Depressive symptoms and associated factors among persons with physical disabilities in disability care homes of Kathmandu district, Nepal: A mixed method study

Depression is one of the most common mental disorders, affecting 300 million people worldwide and 75% of these occur in low- and middle-income countries. Persons with physical disabilities are vulnerable groups and are more prone to experience depressive symptoms than the general population. This study investigated the prevalence of depressive symptoms and the associated factors among persons with a physical disability. We conducted a concurrent triangulation mixed methods design using Beck’s Depression Inventory scale among 162 persons with physical disabilities in the Kathmandu district. In parallel, eight in-depth interviews were conducted with an interview guideline to collect the participants’ perceptions and experiences of disability. Both quantitative and qualitative findings were integrated into the results. We found that about 77% of the participants with a physical disability had experienced depressive symptoms. Unemployment status (adjusted odds ratio (AOR) 2.7, 95% confidence interval (CI) 1.0–7.3) and comorbidity (AOR 2.5, 95% CI 1.0–6.0) had a statistically significant association with depressive symptoms. The majority of people with physical disabilities had negative experiences with societal prejudice and coping with their limitations. They were depressed as well as angry over having to stop their careers, education, and possibilities. Nevertheless, they were significantly happier and less sad than in their earlier years of life because of the possibilities, family environment, improved means of subsistence, therapeutic facilities, and supportive atmosphere at disability care homes. The policymakers should focus on preventing comorbidity and providing technical skills to persons with physical disabilities to improve their employment status and promote a healthy lifestyle.


Study design
We used a concurrent triangulation mixed methods study design where both quantitative and qualitative data were collected simultaneously and independently. This is a concurrent design where the quantitative method was dominant and the qualitative method was used for the triangulation of quantitative results in this study. The study aimed to determine the status of depressive symptoms and explore its associated factors among persons with physical disabilities living in care homes of Kathmandu District. The study was carried out from July to December 2018.

Study population and sample size
At first, the lists of care homes for persons with disabilities were collected from the National Federation of Disabled-Nepal and then these care homes were approached for the data collection.
All care homes in the Kathmandu district provided a list of all individuals with physical disabilities. All persons with physical disabilities from disability care homes were included in the sampling frame. Each person with a physical disability who was selected for sampling was taken as a study unit. The inclusion criteria of participants were limited to a single type of disability to avoid the complexities of multiple disabilities.
The required sample size was 162. Based on the formula, n = z 2 pq/e 2 , where z is the standard normal variate (1.96) at 95% confidence interval, p is the prevalence and 0.5 was used for the unknown prevalence [12], q is 1-prevalence (i.e. 0.5), and e is the margin of error (0.05), the sample size was 384. Further, using finite population correction methods, i.e., n = n/ (1+n/ N), where N = 256 (Total persons with physical disabilities in all the disability care homes of Kathmandu district were 256), we got 154 as a sample size for the study. Moreover, a 5% nonresponse rate was added to get the final sample size of 162.
The samples were selected by using a systematic random sampling technique. The list of all persons with physical disabilities was obtained from all the care homes of Kathmandu district and arranged alphabetically by care home names followed by the names of individuals. The first participant was selected by the lottery method. Then, each study participant was chosen using systematic random sampling from the arranged list where the sampling interval (K) was two, as N was 256 and n was 162.
A total of 162 participants were interviewed for the quantitative study. Eight persons with physical disabilities from among the same sample frame were selected purposively for the qualitative study, where in-depth interviews (IDIs) were conducted. Eight persons with disabilities were selected, considering that Manns et al. (2019) conducted the IDIs with eight respondents from non-profit organizations, a similar setting to our study [13].

Quantitative data collection
A face-to-face interview was done with each participant to collect quantitative data from the representative sample. The validated tool of the Beck's Depression Inventory (BDI) scale was used in the study [14,15]. The BDI is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression [16] and has already been validated in the Nepali language [17] (S1 Text).

Qualitative data collection
For the qualitative method, the principal investigator himself conducted in-depth interviews who had previous academic and professional experiences in conducting qualitative research and also had experience working for the rights of persons with disabilities. Similarly, IDIs were conducted with participants using the interview guideline. A face-to-face interview allowed the researcher to observe any non-verbal communication and also allowed both the interviewer and participant to seek any clarification necessary. Non-verbal communication was noted down during the time of the interview. Interviews were audio-recorded with permission from the participant to ascertain an accurate account of the interview, which can be replayed for analytic purposes and anonymity was assured during the course of the recording. We carried out the interviews on 15 days duration, i.e.,15 th to 30 th of September 2018.

