|Year : 2021 | Volume
| Issue : 3 | Page : 85-97
The psychological impact of COVID-19 on health-care workers in African Countries: A systematic review
Anthony A Olashore1, Oluyemi O Akanni2, Ayodele L Fela-Thomas2, Kadimo Khutsafalo3
1 Department of Psychiatry, University of Botswana, Gaborone, Botswana, Nigeria
2 Department of Clinical Services, Federal Neuropsychiatric Hospital, Benin City, Edo State, Nigeria
3 Department of Library Services, University of Botswana, Gaborone, Botswana, Nigeria
|Date of Submission||04-May-2021|
|Date of Decision||16-Jun-2021|
|Date of Acceptance||07-Jul-2021|
|Date of Web Publication||26-Jul-2021|
Oluyemi O Akanni
Federal Neuropsychiatric Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
In Africa, a systematic appraisal of the associated pattern of psychiatric disorders (PDs) among health-care workers (HCWs) is lacking. We, therefore, aimed to ascertain the pattern of PDs and their associated risk factors among HCWs in Africa during the Coronavirus Disease 2019 pandemic. We identified 12 studies for inclusion after searching four databases: Web of Science, PubMed, AJOL, and EBSCOhost for articles written in English from January 2020 to April 2021. Anxiety disorder with rates from 9.5% to 73.3% and depression, 12.5% to 71.9%, were the most reported PDs. Availability of protective gear and information regarding preventive measures reduced the risk of developing any PDs, while psychoactive substance use, history of chronic medical illness, low level of resilience, and low social support increased these risks. A considerable proportion of HCWs manifest various psychological problems such as their counterparts in other parts of the world. Multiple factors were also implicated as risk, albeit associations were not consistently established across the studies. There is a need to increase research capacity tailored to the HCW population's needs in the continent.
Keywords: African countries, coronavirus disease 2019 pandemic, health-care workers, psychiatry, review
|How to cite this article:|
Olashore AA, Akanni OO, Fela-Thomas AL, Khutsafalo K. The psychological impact of COVID-19 on health-care workers in African Countries: A systematic review. Asian J Soc Health Behav 2021;4:85-97
|How to cite this URL:|
Olashore AA, Akanni OO, Fela-Thomas AL, Khutsafalo K. The psychological impact of COVID-19 on health-care workers in African Countries: A systematic review. Asian J Soc Health Behav [serial online] 2021 [cited 2021 Sep 21];4:85-97. Available from: http://www.healthandbehavior.com/text.asp?2021/4/3/85/322292
| Introduction|| |
Coronavirus Disease 2019 (COVID-19) is caused by the Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-COV 2), which was first detected in 2019 at a wet market in Wuhan, China.
Early 2020, the WHO declared the COVID-19 a global pandemic as it spread across several continents, causing a high mortality rate in most countries affected. Africa confirmed its first case in Egypt on February 14, 2020. As of June 30, 2021, 47 countries in Africa were affected, with about 3,962,827 confirmed cases and 94,634 reported deaths. Nevertheless, Africa seems to be the least hit continent than other continents.,
The transmission route is believed to be through air droplets and respiratory secretions produced when an infected person speaks sneezes or coughs. Generally, most people infected will produce mild or no symptoms, but in some people (elderly and those with comorbidities), it may provoke severe symptoms, which may be fatal.
The health-care workers (HCWs) are usually the first point of contact during epidemics and are susceptible to infectious diseases during outbreaks. In Africa, where inadequate resources and low human resources hamper the health-care system, there may be concerns about the personal protection of the HCWs against this infection, whose prognosis is rife with uncertainties. HCWs may also be required to work longer hours to meet up with an ongoing pandemic's demands. Furthermore, there may be anxiety and concerns about contracting the virus and transmitting it to their loved ones. These may precipitate mental health issues in this group of workers and invariably impact service delivery., For instance, a cross-sectional web survey conducted among some selected HCWs in New York during the peak of COVID-19 inpatient admission revealed that 57% of the respondents had acute stress, 48% depression, and 33% anxiety. Other risk factors associated with developing mental health issues among HCWs during this pandemic have also been reported., Protective factors mitigating the risk of developing mental health problems in HCWs during the pandemic include receiving clear communications and directives about precautionary measures from their organization, provision of early support, adequate compensation from their organizations, provision of mental health services to the HCWs, especially those with severe psychological distress, training, human resources allocation, and adequate equipment.,
There is a dearth of data on COVID-19-related psychological effects on HCWs in Africa, with most reviews on this subject being conducted in other continents., This review intends to bridge this gap, thereby informing the government's decision on policies to put in place to mitigate the psychological effects of the disease on the mental health of the HCWs during this ongoing pandemic. This review's objectives were to ascertain the pattern of psychiatric disorders (PDs) among HCWs in Africa during COVID-19 and to determine the common risk factors for developing PDs among these workers during this pandemic.
