. There was equal gender distribution. Most participants attended were from the tertiary referral clinic MNH clinic at (49.1%) followed by the regional hospital clinics, Temeke (23.6%) and almost equal proportion were from Mwananyamala (10.1%) and Amana (10.4%). Majority of participants had either primary level education (48.2%) or secondary level education (46.9%), with a small proportion (4.9%) having no formal education at all. Majority of participants were from Dar es salaam (urban and rural) (87.7%) and few (12.3%) were from Up-country (other regions in Tanzania). Sixty five (65%) of participants had health insurance coverage. Participant’s Clinical profile Three quarters of adolescents (74.5%) with SCA were on hydroxyurea (Table 2 ). Sickle cell disease Severity Score (SSS) was used to determine severity of SCA among participants classifying them as mild, moderate and severe disease category. It was observed that (96.3%) had mild disease severity, (3.7%) had moderate disease severity and none of them had severe disease. When looking at painful episodes, 39.6% of the adolescents reported to be pain-free in the past 12 months while the remaining had either 1 (26.4%), 2–3 (22.7%) or more than 3 (11.3%) painful episodes. The majority of the participants in the study did not receive blood transfusions (85.0%) or require hospital admission (66.3%) in the past 12 months and most of them had no current symptoms of hepatomegaly or splenomegaly represented by (97.9%) and (91.1%) of participants respectively. Majority of adolescents in this study had no complications of SCA (Table 3 ). Of the few that reported complications, the most commonly observed complication was respiratory complications (pneumonia or acute chest syndrome) (Fig. 3 ). Table 1 Socio-demographic characteristics of adolescents with SCA No of participants-326 Percentage (%) Age(years) 10–14 211 64.7 15–19 115 35.3 Sex Male 160 49.1 Female 166 50.9 Clinic MNH 182 55.8 Temeke 77 23.6 Mwananyamala 33 10.1 Amana 34 10.4 Education No formal education 16 4.9 Primary 157 48.2 Secondary 153 46.9 Address Dar es salaam 286 87.7 Up-country 40 12.3 Health insurance absent 212 65 present 114 35 Table 2 Participant’s Clinical profile No of participants-326 Percentage (%) Hydroxyurea use No 80 24.5 yes 246 75.5 Painful Episodes none 129 39.6 once 89 26.4 2–3 74 22.7 > 3 37 11.3 Hospital admission none 216 66.3 once 69 21.2 2–3 32 9.8 > 3 9 2.8 Blood transfusion none 277 85.0 once 34 10.4 2–3 13 4.0 > 3 2 0.6 Spleen enlargement 10cm 1 0.3 Liver enlargement < 5cm 323 99.1 5-10cm 3 0.9 Table 3 Participant’s Clinical profile; - Complications of SCA among participants No of participants Percentage (%) Stroke No 320 98.8 Yes 4 1.2 Osteomyelitis No 324 99.4 Yes 2 0.6 Arthritis No 324 99.3 Yes 2 0.6 Chronic leg ulcer No 323 99.1 Yes 3 0.9 Sickle cell nephropathy No 324 99.4 Yes 2 0.6 Respiratory complications No 313 96.0 Yes 13 4.0 Priapism No 320 96.0 Yes 6 1.8 Gallstones No 325 99.7 Yes 1 0.3 SCA disease severity Mild 341 96.3 Moderate 12 3.7 Magnitude of depression among adolescents with SCA Out of the 326 adolescents screened, 216 had depression, resulting in an overall prevalence rate of 54%. (Fig. 4 ). Depression was categorized as mild in 167 (38.7%) adolescents, moderate (moderate and moderately-severe) in 48 (14.7%) adolescents, and severe in 1(0.3%) adolescent (Fig. 5 ). Moreover, the study identified 49 adolescents (15%) with clinical depression, encompassing those in moderate, moderately-severe, and severe depression category. 3.4 Factors associated with clinical depression. In the univariate and multivariable analysis, various factors including age, gender, education level, health insurance, use of hydroxyurea, hospital admission and blood transfusion showed no significant association with depression, p > 0.05. Those the multivariate analysis, those who experienced pwho experienced painful episodes in the previous 12 months had a significantly higher odds of depression compared to those who had no painful episodes, with a crude OR of 2.56(95% CI: 1.25–5.23, p = 0.01). After adjusting for other variables in the multivariate analysis, those who experienced painful episodes still exhibited higher odds of depression (adjusted OR = 2.49, 95% CI: 1.17–5.29, p = 0.01). Table 5 Logistic regression factors associated with clinical depression Univariate analysis Multivariable analysis cOR 95% CI P-value aOR 95% CI P-value Age(years) 10–14 ref 15–19 1.46 0.79–2.71 0.23 1.29 0.56–2.97 0.54 Gender Male ref Female 1.34 0.73–2.48 0.34 1.35 0.70–2.58 0.37 Education level No formal education ref Primary 0.59 0.16–2.29 0.45 0.60 0.14–2.50 0.48 Secondary 0.93 0.25–3.48 0.91 0.74 0.19–2.90 0.69 Health insurance Non insured Insured 1.41 0.73–2.75 0.31 1.47 0.72–3.02 0.29 SCA disease severity Mild ref Moderate 0.58 0.07–4.44 0.56 0.35 0.04–3.39 0.36 Painful episodes No ref Yes 2.56 1.25–5.23 0.01 2.49 1.17–5.29 0.01 Hospital admission No ref Yes 1.30 0.69–2.42 0.42 1.14 0.53–2.43 0.73 Blood transfusion No ref Yes 0.76 0.30–1.89 0.555 0.79 0.26–2.39 0.69 Use of hydroxyurea No use Use 1.80 0.80–4.02 0.15 1.65 0.70–3.87 0.25 DISCUSSION This study aimed to determine the magnitude and associated factors of depression; and to explore lived experiences among adolescents with SCA and depression. The overall prevalence of depression was seen to be quite high in our settings, more than half of the adolescents experienced depression mostly mild symptoms and only 15% were found to have clinical depression (moderate and severe depression). This was similar to studies done in various continents which also demonstrated higher prevalence of depression among adolescents with SCA. Results revealed that 46% of adolescents with SCA had depression in America, 48% of adolescents attending sickle cell clinics also had depression in Saudi Arabia and in Congo 86% of adolescents were found to have depression. 8 , 12 – 13 Variations of prevalence estimates across different studies and between different countries could be attributed to differences in awareness of mental health and mental health seeking behavior which not so common in low income settings. Advancement in psychosocial care in high income settings lessens the burden of depression. Other minor variations could be due different diagnostic tools (PHQ-9, BDI, and DSM-V etc.), adopted classifications, and study methods used. Mild depression was more common compared to moderate and severe depression this could mean that most adolescents suffer mild symptoms of depression which resolve however few progress to moderate and severe symptoms. This was similarly observed and reported by Aljumah et al (2016) in Saudi Arabia were the prevalence of mild, moderate and severe depression were 23.2%, 20.6%, and 6.8% respectfully; and another study by Sahril et al in Malaysia (2019) where prevalence of mild, moderate, and severe depression was found to be 16.6%, 12.8%, and 3.8% respectively. However, Lukoo et al (2015) reported mild, moderate and severe depression with prevalence of 14.3%, 77.1%, 8.6% respectively. 