Data management and analysis
Quantitative data. The questionnaire was checked at the time of data collection for completeness of data. Data entry was done using Epi-Data version 3.1 and analysis was done in SPSS v 21 (IBM Corp., 2012. Armonk, NY). Quantitative data were expressed in the form of frequency and percentage. Individual's BDI score was categorized: 0-9 minimal depression, 10-16 mild depression, 17-29 moderate depression, and 30-63 severe depression [18]. Using logistic regression, we performed bivariate and multivariable analysis to observe the association of independent variables, including the individual's socio-demographic characteristics, health behaviors, educational and employment status, with depressive symptoms. Independent variables, those found statistically significant (p value< 0.05) in bivariate analysis and important variables from the literature review, were further utilized in multivariable analysis. Multi-collinearity of variables was checked using the variance inflation factor (VIF). The highest VIF was 1.54, which suggested there was no multi-collinearity problem [19]. Statistical testing was done on a 95% significance level, where a p-value of less than 0.05 was considered to be significant.
Qualitative data. All the recordings of IDI were transcribed-translated, and verbatim were generated and compiled for coding. We used the thematic analysis method, as this method could be used in all types of qualitative studies in health science and patterns in the data that relate to participants' lived experiences, opinions and viewpoints, as well as behavior and practices, can be found by it [20]. We used Braun and Clarke's [21] six steps for doing thematic analysis, which involved "familiarizing with the data, creating initial codes, looking for themes among codes, reviewing themes, defining and labeling themes, and producing the final report". As part of the thematic analysis, final transcripts were coded by PK in tandem with another investigator (RB) with 75% inter-coder agreement in order to find similar patterns in transcripts. Afterwards, a consensus was built to finalize the codes through mutual understanding of coders and peer validation with a third researcher (BS). Each interview was summarized after coding with identified themes and categories of information. To generate meaning and further develop the themes, we looked over the textual data again. After analyzing quantitative and qualitative data, both results were combined and presented using convergent, divergent and expansive findings as per the concurrent triangulation design principles [22].

Ethical consideration
Ethical approval for undertaking the study was obtained from the Institutional Review Committee (IRC) of the Institute of Medicine, Tribhuvan University (Ref: 178-075/76). The purpose of the study was clearly explained by the researcher to the administration of disability care homes and approval was taken before conducting the study. Considering the participants as persons with physical disabilities, written and verbal consent was taken from the participants before conducting the interview, and the interviewer ensured the right to terminate the interview at any time if s/he felt uncomfortable. The given consents were recorded in the questionnaire and then moved forward by the researcher. Also, verbal consent was recorded while recording the interview for the qualitative study which was approved by IRC. The participants, who were found to be severely depressed, were counseled by the interviewer and further informed to the administration of the disability care homes and referred to a nearby hospital.

Quantitative findings
Distribution of participants by their socio-demographic and health behavioral characteristics. The participants' age ranged from 18 to 87 years, with a mean age of 47.5 ± 19.4 years. The socio-demographic characteristics of the study population are summarized in Table 1. Thirty-eight percent of the participants' families were dependent on agriculture, while 5.3% of the participants' families were involved in the service sector (monthly salary). At the same time, other families (38.8%) were fully dependent on the allowance provided by the government. More than 50% of the respondents were literate; among them, 13% had an informal education, and 2% had a bachelor's or above level of schooling. Among the participants, 48.8% had comorbidities. Major comorbidities were Gastritis, Hypertension, Arthritis and Asthma, among many others. Around 16.7% of the respondents were found to smoke cigarettes. Similarly, 16% of them were drinking alcohol.
Distribution of participants by their nature of disability. The nature of disabilities, use of assistive devices and the infrastructure are summarized in Table 2. Among the causes, 93.2% of participants became physically disabled after birth, either from accidents or from leprosy, while 6.8% had physical disabilities by birth.
Almost half (50.6%) of the participants used assistive devices such as wheelchairs, crutches, and prosthetic legs. The surrounding environment and the infrastructure of the disability care home were satisfactory to 89.5% of the participants. Table 2 also shows the description of the participants based on the type of physical disability. We found most of the respondents (54.3%) had been affected by leprosy. Similarly, 26.5% of the respondents had a disability due to joint and spinal cord problems, while 4.3% had other types of physical disability, including stunting, muscular dystrophy and rickets.
Distribution of participants by physical disability and depression-related characteristics. Table 3 shows that the majority (77.4%) of the participants in the study had depressive symptoms. At the same time, 22.6% of them were found to have minimal disturbance or normal level of depression.  Table 4 describes the association of covariates with depressive symptoms. From the bivariate analysis (Crude Odds Ratio), the variables such as sex of participants, marital status, education status, alcohol drinking, employment status and comorbidity had a statistically significant association with depressive symptoms. After adjusting the variables, participants' employment status and comorbidity were found to be associated with depressive symptoms. The depressive symptom was more likely among participants who were unemployed [(AOR 2.7, 95% CI 1.0-7.