| Methods|| |
The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were used to guide the design and reporting of this review. Before the onset of this project, a protocol was written, registered, and published on PROSPERO: the registration number is CRD42021265093.
This review involved a rigorous systematic search of the peer-reviewed literature. The following electronic databases were searched: The Web of Science, PubMed, AJOL, and EBSCO (Academic Search Complete, CINAHL with Full Text, MEDLINE, MEDLINE with Full Text, MLA International Bibliography, and Open Dissertations) for the peer review published articles from Africa. In addition to these, reference lists of the articles were hand-searched for additional relevant studies (snowballing). The keywords include synonyms of PDs, COVID-19, HCWs, the list of all African countries, and their combinations.
The electronic databases were searched for titles or abstracts containing these terms in all published articles after December 31, 2019, to March 14, 2021. The search was limited to studies published in English. The review included all quantitative studies such as cross-sectional and longitudinal observational.
A HCW was defined as anyone who delivers care and services to the sick and ailing directly as doctors and nurses or indirectly as aides, helpers, laboratory technicians, or even medical waste handlers. The PD was defined by DSM-5 or ICD-10 criteria including substance use disorders as well as symptoms of disorders that may not meet diagnostic thresholds (e. g., depressive symptoms), psychological distress, insomnia, and suicide attempt. COVID-19 on the other hand, is an illness caused by a novel coronavirus now called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; formerly called 2019-nCoV).
All studies meeting the following inclusion criteria were selected for the review:
- Studies that measure one or more PDs or measures of symptoms of mental disorder
- Studies limited to the current COVID-19 pandemic
- Studies reporting data on HCWs located in African countries.
Studies were excluded based on the following criteria
- Publications reporting duplicate data from the same population: In such cases, the report with the larger sample size was preferentially included
- Studies that include mixed HCW and general populations
- Qualitative studies: case reports, conference proceedings, dissertations, or any other form of unpublished data.
One of the researchers, a medical librarian (KK), searched for articles relevant to the keywords using their titles and abstracts. The selection criteria were applied to the titles and abstracts independently by two researchers (AF and OA) using the same databases. The complete reports for all related articles were obtained and screened to decide whether they met the inclusion criteria. Wherever there was any uncertainty or disagreement, the researchers resolved through discussions and consensus. A flow diagram was used to depict how the systematic review's final studies were arrived at [Figure 1]. In accord with the PRISMA statement, the following phases of selection were used as a guide: identification phase, a screening phase, eligibility phase, and inclusion phase [Figure 1].
Data extraction (selection and coding) and strategy for data synthesis
Study data were extracted onto a structured, customized data-extraction sheet, and this includes authors, country, aims, study characteristics (including sociodemographic/clinical variables, measures, study design, and sampling strategy), and outcome (mental disorder or psychiatric).
Quality assessment was done using a modified form of New Castle Ottawa Checklist and articles were selected if:
- Data selection process and sample size were justified
- At least, even if nonvalidated measurement tool, the tool is available or described
- Outcomes were specified and defined
- The statistical test used to analyze the data is clearly described and appropriate, and the measurement of the association is presented.
The criteria used in assessment are shown in [Table 1].
A narrative synthesis was conducted to describe the design, implementation, and findings of the studies. Where a nonstandardized measure/instrument was used for the diagnosis of PD, it was stated in the table [Table 2].
| Results|| |
We identified 233 records through database searching. After removing duplicates and screening for eligibility, we ended up with 12 published studies for analysis.
Characteristics of included studies
Studies included were conducted between March 2020 and September 2020. Almost half of the studies included were conducted in Ethiopia.,,,
The studies included HCWs from various settings such as health-care referral centers, general medical facilities, and community care centers. All the studies included participants from various health-care professionals such as doctors, nurses, and pharmacists, except three studies that included only a single profession: nurses, and radiographers.