8,12,14 Depression severity has implications when it comes to choice of treatment and prognosis. Socio-demographic factors like age, sex, level of education and health insurance, had no significant association with depression in this study. Contrary, studies by Alhamoud et al (2018) in Saudi Arabia and Mallicka et al (2021) in India reported that gender, low level of education and low socio-economic status were significantly associated with depression. 15 , 16 Furthermore Asnani et al (2010), revealed that higher level of education was associated with higher odds of depression. The difference observed could be attributed to different cultural backgrounds and environmental settings of participants. 17 Owing to SCA disease severity, participants in this study had mild to moderate disease severity; this could be attributed to the fact that participants were outpatients attending clinic and had no severe symptoms requiring admission. Mild to moderate disease severity had no significant association with depression. These findings were comparatively similar to a study done in Nigeria by Ezenwosu et al (2021), where disease severity in children and adolescents with SCA had no significant association with depression. A similar tool for assessing disease severity was used in this study. 9 Painful episodes in the previous 12 month had 2.4 higher odds of depression with P value of 0.01. Similarly, a study by Asnani et al (2010), in Jamaica, showed that participants with frequent painful crises had 2.5 times higher odds of developing depression with a p-value of 0.003. 17 Another study by Ballah et al (2023), showed that among adolescent who had experienced crisis, more than half had mild to moderate depression. 18 Chronic or frequent painful episodes if not well controlled are associated with unusually high levels of stress hormone production which disrupts sleep patterns and affects mood, hence associated with development of anxiety and mood disorders. CONCLUSION Depression is common among adolescents with SCA in our setting with prevalence of 54%; where by mild, moderate and severe symptoms were found to be 38.7%, 14.7% and 0.3% respectively. Painful episodes experienced by these adolescents were significantly associated with depression. This study highlights the need for screening adolescents with SCA for depression as part of comprehensive care. Furthermore mental health services should be integrated in sickle cell clinics with the availability of a psychologist or counselor. Clinicians must prioritize effective prevention and comprehensive management of chronic pain or frequent painful episodes. Abbreviations cOR - Crude Odds Ratio aOR - Adjusted Odds Ratio Hb - Hemoglobin HbS - Sickled hemoglobin HbAS - Heterozygous sickled hemoglobin HbSS - Homozygous sickled hemoglobin HPLC - High-Performance Liquid Chromatography IDI - In Depth Interview MUHAS- Muhimbili University of Health and Allied Sciences MNH - Muhimbili National Hospital RBC - Red Blood Cells PHQ - Patient Health Questionnaire RRH - Regional Referral Hospital SCA - Sickle Cell Anemia SCD - Sickle Cell Disease SPSS - Statistical Package for Social Sciences. SSS - Sickle cell anemia Severity Score Declarations ACKNOWLEDGMENTS Authors would like to appreciate parents/guardians and adolescents for their participation and members of staff-Sickle cell clinics at Muhimbili National Hospital, Temeke, and Amana Regional Referral Hospitals for their support during data collection. ETHICAL APPROVAL Ethical approval obtained from the Muhimbili University of Health and Allied sciences Ethical Board Committee MUHAS-REC-06-2023-1770. Permission letter for data collection were also obtained from each health facility. The data collected did not interfere with the routine care provided at the clinic. A clear informed consent and assent were sought and participants found to have moderate to severe depressive symptoms, were contacted and channeled to a clinical psychologists for further evaluation and therapy. FUNDING Research reported in this publication was supported by the National Heart, Lung, and Blood Institute (NHLBI) of the US National Institutes of Health (NIH) under Award Number U01 HL156853 (Sickle Pan-African Research Consortium—SPARCO Tanzania). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. DISCLOSURE The authors report no conflicts of interest in this work. 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BMC Psychol . 2021;9(1):1-14. doi:10.1186/s40359-021-00543-4 Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): A diagnostic meta-analysis. J Gen Intern Med . 2007;22(11):1596-1602. doi:10.1007/s11606-007-0333-y Aljumah Z, Ibrahim Ali S, Al-Saleem M, Almogarab K, Alghadeer F, AlEssa F. Depression in Sickle-Cell Disease patients in the Eastern Province. Int J Healthc Sci . 2015;3(February 2016):300-302. www.researchpublish.com Jerrell JM, Tripathi A, McIntyre RS. Prevalence and treatment of depression in children and adolescents with sickle cell disease: A retrospective cohort study. Prim Care Companion J Clin Psychiatry . 2011;13(2):21977359. doi:10.4088/PCC.10m01063 Sahril NB, Yaacob NM, Ahmad NA, Abdullah S, Mahadir Naidu B, Aris T. Depression Severity and its Associated Factors among School-Going Adolescents in Malaysia. 