Qualitative findings
The age of interviewees ranged from 21 to 85 years. Interviewees' characteristics were illustrated in S1 Table. The findings from the interviewees were categorized into five major themes:

Theme-1: Inaccessible geographic and social locations stimulate home stranding
Most of the interviewees said that they had their own home and family. They also wanted to live in their home along with their family members. However, they decided to live in a disability care home for various reasons. The most common reasons were mobility difficulties, inaccessibility, unavailability of essential health services, interruption in continuing education and work, discrimination in society, and feeling a burden on family members. Sub-theme 1: Mobility difficulties. Some of the interviewees who were not able to walk on themselves or needed to use a wheelchair mentioned those mobility difficulties due to the lack of wheelchair-friendly infrastructure around their homes and thus were obliged to leave home. Family members were required for their continuous care and support, making them feel burdened on the family.
". . .Geographical structure of our village is not appropriate to use a wheelchair, there is no comfort toilet. . ."-35 years old, male, spinal-cord injury (P1) Sub-theme 2: Social stigma. Some of the participants who were affected with leprosy; expressed that they had faced social discrimination leading to a feeling of humiliation and harassment-prevailing discrimination from society deprived them of various opportunities like education, work, social interaction and social support. The behaviors and responses from society and relatives made persons with physical disabilities feel humiliated. All of these factors were associated with them leaving their homes and staying in a disability care home where they were able to find opportunities and friends with similar conditions to share their feelings and time with.

Theme-2: Persons with disabilities are in jeopardy because of impoverished families
It was reported that the interviewees who had disabilities after accidents or injuries received financial support from their families initially, but the support was minimal and insufficient. Some participants' families were unable to provide financial support because of their lower economic status. Nevertheless, the provision of treatment and social security allowance from the government helped them live independently to some extent. They were able to get better food and shelter.
". . .Doctor comes into the room and treats us, gives us care. The government gives us allowance by which we are living. . ."-85 years, male, and leprosy affected (P8) Theme-3: Accepting and adopting bad and good environments of the care homes Some of the participants who needed assistance during regular activities perceived that the response and behavior of their caretakers towards them were good. All the participants expressed that the disability care home is like a home where they lived as a family. They responded that they could satisfy themselves by looking at each other because they were not the only ones and alone to have a disability. ". . . It's good to stay here. All people affected with leprosy. . .stay here. . ."-71 years, male, leprosy affected (P5) The participants said that various organizations also support their livelihood and they were able to receive vocational training, which helped them gain knowledge and skills and fruitfully spend their days. ". . .After coming to this disability care home, I am taking training. I now feel that I can do something. I was a bit depressed. I came here and learned this job (making tools from bamboo). . ."-35 years, male, spinal cord injury (P1) Sub-theme 2: Negative. Despite positive perceptions towards the environment of disability care homes, they experienced problems with the facilities and opportunities. The washrooms were inaccessible to the persons who were stunted and had prosthetic legs. They claimed that the restrooms were slippery and in unsanitary conditions. ". . .But toilets in this home is uncomfortable for me. . ."-34 years, female (P7) ". . .I feel good, but as I have a prosthetic leg, the toilet and bathroom is difficult for me. . ."-21 years old, male, leprosy affected (P4) There had been a few training sessions for persons with disabilities; however, some of the interviewees stated that the daily allowance provided in training was minimal. A few participants were reluctant to answer about their perception of living in a disability care home. Participants expected more government-supported rehabilitation homes with beneficial vocational training.
Sub-theme-3: Perceptions of using assistive devices. Despite various benefits of using assistive devices, they had a more negative perception of the longevity and maintenance of the device. The maintenance cost of wheelchairs was prohibitive. Sometimes accessories for the wheelchair were challenging to find in the market, and they had to strive to get a new wheelchair. The wheelchairs they were using were donated by volunteer organizations or individuals. They also saved their limited pocket money for its maintenance. They were stressed, thinking the government has no policy provisions for distributing free assistive devices to people like them.