Except for the study conducted in South Sudan by Zhang et al., which was longitudinal, all the studies were cross sectional. The instruments used varied and include self-report/interviewers designed tool,, the Patient Health Questionnaire-9 for depression, and the 7-item Generalized Anxiety Disorder (GAD-7),,,, and the Depression, Anxiety, and Stress Scale-21 Items (DASS-21).
Prevalence of psychological disorders among health-care worker
Outcome measures vary from general psychological distress and stress,, to specific PDs such as depression, anxiety, and insomnia.,,,,
The prevalence of anxiety disorder ranges from 9.5% to 73.3% using GAD-7, HAD, and DASS-21.,,,,, Depression was reported to range from as low as 12.5% to as high as 71.9%, using the same tools.,,,, Only one study measured insomnia among HCW and found a rate of 77% using the Insomnia Severity Index. Stress was found to be 20% by Mekonen et al. and 75.4% by Akudjedu et al. However, while the former used a standardized instrument (DASS), the latter used an investigator-designed self-report tool. According to two Ethiopia studies, the rates of psychological distress were 42% and 83.5%.
Factors that are associated with psychiatric disorders during coronavirus disease 2019
Anxiety was found to increase among HCWs who had symptoms of COVID-19. Inability to cope with stress (aPOR = 2.74, 95% confidence interval [CI] = 1.633, 4.606) and having COVID-19-related worry were found to increase the risk of developing anxiety. In the same, vein, anxiety, and increased stress score were twice as common in those who had contact with confirmed cases, were significantly more common among those who were afraid of contamination or infecting their families.,, Those who do a night shift and those who reported having chronic disease had increased stress scores in one of the studies.
The increasing number of weeks on COVID-19 frontline duty, working in the general medical center, history of mental disorder as well as having a chronic medical disease increased the risk of depression. Depression and insomnia were significantly more common among women,, while depression was significantly more common among nurses, insomnia was less common among this group compared to others in the medical team.
HCWs who were not given adequate information, training, or guideline regarding COVID-19 prevention measures reported an increase in the risk of PDs such as depression, stress, and anxiety among HCWs.
Psychological distress was significantly more common among nurses and pharmacists. The use of a psychoactive substance, having a history of chronic medical illness, low level of resilience, and low social support increases the risk of developing psychosocial distress.
Factors that are protective against psychiatric disorders during coronavirus disease 2019
Sagaon-Teyssier et al. reported that in Mali, the availability of face masks or other protective gears reduce the risk of developing depression by 51% (IRR: 0.49, 95% CI [0.34–0.70]), insomnia by 43% (IRR: 0.57, 95% CI [0.38–0.86]), and anxiety by 49% (IRR: 0.38, 95%CI [0.21–0.67]). Conversely, Debes et al. explored the association between depression and PPE availability or lockdown in Ethiopia, Tanzania, Nigeria, Egypt, Uganda, and Sudan and found no association.
| Discussion|| |
This review focused on establishing the psychological impact of COVID-19 on HCWs in African countries. A total of 12 studies were identified as at the time of writing this report, which is more than a year after the first case was identified in the continent. This number is vastly lower than the hundreds of studies reported from developed countries since the beginning of the pandemic. The little data in Africa are not due to researchers' deficiency in the continent but because of the lack of support from the governments. The downside is that local data do not drive policies instituted in African countries but heavily rely on outside information, which often does not consider the peculiarity of the culture and may at times not apply to the setting. Moreover, the few research work undertaken are self-funded, and the quality of such work may not meet international standards. Therefore, there is a need for the government to give priority to research in the region.
This systematic review showed that HCWs manifested a range of psychological problem during the COVID-19 pandemic, from common PDs such as depression, anxiety, and insomnia,,, to general psychological distress/stress.,, This report pattern is consistent with similar systematic reviews done in other parts of the world, in which anxiety/depression are the most common psychological disorders reported and followed by others such as general distress, stress, and insomnia. This is also similar to the pattern recorded in the general population during an epidemic, though a higher prevalence of PDs is seen among HCWs when compared with the general populace.
There are several reasons why disorders such as depression and anxiety may be on the rise in times like this. The outbreak is characterized by uncertainty and fear of the disease and infectiousness,, loss of loved ones, and degrading of socioeconomic status of people, such as job losses, financial difficulties, and social isolation. This is apart from conditions related to or specific to health professionals' nature of work in Africa such as high level of stress, job dissatisfaction as a result of poor remuneration, increase job demand, long working hour, and pitiable work environment. All these increase stress levels, which explains the higher prevalence of anxiety and depression compared to the general population.