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Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2025 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 16 Jul, 2024 Editor assigned by journal 16 Jul, 2024 Submission checks completed at journal 12 Jul, 2024 First submitted to journal 05 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4693535","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":327507157,"identity":"3c6b1fbc-d434-49c7-a803-68bc6a962519","order_by":0,"name":"Linda Paul 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Sciences","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Balandya","suffix":""}],"badges":[],"createdAt":"2024-07-05 16:43:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4693535/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4693535/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-024-05359-w","type":"published","date":"2025-01-07T15:57:26+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62190229,"identity":"d9b46b60-89ed-42b4-a7c7-aee4b26f4d75","added_by":"auto","created_at":"2024-08-10 12:26:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41783,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2: Flow chart showing recruitment of participants\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4693535/v1/b4073fa981d8a1efd26032b0.png"},{"id":62190230,"identity":"0e4c4c16-4ab3-46f3-a48c-d9cfb83316e5","added_by":"auto","created_at":"2024-08-10 12:26:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61339,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 3: Clinical profile; -Complications of SCA among participants\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4693535/v1/161477feda420dd13b5d46ad.png"},{"id":62190232,"identity":"0945d9ef-6b90-43d9-863b-15249cbf3df1","added_by":"auto","created_at":"2024-08-10 12:26:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21940,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 4: Prevalence of depression among adolescents with SCA\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4693535/v1/008b17bb3a7986508d42d2a5.png"},{"id":62190231,"identity":"d9063f19-ed37-459d-b783-7a6a079c58c0","added_by":"auto","created_at":"2024-08-10 12:26:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":27052,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 5: Prevalence of depression by severity among adolescents with SCA\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4693535/v1/46e954f1ac46633d7c64e7af.png"},{"id":73693908,"identity":"f475a667-053a-413e-819f-4afc0676fe5f","added_by":"auto","created_at":"2025-01-13 16:09:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1035269,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4693535/v1/f5e9fc73-e7b8-4e6d-8b30-7efcbe3bb08e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDepression Prevalence and Associated Factors Among Adolescents with Sickle Cell Anemia in Dar es Salaam, Tanzania: A Cross-Sectional Study\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eDepression also known as major depressive disorder or clinical depression; is a mood disorder that affects how a person feels, thinks, and conducts daily activities. Globally, it has been estimated that 1 in every 7 (14%) 10-19-year-olds experience mental health conditions, majority being; depression, anxiety, and behavioral disorders. Depression occurs among 1.1% of adolescents with the age 10\u0026ndash;14 years, and 2.8% of 15-19-year-olds. \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e It is predicted that, by 2030 depression alone is likely to be the 3rd leading cause of disease burden in low-income countries and 2nd highest in middle-income countries. \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSickle cell disease (SCD) is a global disease which occurs as a result of a genetic mutation that leads to abnormal hemoglobin molecules which polymerize when deoxidized.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Sickle cell Anemia (SCA), is an autosomal recessive hemoglobin S mutation (HbSS) which has been linked to significant mortality and morbidity in African and Mediterranean ancestry.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Tanzania is among the top 5 countries in Sub-Saharan Africa and the top leading in East Africa with the highest prevalence of SCD estimated at 8000-11,000 births per year.\u003c/p\u003e \u003cp\u003eAlmost half of SCA patients (47.4%) in Tanzania were in the age group of 5\u0026ndash;17 years \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. With improved care and advanced treatment modalities, there has been reduced mortality and thus increasing survival and transforming SCA into a chronic illness, accompanied with psychosocial and mental health burden. The occurrence of acute and chronic painful episodes, delayed puberty, recurrent hospital admissions and blood transfusion among others have been greatly linked to development of depressive symptoms in adolescents. Depression rates are found to be high in adolescents with SCA as compared to the general population of adolescence. \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite the huge burden of SCA in Sub-Saharan Africa very few studies have been done to explore the burden of depression among adolescents with SCA. Depression magnitude among adolescents in Tanzania is unknown however we noted high prevalence 84% in some African countries like Congo \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Studies done in Nigeria and other resource limited settings identified factors that may explain the presence of depression. These include; painful episodes, age, gender, level of education and socio-economic status.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Similar studies have been conducted for adult patients with SCA. \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Data from this study provides the magnitude and severity of depression in adolescents with SCA. It further enlightens on factors associated with depression among adolescents with SCA.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting:\u003c/h2\u003e \u003cp\u003eA cross-sectional analytical study conducted among adolescents attending sickle cell clinics found in Dar es Salaam form October 2023 to March 2024. Dar es Salaam is one among the largest and fastest growing cities in Tanzania with estimated population of 7.4\u0026nbsp;million residents as per 2022 census and experience a rapid growth rate of about 5.6% per year. It comprises of 4 referral hospitals including a national referral hospital and three Regional Referral Hospitals (RRH) Mwananyamala RRH, Amana RRH and Temeke RRH.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy participants:\u003c/h2\u003e \u003cp\u003eAdolescents aged 11\u0026ndash;19 years, confirmed with SCA by Hb electrophoresis or HPLC were included. Among these; adolescents who declined assent and consent, those with painful crisis at that time and those with additional comorbid illness which could further contribute to depression were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSample size and selection\u003c/h2\u003e \u003cp\u003eThe sample size (N) was calculated using the formula for proportion. Where; N\u0026thinsp;=\u0026thinsp;minimum sample size required, P\u0026thinsp;=\u0026thinsp;86% - mean prevalence of depression in adolescence with SCA in Congo.