Theme-4: Not being able to accomplish social tasks creates emotional distress
They seemed happy and usually accepted their disability after years of living along with other individuals with disabilities. But they were stressed and frustrated deep inside with the fact of having a disability. They felt humiliation, frustration, and stress when separated from their society and could not do routine tasks because of a disability. They shared that being physically disabled ruined their aims and deprived them of education and jobs. The participants were also concerned and worried about their children's future. Because of a disability, they had to live away from their families, and the dream of supporting their families was destroyed. The discrimination and ignorance from family and society made them sad. One of the participants planned to have a happy married life, which was unsuccessful because of being paralyzed. They found the disability care home to be comfortable and beneficial. The quality of life was increased after staying in the disability care home due to improved livelihood opportunities. All the people with physical disabilities were sharing one roof and had created and enjoyed their own wonderful world. The training provided by the care homes helped participants to be engaged the whole day fruitfully. Care homes provided organizational support and created a conducive environment for those who were literate where they were able to seek help from national and international supporting agencies to themselves and friends, regarding financial and other materialistic support by writing proposals.

Integrated findings
The results of quantitative and qualitative results were integrated into two domains, and they are presented below.
Convergent findings. The initial finding was that employment opportunities reduce depressive symptoms for persons with physical disabilities ( Table 5). The quantitative results showed that unemployed persons with physical disabilities were more likely to have depressive symptoms than that of employed. Similarly, qualitative findings showed that persons with physical disabilities are eager to get jobs and become financially capable of running their life. Another finding was that the presence of comorbidity among persons with physical disabilities might lead to a higher possibility of having depressive symptoms ( Table 5). The quantitative finding suggested that persons with physical disabilities with comorbidity were more likely to get depressive symptoms compared to persons with physical disabilities without comorbidity. Moreover, findings of the qualitative study support that people with physical disabilities were feeling blue due to their other health conditions. They had to leave their homes and families to get regular medical services and they were worried that if they stayed back in villages, their health would have been worsened. In addition, being unable to accomplish social functions due to comorbidities caused them to have more distress.
Divergent findings. Some of the qualitative findings opposed the findings from quantitative data analysis. The quantitative data analysis did not show an association for males and unmarried with depression; however, qualitative data showed that they were having distress. Nevertheless, the risk of depression was higher among unmarried [OR = 2.4 (95%CI = 0.9-6.4)] in quantitative analysis, although the risk was not statistically significant.
Likewise, qualitative findings showed that males had greater family responsibility and could not fulfil needs due to physical disability, which increases the discrimination and ignorance from family, by which they feel stress and humiliation.
Educational status was not found to be statistically significant in quantitative analysis, but those who were literate were able to seek help from relevant donors for financial support, capacity-building training and other necessary requirements for them and other members.
The quantitative analysis showed no association of depressive symptoms with family support. But qualitative study explores that many participants shared that low family support was the reason for the delay in treatment which leads to irreversible disability.
The use of assistive devices was not found to be statistically significant for depression in quantitative data analysis. But, the participants had a more negative perception on the longevity of the device. They often found it challenging to use a wheelchair because of the lack of wheelchair-friendly infrastructures. As some participants were economically unstable, they felt burdened to receive a wheelchair or other assistive devices without ensured maintenance from non-profit organizations.
In the qualitative study, most of the people with physical disabilities expressed that their overall quality of life has increased after residing in the care home. However, when probed if there were any challenges or negative aspects of living there, participants hesitated to talk about the institution where they were living.

Discussion
In our study, more than two-thirds [i.e.,77.4% CI (69.1-84)] of the participants had depressive symptoms, which indicates physical disability can lead to depression [23]. This finding is consistent with the study conducted in Iran that showed 71% of the respondents had depression [24]. Similarly, a study conducted in Ethiopia showed the prevalence of depression among people with physical disabilities was 75.5% [25]. These findings are slightly higher than the studies conducted in Turkey (57.8%) [26] and Colombia (24%) [27]. These observed differences could be due to study design, such as sample size and measures of depression, as well as cultural differences.