We noticed that less commonly occurring disorders were omitted or least likely inquired. For instance, only one of the studies reported insomnia which is well reported in other studies and reviews outside of Africa.,,, None in this review enquired for suicide, somatization, or stress-related disorders such as posttraumatic stress disorder, which have been reported in others.,,,, It may also be informative to know that disorders such as alcohol/substance use and adjustment disorder are rarely investigated in most studies. Adjustment disorder, though a mild mental illness, is not unexpected in a pandemic period because measures taken to curtail viral spread have led to many social changes that will require adjustment. While it is understandable why research light will be focused on commonly occurring conditions, researchers must be careful not to neglect these other cases, which merit investigation in their right because of their disabling consequences. Researchers in Africa and other parts of the world should be aware of this proposition.
We attempted to synthesize all the etiological factors in the development of psychological problems and discovered a substantial range of risk factors. Moreover, among these varying associated factors, none appeared to be consistent across the studies. Varieties of risk factors established for anxiety, though not reproducible, were HCWs who had symptoms suggestive of COVID-19, inability to cope with stress, and having COVID-19-related worry. However, only contact with confirmed cases and fear of contamination or infecting their families were replicated in three studies as anxiety correlates.,, Furthermore, those who do a night shift and those who reported having a chronic disease had greater anxiety, while the increasing number of weeks on COVID-19 frontline duty, working in the general medical center, history of mental disorder as well as having a chronic medical disease increased the risk of depression. Besides, the female gender and nursing profession were significantly important in the development of depression. For distress, they were nurses and pharmacists profession, the use of a psychoactive substance, having a history of chronic medical illness, low level of resilience, and low social support.
Similarly, though two, the studies that investigated protective factors did not arrive at a consensus but a somewhat conflicting position. For instance, the availability of PPE was found to protect against depression by Sagaon-Teyssier et al., while the Debes et al. study failed to replicate this. The divergent or contradictory observation may be because of diverse methods adopted, different materials used for measuring outcomes, and sometimes the use of unstandardized scales. However, because the number of studies gathered is few, it may be premature to conclude on the disagreement with the studies' outcome. More studies are required for stronger evidence and a better decision to be reached.
It is also significant to note that most of the studies mirror those from the USA, Europe, and Asian countries. Culturally determined disorders, which are often depression or anxiety related, were omitted. Brain fag syndrome, a typical example of a culture-bound syndrome, is described not only among African students but also as “brain workers,” and others were missing.,, Debatable syndrome like this, which is believed to be anxiety parallel, is thought to be going into extinction because they are not sought for., Furthermore, coping mechanism such as religion/spirituality which African popularly applies for the protection against mental illness, was not investigated. Indigenous investigators should measure outcomes and factors that may be more relevant within the African context rather than copying research from abroad.
There are key limitations to the review. The number of studies available is relatively low, considering how long the pandemic has lasted. This makes it difficult to arrive at a generalizable conclusion. More studies are encouraged to come from the continent to fill in gaps pertinent to knowledge in the region. For example, it is uncertain why the higher prevalence of anxiety previously and consistently reported among nurses, when compared to other hospital workers in other climes,, was not found in most African studies.,,
Moreover, the included studies varied widely in their methodologies and diversity of scope, hence making the synthesis of the findings challenging. Furthermore, some of the studies had methodologies and results with inadequate information and fell short of the standard. Authors from the continent can adopt standard guidelines to improve their work presentation, which will make data gathering for future systematic review more manageable.
Nevertheless, the study has a strength. To our knowledge, this is the first systematic review to examine the pattern of psychological disorders, their risk, and protective factors as experienced by HCW in Africa during the COVID-19 outbreak. It thus becomes a reference point for other work to build on.
| Conclusion|| |
The 12 studies on psychological impact among African HCWs during the COVID-19 pandemic have shown that there is a considerable proportion of HCWs who manifest various psychological problems of mood and stress similar to counterparts in other parts of the world. The evaluation revealed multiple factors implicated as risks; however, there was no match in the association of these sociodemographics and other COVID-19-related factors across the studies. We recommended funding and support to researchers to improve both the quantity and quality of research work and suggested a need for research to be tailored to the HCW population's needs in the continent.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]