(19); E\u0026thinsp;=\u0026thinsp;Maximum allowable error of the study, which is 5%; Z\u0026thinsp;=\u0026thinsp;Standard normal distribution that corresponds to 95% level of confidence, which is 2.85. Therefore, the minimum sample size required was 320 participants. Convenience sampling was used to obtain participants and a total of 326 participants were recruited.\u003c/p\u003e \n\u003cp\u003e\u003cimg src=\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAASQAAAAzCAYAAAA+XXV7AAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAADsMAAA7DAcdvqGQAAAl0SURBVHhe7Z0/jhQ9E4d7v2MghBBwBgIEBAQsByAAIiKkJUaQcAEQMaRkyxGAgADQBpwBEEKIa7xfPz3927e2Xtvjnp7Z7empR7Km/7jtcrlcY9fstvf+aWmCIAgmwP/6zyAIgjMnHFIQBJMhHFIQBJMhHFIQBJMhHFIQBJMhHFIQBJNhqxzSy5cvm729vS79/PmzvxrMlStXrnR9fefOnf5KMHe2xiHJAfFnUy9evGgeP37cnQfzhC+fjx8/dv39/fv35t27d/2dYNbwh5G1/Pjxgz+iPE6tY+jvLDg8PDxxn/Na7HM+Xb58uc/1L1z78uVLMj+JeymQ6eDgoD9bQFn7+/v9WR6eS9Vl5SPPkHavAy+XB/lSsq6Craemnd5mvJ45z90T1ONtbVUoS/XVyF8jHyCf8tHmsVCORXLn7DqFtYsamZSXVNK3dCJb4nhdrFySBE8pqNRxKVBW6hk1PIXNz7E/5zlvcHSQzWcdmr1eQgNMZdsBJyiLuk4bDYpUW5C3ZgCWsM5MdS0rs6QH7nlnnsq/DtmBMmx9HJfKrZXP9/8YZJPWgcieSbUOycoqG7VleminbVtKN5LN25fKr5WtxMpaRCiERhBPakCUoCG+8TL4VCO55zvM1ikF2WuUn5PLP19CZVt5U4OT8nybNg1yYFTIwrEFWcbIQz94g/ZG7CG/l8PC8/Y+8qX6oVTHEPwg45hrOWrk83Y2FsrzegY5g5pBLxu15aDDnB6V35ZNXtt21Z/rT5UxllExJNb4MDboeP369ebevXv9WdN8/fq1efbsWRcr4p5FsaRLly51nym41xpTF3sQ9+/fb54/f96frZdr1651n79//+4+4fXr112dp82DBw+a1pg6/aHHdUE/eJ0TdC7x6tWrTg4C0ylZeP7Tp0/92QJfB7GkJ0+e9Gerg920g6a5evVqf6XpjrmW+4FkmXzEMbGz9+/f91fGQXn0Xcm2a/j27Vsnly3n5s2bx+PVo3xHR0fdp7hw4UJ/1DQPHz7sZHv69Gl/5SSUwXgdG9sd5ZAQov3WaD58+NAZjgcj1K9iuZQy1Bs3bnQK9Y3HcG7fvt1d57gU6MTQNGDIR3neua2LP3/+dJ+2A9ENdZ5FMBZnSN3oMQVfIKm+UBryBYOh58CRtF96nY0giy+XLwhsByOmP9++fdvJLmRT6NLbl36BI6FjyrDnHgYpaPBZ/v792x+dZJl8b968aR49enRcL0nObah8QHl8oYzl8+fPx7ZvYUzkwJnw5YFspIsXLx5PEhijPMs1tSFVPl/MtGEUi4nScOw0lekdRWnKN2YKq7JaBfRXFmjKaJOgvpQ8mp5zXpLJP18CuWzZ4OUR1Es6LZhOqw8kp9qFvFbmsVB+rc4gpTfgnOutA+2vLFAfKqX0qDyUTdt9GRbVY5FMdqniyckne7Q6II/NN0Q+lUfeFLpfklVQr++bVPs9ktfrGtm5zidIbz4f1MqYYy0OCVC2GjzEUC1SGp9DoD6es0nKA+6nlCe4XyuzOsOnlCGlDGOT0GZrDNIn1zkeqtcStCs3eHIgh+8HlSM9DoXneW6ZnqULi+otDaCcfKnyUk5jjHyWVNk5Una3rHxgDKse+3yqPPoyVR7XxtjZ2v4OKRVPGrJkY6pLzKVt+Il4Ui0817bnOOXWurWwRLBy+rVxq/QT9aWWAmcNemyNqZuKM40XY5ds6IblzNA2K9Ym0OmtW7e6ctAhfZhaCpTQEoqlVQnFjrSkAi3Vzp071316hsqXKqdWvlXxfUf7WEbb+CkQ32wdTn/2X2gXS1LCGrRVS9UcNjyxTtbmkOg0BikNkTLUuFJSXEeNTwUIS4qpAdmsIdaAQ7Ny2tjBEIYO2nWD3BiiXdujY9s2n0pBWsU/VonHETS1MSdksoaNrO1sZFBfEVPkmWXOgn5AD4olAbE/nsv1UUk+ObhUDNQ6plr5zp8/330OtVPfd7QlFaz/9etXF+9KoRiRlZuxrEkGfZZyqDkHp7asRNuIlWgV3B+dhOkdU78haPqXmo4y/fPTfA+y5OQByijJtOx5S9tx1dNS6qzJty78kk0MkblEqi9ydXrI43XMue2XZf3k4XnaJni29LwvP2dzYpl8tN2eoxurn6HyleTh+jJ5LVYWPVuC+1b2VFvsOe3w9lRTzzIGPy3noZRSEMLXokaUkm+4SD2bkgdS9zRQbbIG5KFDbN6Scans08LKldI/OszpsQbf76m67IDzus3ZBPmVp6RPD+XZcr18OWw+rw8rv1gmn7UJP4C5NkQ+nrdlCG93qTwpJAPJ2rX6xpbj+ytVh9VFypZoY61sOXbmndosNVgjr+tvRpbBMpOfScfGsoLdgjhQ6xzOfKm/CuuQfWv+uXYsBHgJUA4Nmq6CgsLhjIKhMKDbmUgyNjVViFXhjNoVyGhHOokZEo2ZM9s4CZ17nwSbZVWbj22QgiCYDDuzZAuCYPqEQwqCYDKEQwqCYDKEQwqCYDKEQwqCYDKEQwqCYDKEQwqCYDKEQwqCYDKEQwqCYDKEQwqCYDKEQwqCYDLsrEPSfyiTUjumBEENeh3wabxFYhfYWYfEnmH8XzGve+Cd00NfHRoEvGOLd4tjRzik+GIbz+wcEoahmU8qyWj0jmze33JwcJDdmyvYPuzmEjVOoia/7pM0G+IdW3q3OI6J91YH45idQ2KDgcPDw+6Y2Q/fXkqc54wmt/NEsF3gXNiUUn3OzrMlp1STn3NrS35HD8EbQoORtAqeHbzvl6a1RtRfyUMe3gUczAPeI237U+9dz1GTv+Y90WPfJR0s2BmHxHHqxeRhSPOCfvebOaSuiWX57cv5U/YDXM+VHwxjZ4Ladj8uwS8k2ku9JtYQTBu9hzq1/GYPNk9N/rt373bLtNbhdBuZ+l/TCGyzCSexJI7jx5FxzNoh8bJ0BSIxJguGxeZ3xA+4v6mdOIPtRi+t16anxJL05cUndsWGktgQu9ps424hU2LWDgnjwYhI7bS6v7qAwKTukVbZvjvYPbAjAt/gdzc+rS225szOLNm09XEwX/QTvP0TDi2hUts7D80PYUebZWccElNpZkGs80nBPNnf32+Ojo76s4WzYeku5+MZmp9YJPv7BRuinWrODn71oGn2VzbgfKZNDnr4tcv2Mds/534dgyH5sR/uB5tjdqMTg8HAcil+5p8/+kIi+b8x0373llJ+XSeFM9o8sVFkEASTYWdiSEEQTJ9wSEEQTISm+T/Lpb9O5LkEwgAAAABJRU5ErkJggg==\" width=\"292\" height=\"51\"\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection methods\u003c/h2\u003e \u003cp\u003eData was collected by the principal investigator with the help of 3 research assistants (medical personnel\u0026rsquo;s). The research assistants were pre-trained on the entire data collection process and had good understanding of the study. The study was conducted using pre-structured and pre-tested questionnaire to assess the prevalence, severity and factors associated with depression. The questionnaire had three sections including socio-demographic data, severity of SCA and Patient Health Questionnaire (PHQ-9) tools.\u003c/p\u003e \u003cp\u003eThe interviews took place during the time at which clients waited to see the attending doctor or after they were done with their visit. This did not affect their access to necessary services during their clinic visit. The researcher administered the questionnaire due to the sensitivity of data and ease of obtaining data from participants who can\u0026rsquo;t read or write.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection tools:\u003c/h2\u003e \u003cp\u003eStructured questionnaire was used to obtain socio-demographic data and clinical profile of study participants. Sickle cell disease severity scores adapted from a study by ezenwosu et al was analyzed as follows. Items in the previous 12 months (number of hospitalizations, number of blood transfusions, and number of painful crises) were scored according to the frequency of their occurrence (0\u0026ndash;3). Items in present state- splenic and liver enlargement were scored by severity (0\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;5cm, 1\u0026thinsp;=\u0026thinsp;5-10cm, 2\u0026thinsp;\u0026gt;\u0026thinsp;10cm) while lifetime complications of SCA; leg ulcers, stroke, priapism, respiratory complications, arthritis, osteomyelitis, sickle cell nephropathy and gallstones (0\u0026thinsp;=\u0026thinsp;absent, 1\u0026thinsp;=\u0026thinsp;present). Total score was 21, whereby; a score\u0026thinsp;\u0026le;\u0026thinsp;6 (mild), score 7\u0026ndash;12 (moderate), and score\u0026thinsp;\u0026gt;\u0026thinsp;12 (severe).\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePatient Health Questionnaire (PHQ-9) tool was used to screen for depression.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e The severity of depression was obtained from the PHQ-9 tool scores whereas the total score from the 9 items ranged from 0 to 27. Clinical depression or major depressive disorder was suggested if PHQ-9 score\u0026thinsp;\u0026ge;\u0026thinsp;10 or if of the 9 items, 5 or more are checked as, \u0026ldquo;at least more than half the days\u0026rdquo; or each item 1 or 2 was checked as, \u0026ldquo;at least more than half the days\u0026rdquo;. A score of 0\u0026ndash;4 (none-minimal depression), 5\u0026ndash;9 (mild depression), 10\u0026ndash;14 (moderate depression), 15\u0026ndash;19 (moderately severe depression), 20\u0026ndash;27 (severe depression).