Convergent findings
In the bivariate analysis, gender, marital status, education, employment status and comorbidity condition of participants were associated with depressive symptoms. After adjusting all possible covariates, employment status and comorbidity conditions were associated with depressive symptoms. Factors such as gender, employment and education are a sign of social status, which may have an impact on mental health [28]. This study illustrates that unemployed persons with a physical disability were likely to have a higher chance of getting depressive symptoms. Participants reported minimal financial support from their families. Unemployed people were more vulnerable to economic problems, difficult life experiences and psychological problems as they face numerous barriers to employment [29]. At the same time, employment of persons with disabilities builds the self-confidence and motivation required to foster higher challenges [30]. In our study, both quantitative and qualitative findings showed employment status of participants was significantly associated with depressive symptoms. Similar findings were reported in the study conducted in Mexico, the United Kingdom [31] and Korea [32], which reflects that unemployed participants are more likely to have depressive symptoms.
Our study evidenced that participants with additional health conditions were significantly associated with depressive symptoms. This might be because the financial burden faced by being disabled is exaggerated by out-of-pocket expenditure due to treatment of additional health conditions. This finding is supported by the study conducted in Korea, which shows a significant linear association between depression and comorbidity [33]. Our qualitative study showed that the potential dependence due to various comorbidity and the burden of its management that requires others' support and financial problems causes increased stress to persons with physical disabilities, further leading to depression. Comorbidity is an additional burden to a person with a disability and may increase the severity of the condition, leading people into a depressive condition. A study conducted among adult males with lower limb amputation also found an association between socioeconomic status, society's attitude towards disability and comorbidity with depression. Rather than physical disability, low financial status was the major reason for experiencing depressive symptoms [34].

Divergent findings
In our study, the gender of participants was not associated with depressive symptoms in multivariate analysis. But the qualitative study showed that males have greater family responsibility and cannot fulfil needs due to physical disability, which increases the decimation and ignorance from family, by which they feel stress and humiliation. However, the result of a longitudinal study conducted in Canada showed both males and females with a disability had a higher risk of depression [7]. A study conducted in Jordan showed that unmarried adults with disabilities were more likely to experience depression. Nonetheless, our study showed no significant association between marital status and depressive symptoms among persons with physical disabilities after adjusting all the possible covariates. But unmarried persons with disabilities were lonelier as they were unable to share their feelings with anyone.
This study showed no association of depressive symptoms with family support. But qualitative study explores that many participants shared that low family support was the reason for the delay in treatment which leads to irreversible disability. In addition, a study conducted in India found that people with physical disabilities have higher levels of depressive symptoms than non-disabled people. At the same time, they feel much more frustrated and helpless and do not fit with ordinary people in society. The study also found a positive correlation between a low level of self-esteem and a high level of depression among persons with physical disabilities [35]. Also, this study found that having a physical disability contributed to experiencing depressive symptoms. Participants' experienced societal discrimination, mobility difficulties, lack of family support, and being deprived of various opportunities after being affected by a disability had a cumulative effect on experiencing depressive symptoms.
A study conducted in the United States, using a large population-based sample, found the prevalence of current depressive syndrome (CDS) higher among adults with physical disabilities who used assistive technology (AT) than those who did not use any AT. Similarly, the prevalence of CDS among AT users was about three times higher than among AT non-users [36]. In contrast, the use of assistive devices was not found to be statistically significant in our study. The participants had a more negative perception of the longevity of the device. They often found it challenging to use a wheelchair because of the lack of wheelchair-friendly infrastructures. Though some of the organizations supported assistive devices, it was very difficult to manage the costs even for their maintenance. Thus, they were stressed that the government had not taken any steps to provide support on assistive devices.
Though the majority said that the environment was good in the institute, many of them were found to have depressive symptoms. This could be due to the Hawthorne effect, as they were residing there and were reluctant to say bad about the institute. A study conducted among adults with physical disabilities in China found that a physical disability hindered their basic activities of daily living, and were profoundly depressed, further resulting in more functional limitations [37].

Expansive findings
In general, the factors like mobility restrictions, social stigma, and inaccessibility to health services displaced persons with physical disabilities from their homes and communities as it exaggerated their frustrations. In addition, from the qualitative study we found that the care homes provided the basic needs required in their daily life, which was not readily available at their home. Furthermore, care homes provided infrastructure, government and other non-governmental support at institutions, and training, among many others.

Limitations of the study
Our study did not include persons with multiple disabilities to reduce the non-response rate because of the severity and lack of specialized human resources to interview those with deaf, deaf-blind, or other disabilities. In addition, the perception of caretakers and families was not included; therefore, their impression is unknown. As the qualitative analysis was done independently in our study, interviews with only eight persons with physical disabilities may not be sufficient to reach saturation. Also, this study is institution-based rather than communitybased, which might have affected the depression status of persons with physical disabilities positively or negatively as they were living in an enabling environment but far away from their families.

Conclusion
Our study revealed that more than three-quarters of the persons with physical disabilities had depressive symptoms, where employment and comorbidity status were strongly associated with depressive symptoms among them. The findings indicate the major factor behind the depressive symptoms could be comorbidity and financial dependence. Also, qualitative findings showed that males and persons with physical disabilities without family support were more likely to be stressed due to social roles. Based on the results, we would like to suggest authorities for the provision of occupational therapy and psychotherapy along with vocational and life skills training to improve their quality of life.