Study design, period and setting
Institutional based cross-sectional study was conducted from November 28 –December 28, 2021, in Amhara regional state Orthodox Tewahido churches, Ethiopia. The study was conducted in Amhara nationalregional state Orthodox churches, which have holy water users for different purposes like the healing of mental illness. Amhara Region is a regional state in Northwest Ethiopia, and its capital city is Bahir Dar. Iaccording to central statistical agency Ethiopia (CSA), 2017 the total population were 21,134,98 8[27]. The study was conducted in five randomly selected churches, namely Wonkshet Gebreal, Gono Gebreal, Megendi Giorgis, Andasa Giorgis, and Tsadikane Maryam. Wonkshet Gebreal and Gono Gebreal located in South Gondar district, Megendi Giorgis and Andasa Giorgis in west Gojjam district, and Tsadikane Maryam located in North Shewa district.
Source population
All clients who used Orthodox Tewahido churches holy water in Amhara region.
Study population
All adults who used Orthodox Tewahido churches holy water in Amhara region during the study period.
Inclusion criteria and exclusion criteria
People, who use Orthodox Tewahido churches holy water in the Amhara region and age of 18 and beyond were involved in the study. On the other hand individuals who had problem of communication, and holy water user who interrupted the interview were excluded from the study.
Sample size determination
The single population proportion formula was used to determine the required sample size by considering a 50% estimated proportion of mental illness among holy water user adults, since no study was done on this problem in Ethiopia.
By considering 95% confidence interval (CI) and 5% as margin of error, sample was calculated as follows:
$$\mathrm n\;=\;\left({\mathrm z}_{\mathrm\alpha/2}\right)^2\;\mathrm p\;\left(1-\mathrm p\right)/\mathrm d^2$$
$$\text{n}={(1.96)}^20.5\ast0.5=384.16=384$$
Then total sample size = 384 + 10% non-response rate (39) = 423.
Sampling techniques
First, permission was obtained from the selected church administrators. Then, lists of holy water users at selected churches were taken from the registration books. After listing, the selection of participants has conducted by the lottery method. The number of samples in each selected churches was distributed proportionally based on the total number of holy water users in individually selected churches.
Dependent variable
Common mental illness.
Independent variable
Socio demographic variables and psychosocial factor
Sex, Age, Ethnicity, Religion, Marital status, Educational status, Occupation, Residence, Social support
Behavioral factors
Alcohol, Tobacco, and Khat.
Clinical factors
Previous mental disorder, Family history of mental illness, known medical/surgical disease.
Operational definitions
Common mental illness
Those participants who had self-report somatic illness, anxiety and depression by using Brief Psychiatric Rating Scale (BPRS) [28, 29].
Current and ever use of substance
Using a specific substance for non-medical purpose in the last 3 months and using of a particular substance for non-medical purpose once in lifetime respectively [30].
Data collection tools
Data collection was conducted by using an interviewer-administered structured questionnaire, interview and observation by Brief Psychiatric Rating Scale (BPRS) for mental illness symptoms. Data were collected by four BSc psychiatric nurses and supervised by two MSc psychiatry nurses. BPRS has 24 items with seven scale measurements ranging from “not present” to “extremely severe, the first three items were used to asess common mental illnesses (somatic concern, anxiety and depression) [29, 30]. The Extent of soscial support was assessed by using three-item Oslo social support scale with a range of between 3 and 14. “scoring of 12–14 = strong social support”, “score of 9–11 = moderate social support and”, “score of 3–8= poor social support” scale [31].
Data quality assurance
The questionnaire was first prepared in English and translated to Amharic language for data collection and back re-translated to English language by fluent speaker language experts to maintain its concistency. The training was given to data collectors and supervisors on BPRS. The pre-test was done on 5% of holy water users at Recha Gebreal church; 2 weeks before the start of actual data collection and revision was made accordingly. Reliability was checked and Cronbach’s alpha was 0.921. The supervisors and principal investigator have checked the completeness and consistency of the filled questionnaires daily.
Data processing and analysis
Data were coded, filtered, and entered into EpiData version 4.6 and then exported to SPSS version 25 for analysis. Binary logistic regression analysis was used to determine the association between the dependent and independent variables. Firstly, bivariable logistic regression was performed and all variables with P ≤ 0.25 in the bivariable analysis were included in the final model of multivariable analysis in order to control all possible confounders. The goodness of fit was tested by Hosmer-Lemeshow statistic and the data fitted to the model. The direction and strength of statistical association were measured by the odds ratio with 95% CI. The adjusted odds ratio along with 95% CI were estimated to identify factors associated with complications by using multivariable analysis in binary logistic regression. Finally, P-value ≤0.05 was considered to declare as a statistically significant.