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis:\u003c/h2\u003e \u003cp\u003eData was entered in SPSS V23 and data cleaning was done. For numerical variables, mean and standard deviation were used. Categorical variables were described using frequencies and proportions with difference in proportions analyzed using the chi squared or Fishers exact test, as appropriate. Univariate and multivariate analysis were used for the associated factors. A P value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant\u0026rsquo;s socio-demographic characteristics\u003c/h2\u003e \u003cp\u003eParticipant\u0026rsquo;s socio-demographic characteristics as elaborated on Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e revealed that the majority (64.7%) of participants were 10\u0026ndash;14 years of age, with the mean age of 13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 SD. There was equal gender distribution. Most participants attended were from the tertiary referral clinic MNH clinic at (49.1%) followed by the regional hospital clinics, Temeke (23.6%) and almost equal proportion were from Mwananyamala (10.1%) and Amana (10.4%). Majority of participants had either primary level education (48.2%) or secondary level education (46.9%), with a small proportion (4.9%) having no formal education at all. Majority of participants were from Dar es salaam (urban and rural) (87.7%) and few (12.3%) were from Up-country (other regions in Tanzania). Sixty five (65%) of participants had health insurance coverage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipant\u0026rsquo;s Clinical profile\u003c/h2\u003e \u003cp\u003eThree quarters of adolescents (74.5%) with SCA were on hydroxyurea (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Sickle cell disease Severity Score (SSS) was used to determine severity of SCA among participants classifying them as mild, moderate and severe disease category. It was observed that (96.3%) had mild disease severity, (3.7%) had moderate disease severity and none of them had severe disease. When looking at painful episodes, 39.6% of the adolescents reported to be pain-free in the past 12 months while the remaining had either 1 (26.4%), 2\u0026ndash;3 (22.7%) or more than 3 (11.3%) painful episodes. The majority of the participants in the study did not receive blood transfusions (85.0%) or require hospital admission (66.3%) in the past 12 months and most of them had no current symptoms of hepatomegaly or splenomegaly represented by (97.9%) and (91.1%) of participants respectively.\u003c/p\u003e \u003cp\u003eMajority of adolescents in this study had no complications of SCA (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Of the few that reported complications, the most commonly observed complication was respiratory complications (pneumonia or acute chest syndrome) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\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\u003eSocio-demographic characteristics of adolescents with SCA\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=\"char\" char=\".\" 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\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo of participants-326\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eClinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMNH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTemeke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMwananyamala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAddress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDar es salaam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUp-country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealth insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eabsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e212\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\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\u003eParticipant\u0026rsquo;s Clinical profile\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\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\u003eNo of participants-326\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHydroxyurea\u003c/p\u003e \u003cp\u003euse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e75.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003ePainful Episodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eonce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHospital admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eonce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eonce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSpleen enlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e97.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u0026ndash;10 cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLiver enlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5-10cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \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\u003eParticipant\u0026rsquo;s Clinical profile; - Complications of SCA among participants\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\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\u003eNo of participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e98.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOsteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eArthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChronic leg ulcer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSickle cell nephropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRespiratory complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePriapism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGallstones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e325\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSCA disease severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.7\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=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMagnitude of depression among adolescents with SCA\u003c/h2\u003e \u003cp\u003eOut of the 326 adolescents screened, 216 had depression, resulting in an overall prevalence rate of 54%. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Depression was categorized as mild in 167 (38.7%) adolescents, moderate (moderate and moderately-severe) in 48 (14.7%) adolescents, and severe in 1(0.3%) adolescent (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Moreover, the study identified 49 adolescents (15%) with clinical depression, encompassing those in moderate, moderately-severe, and severe depression category.\u003c/p\u003e\u003cp\u003e \u003cb\u003e3.4 Factors associated with clinical depression.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the univariate and multivariable analysis, various factors including age, gender, education level, health insurance, use of hydroxyurea, hospital admission and blood transfusion showed no significant association with depression, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05. Those the multivariate analysis, those who experienced pwho experienced painful episodes in the previous 12 months had a significantly higher odds of depression compared to those who had no painful episodes, with a crude OR of 2.56(95% CI: 1.25\u0026ndash;5.23, p\u0026thinsp;=\u0026thinsp;0.01). After adjusting for other variables in the multivariate analysis, those who experienced painful episodes still exhibited higher odds of depression (adjusted OR\u0026thinsp;=\u0026thinsp;2.49, 95% CI: 1.17\u0026ndash;5.29, p\u0026thinsp;=\u0026thinsp;0.01).\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 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression factors associated with clinical depression\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=\"left\" 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 \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eMultivariable analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eaOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.79\u0026ndash;2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.56\u0026ndash;2.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.73\u0026ndash;2.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.70\u0026ndash;2.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16\u0026ndash;2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.14\u0026ndash;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u0026ndash;3.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.19\u0026ndash;2.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHealth insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon insured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.73\u0026ndash;2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.72\u0026ndash;3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSCA disease severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.07\u0026ndash;4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.04\u0026ndash;3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePainful episodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25\u0026ndash;5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.17\u0026ndash;5.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHospital admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u0026ndash;2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.53\u0026ndash;2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eref\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.30\u0026ndash;1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.555\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.26\u0026ndash;2.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUse of hydroxyurea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80\u0026ndash;4.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.70\u0026ndash;3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.25\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"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study aimed to determine the magnitude and associated factors of depression; and to explore lived experiences among adolescents with SCA and depression. The overall prevalence of depression was seen to be quite high in our settings, more than half of the adolescents experienced depression mostly mild symptoms and only 15% were found to have clinical depression (moderate and severe depression).\u003c/p\u003e \u003cp\u003eThis was similar to studies done in various continents which also demonstrated higher prevalence of depression among adolescents with SCA. Results revealed that 46% of adolescents with SCA had depression in America, 48% of adolescents attending sickle cell clinics also had depression in Saudi Arabia and in Congo 86% of adolescents were found to have depression.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Variations of prevalence estimates across different studies and between different countries could be attributed to differences in awareness of mental health and mental health seeking behavior which not so common in low income settings. Advancement in psychosocial care in high income settings lessens the burden of depression. Other minor variations could be due different diagnostic tools (PHQ-9, BDI, and DSM-V etc.), adopted classifications, and study methods used.\u003c/p\u003e \u003cp\u003eMild depression was more common compared to moderate and severe depression this could mean that most adolescents suffer mild symptoms of depression which resolve however few progress to moderate and severe symptoms. This was similarly observed and reported by Aljumah et al (2016) in Saudi Arabia were the prevalence of mild, moderate and severe depression were 23.2%, 20.6%, and 6.8% respectfully; and another study by Sahril et al in Malaysia (2019) where prevalence of mild, moderate, and severe depression was found to be 16.6%, 12.8%, and 3.8% respectively. However, Lukoo et al (2015) reported mild, moderate and severe depression with prevalence of 14.3%, 77.1%, 8.6% respectively.\u003csup\u003e8,12,14\u003c/sup\u003e Depression severity has implications when it comes to choice of treatment and prognosis.\u003c/p\u003e \u003cp\u003eSocio-demographic factors like age, sex, level of education and health insurance, had no significant association with depression in this study. Contrary, studies by Alhamoud et al (2018) in Saudi Arabia and Mallicka et al (2021) in India reported that gender, low level of education and low socio-economic status were significantly associated with depression. \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Furthermore Asnani et al (2010), revealed that higher level of education was associated with higher odds of depression. The difference observed could be attributed to different cultural backgrounds and environmental settings of participants.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOwing to SCA disease severity, participants in this study had mild to moderate disease severity; this could be attributed to the fact that participants were outpatients attending clinic and had no severe symptoms requiring admission. Mild to moderate disease severity had no significant association with depression. These findings were comparatively similar to a study done in Nigeria by Ezenwosu et al (2021), where disease severity in children and adolescents with SCA had no significant association with depression. A similar tool for assessing disease severity was used in this study.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePainful episodes in the previous 12 month had 2.4 higher odds of depression with P value of 0.01. Similarly, a study by Asnani et al (2010), in Jamaica, showed that participants with frequent painful crises had 2.5 times higher odds of developing depression with a p-value of 0.003. \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Another study by Ballah et al (2023), showed that among adolescent who had experienced crisis, more than half had mild to moderate depression. \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Chronic or frequent painful episodes if not well controlled are associated with unusually high levels of stress hormone production which disrupts sleep patterns and affects mood, hence associated with development of anxiety and mood disorders.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eDepression is common among adolescents with SCA in our setting with prevalence of 54%; where by mild, moderate and severe symptoms were found to be 38.7%, 14.7% and 0.3% respectively. Painful episodes experienced by these adolescents were significantly associated with depression. This study highlights the need for screening adolescents with SCA for depression as part of comprehensive care. Furthermore mental health services should be integrated in sickle cell clinics with the availability of a psychologist or counselor. Clinicians must prioritize effective prevention and comprehensive management of chronic pain or frequent painful episodes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ecOR \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Crude Odds Ratio\u003c/p\u003e\n\u003cp\u003eaOR \u0026nbsp; \u0026nbsp; \u0026nbsp;- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Adjusted Odds Ratio\u003c/p\u003e\n\u003cp\u003eHb \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hemoglobin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHbS \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sickled hemoglobin\u003c/p\u003e\n\u003cp\u003eHbAS \u0026nbsp; \u0026nbsp;- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Heterozygous sickled hemoglobin\u003c/p\u003e\n\u003cp\u003eHbSS \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Homozygous sickled hemoglobin\u003c/p\u003e\n\u003cp\u003eHPLC \u0026nbsp; \u0026nbsp;- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; High-Performance Liquid Chromatography\u003c/p\u003e\n\u003cp\u003eIDI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;In Depth Interview\u003c/p\u003e\n\u003cp\u003eMUHAS- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Muhimbili University of Health and Allied Sciences\u003c/p\u003e\n\u003cp\u003eMNH \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Muhimbili National Hospital\u003c/p\u003e\n\u003cp\u003eRBC \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Red Blood Cells\u003c/p\u003e\n\u003cp\u003ePHQ \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Patient Health Questionnaire\u003c/p\u003e\n\u003cp\u003eRRH \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Regional Referral Hospital\u003c/p\u003e\n\u003cp\u003eSCA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Sickle Cell Anemia\u003c/p\u003e\n\u003cp\u003eSCD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;- \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Sickle Cell Disease\u003c/p\u003e\n\u003cp\u003eSPSS \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Statistical Package for Social Sciences.\u003c/p\u003e\n\u003cp\u003eSSS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Sickle cell anemia Severity Score\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eACKNOWLEDGMENTS\u003c/p\u003e\n\u003cp\u003eAuthors would like to appreciate parents/guardians and adolescents for their participation and members of staff-Sickle cell clinics at Muhimbili National Hospital, Temeke, and Amana Regional Referral Hospitals for their support during data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICAL APPROVAL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval obtained from the Muhimbili University of Health and Allied sciences Ethical Board Committee MUHAS-REC-06-2023-1770. Permission letter for data collection were also obtained from each health facility. The data collected did not interfere with the routine care provided at the clinic. A clear informed consent and assent were sought and participants found to have moderate to severe depressive symptoms, were contacted and channeled to a clinical psychologists for further evaluation and therapy.\u003c/p\u003e\n\u003cp\u003eFUNDING\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported by the National Heart, Lung, and Blood Institute (NHLBI) of the US National Institutes of Health (NIH) under Award Number U01 HL156853 (Sickle Pan-African Research Consortium\u0026mdash;SPARCO Tanzania). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.\u003c/p\u003e\n\u003cp\u003eDISCLOSURE\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest in this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO Fact Sheet.pdf. Accessed December 30, 2022. https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health\u003c/li\u003e\n\u003cli\u003eRathod S, Pinninti N, Irfan M, et al. Mental Health Service Provision in Low- and Middle-Income Countries. \u003cem\u003eHeal Serv Insights\u003c/em\u003e. 2017;10. doi:10.1177/1178632917694350\u003c/li\u003e\n\u003cli\u003eSedrak A, Kondamudi NP. Sickle Cell Disease. 2022 Aug 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan \u0026ndash; . PMID: 29494006. Published online 2023:29494006.\u003c/li\u003e\n\u003cli\u003eInusa BPD, Hsu LL, Kohli N, et al. Sickle cell disease\u0026mdash;genetics, pathophysiology, clinical presentation and treatment. \u003cem\u003eInt J Neonatal Screen\u003c/em\u003e. 2019;5(2). doi:10.3390/ijns5020020\u003c/li\u003e\n\u003cli\u003eMangla A, Ehsan M, Agarwal N, et al. Sickle Cell Anemia. [Updated 2022 May 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482164/. Published online 2022:482164.\u003c/li\u003e\n\u003cli\u003eMakani J, Tluway F, Makubi A, et al. A ten year review of the sickle cell program in Muhimbili National Hospital, Tanzania. \u003cem\u003eBMC Hematol\u003c/em\u003e. 2018;18(1):1-13. doi:10.1186/s12878-018-0125-0\u003c/li\u003e\n\u003cli\u003eBenton TD, Boyd R, Ifeagwu J, Feldtmose E, Smith-Whitley K. Psychiatric diagnosis in adolescents with sickle cell disease: A preliminary report. \u003cem\u003eCurr Psychiatry Rep\u003c/em\u003e. 2011;13(2):111-115. doi:10.1007/s11920-011-0177-3\u003c/li\u003e\n\u003cli\u003eLukoo RN, Ngiyulu RM, Mananga GL, et al. Depression in children suffering from sickle cell anemia. \u003cem\u003eJ Pediatr Hematol Oncol\u003c/em\u003e. 2015;37(1):20-24. doi:10.1097/MPH.0000000000000276\u003c/li\u003e\n\u003cli\u003eEzenwosu O, Chukwu B, Ezenwosu I, et al. Clinical depression in children and adolescents with sickle cell anaemia: influencing factors in a resource-limited setting. \u003cem\u003eBMC Pediatr\u003c/em\u003e. 2021;21(1):1-8. doi:10.1186/s12887-021-03015-1\u003c/li\u003e\n\u003cli\u003eOudin Doglioni D, Chabasseur V, Barbot F, Galact\u0026eacute;ros F, Gay MC. Depression in adults with sickle cell disease: a systematic review of the methodological issues in assessing prevalence of depression. \u003cem\u003eBMC Psychol\u003c/em\u003e. 2021;9(1):1-14. doi:10.1186/s40359-021-00543-4\u003c/li\u003e\n\u003cli\u003eGilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): A diagnostic meta-analysis. \u003cem\u003eJ Gen Intern Med\u003c/em\u003e. 2007;22(11):1596-1602. doi:10.1007/s11606-007-0333-y\u003c/li\u003e\n\u003cli\u003eAljumah Z, Ibrahim Ali S, Al-Saleem M, Almogarab K, Alghadeer F, AlEssa F. Depression in Sickle-Cell Disease patients in the Eastern Province. \u003cem\u003eInt J Healthc Sci\u003c/em\u003e. 2015;3(February 2016):300-302. www.researchpublish.com\u003c/li\u003e\n\u003cli\u003eJerrell JM, Tripathi A, McIntyre RS. Prevalence and treatment of depression in children and adolescents with sickle cell disease: A retrospective cohort study. \u003cem\u003ePrim Care Companion J Clin Psychiatry\u003c/em\u003e. 2011;13(2):21977359. doi:10.4088/PCC.10m01063\u003c/li\u003e\n\u003cli\u003eSahril NB, Yaacob NM, Ahmad NA, Abdullah S, Mahadir Naidu B, Aris T. Depression Severity and its Associated Factors among School-Going Adolescents in Malaysia. \u003cem\u003eJ Depress Anxiety\u003c/em\u003e. 2019;08(04):1-8. doi:10.35248/2167-1044.19.8.350\u003c/li\u003e\n\u003cli\u003eAlhomoud A, Gosadi IM, Wahbi HA. Depression among sickle cell anemia patients in the eastern province of Saudi Arabia. \u003cem\u003eSaudi J Med Med Sci\u003c/em\u003e. 2018;(6):8-12. doi:10.5144/0256-4947.2018.130\u003c/li\u003e\n\u003cli\u003eMallicka SC Das, Sahoe P, Priyadarshini P, Manasa R. Prevalence of Severe Depression among Adolescents in Rural Area of Odisha, India. \u003cem\u003eIndian J Community Med\u003c/em\u003e. 2021;46(3):438\u0026ndash;441. doi:https://doi.org/10.4103%2Fijcm.IJCM_570_20\u003c/li\u003e\n\u003cli\u003eAsnani MR, Fraser R, Lewis NA, Reid ME. Depression and loneliness in Jamaicans with sickle cell disease. \u003cem\u003eBMC Psychiatry\u003c/em\u003e. 2010;10(1997). doi:10.1186/1471-244X-10-40\u003c/li\u003e\n\u003cli\u003eBalla Elnour SM, Hassan Salman F, Elmahdi Z. Depression in Adolescent Sickle Cell Patients - A 2021 Sudan Study. \u003cem\u003eAm J Hum Psychol\u003c/em\u003e. 2023;1(1):50-55. doi:10.54536/ajhp.v1i1.2144\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Depression, adolescents, sickle cell anemia, clinical depression","lastPublishedDoi":"10.21203/rs.3.rs-4693535/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4693535/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Depression commonly arises among adolescents who have experienced long-standing psychosocial difficulties especially those facing chronic illnesses like Sickle Cell Anemia (SCA). \u0026nbsp;SCA is a global health concern, and Tanzania is one of the countries with a high incidence, estimated at 8,000 to 11,000 births per year. This study aims to assess the magnitude and factors associated with depression among adolescents with SCA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology: \u003c/strong\u003eA cross-sectional analytical study conducted on adolescents aged 11-19 years attending sickle cell clinics in referral hospitals in Dar-es-salaam Tanzania, from October 2023-March 2024. A validated Patient Health Questionnaire (PHQ-9) tool was used to screen for depression. Univarite and multivariate regression model was used to determine factors associated with clinical depression.A P value of less than 0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Among 326 adolescents enrolled, the majority (64.7%) were 10-14 years of age. A total of 216 (54 %) had depression; when categorized into severity, 167 (38.7 %) had mild, 48 (14.7 %) had moderate and 1 (0.3%) had severe depression. Clinical depression, encompassing moderate to severe depression, was prevalent in 49 (15%) adolescents. Painful episodes were significantly associated with depression (aOR = 2.49) (95% CI: 1.17 - 5.29, p = 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Depression is common among adolescents with SCA in our setting. Painful episodes experienced by these adolescents were significantly associated with depression. This study highlights the need for screening adolescents with SCA for depression and integration of mental health services in sickle cell clinics.\u003c/p\u003e","manuscriptTitle":"Depression Prevalence and Associated Factors Among Adolescents with Sickle Cell Anemia in Dar es Salaam, Tanzania: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-10 12:25:58","doi":"10.21203/rs.3.rs-4693535/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-16T06:32:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-16T06:13:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-12T06:35:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-07-05T16:41:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c8e3e7e4-91fe-46f4-96a9-29f19de92233","owner":[],"postedDate":"August 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-13T16:01:26+00:00","versionOfRecord":{"articleIdentity":"rs-4693535","link":"https://doi.org/10.1186/s12887-024-05359-w","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2025-01-07 15:57:26","publishedOnDateReadable":"January 7th, 2025"},"versionCreatedAt":"2024-08-10 12:25:58","video":"","vorDoi":"10.1186/s12887-024-05359-w","vorDoiUrl":"https://doi.org/10.1186/s12887-024-05359-w","workflowStages":[]},"version":"v1","identity":"rs-4693535","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4693535","identity":"rs-4693535","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}