COVID-19 Preventive Practices, Psychological Distress, and Reported Barriers to Healthcare Access during the Pandemic among Adult Community Members in Sub-Saharan Africa: A Phone Survey

The COVID-19 pandemic has had serious negative health and economic impacts in sub-Saharan Africa. Continuous monitoring of these impacts is crucial to formulate interventions to minimize the consequences of COVID-19. This study surveyed 2,829 adults in urban and rural sites among five sub-Saharan African countries: Burkina Faso, Ethiopia, Nigeria, Tanzania, and Ghana. Participants completed a mobile phone survey that assessed self-reported sociodemographics, COVID-19 preventive practices, psychological distress, and barriers to healthcare access. A modified Poisson regression model was used to estimate adjusted prevalence ratios (aPRs) and 95% CIs to investigate potential factors related to psychological distress and barriers to reduced healthcare access. At least 15.6% of adults reported experiencing any psychological distress in the previous 2 weeks, and 10.5% reported that at least one essential healthcare service was difficult to access 2 years into the pandemic. The majority of participants reported using several COVID-19 preventive methods, with varying proportions across the sites. Participants in the urban site of Ouagadougou, Burkina Faso (aPR: 2.29; 95% CI: 1.74-3.03) and in the rural site of Kintampo, Ghana (aPR: 1.68; 95% CI: 1.21-2.34) had a higher likelihood of experiencing any psychological distress compared with those in the rural area of Nouna, Burkina Faso. Loss of employment due to COVID-19 (aPR: 1.77; 95% CI: 1.47-2.11) was also associated with an increased prevalence of psychological distress. The number of children under 5 years in the household (aPR: 1.23; 95% CI: 1.14-1.33) and participant self-reported psychological distress (aPR: 1.83; 95% CI: 1.48-2.27) were associated with an increased prevalence of reporting barriers to accessing health services, whereas wage employment (aPR: 0.67; 95% CI: 0.49-0.90) was associated with decreased prevalence of reporting barriers to accessing health services. Overall, we found a high prevalence of psychological distress and interruptions in access to healthcare services 2 years into the pandemic across five sub-Saharan African countries. Increased effort and attention should be given to addressing the negative impacts of COVID-19 on psychological distress. An equitable and collaborative approach to new and existing preventive measures for COVID-19 is crucial to limit the consequences of COVID-19 on the health of adults in sub-Saharan Africa. This survey was conducted by the Africa Research, Implementation Science, and Education (ARISE) Network, a research and training platform including 21 member institutions from nine sub-Saharan African countries. This study was a second-round mobile phone survey building on a 2020 baseline survey that was conducted in three ARISE countries (Ethiopia, Nigeria, and Burkina Faso). The study rationale, sampling strategies, and survey methodology for the baseline survey have been described in detail previously.30 Briefly, the first survey round included one urban and one rural site in three SSA countries: Nouna (rural) and Ouagadougou (urban) in Burkina Faso, Kersa (rural) and Addis Ababa (urban) in Ethiopia, and Ibadan (rural) and Lagos (urban) in Nigeria. The second survey round included a rural (Dodoma) and urban site (Dar es Salaam) in Tanzania and a site in Ghana (Kintampo), which is a largely rural area. The second survey round included a total of nine sites across five countries (Supplemental Figure 1). ARISE Network sites were selected for this survey based on the available data collection infrastructure, research capacity, and willingness of site leaders to take on the survey. The Round 2 survey was conducted between July and December 2021. The current study focuses on data collected from adult community members in the second survey round. The survey also collected data from adolescents and healthcare workers, but the results from those populations are presented elsewhere. Where possible, each site used health and demographic surveillance systems or existing national surveys to construct sampling frames. Health and Demographic Surveillance Systems were used in Burkina Faso, rural Ethiopia (Kersa), Tanzania, and Ghana. In Nigeria, the National Living Standard Survey 2017–2018 and lists from telephone service providers were used. In Addis Ababa, no existing surveys were available before the round 1 survey; therefore, we conducted a household survey in round 1 and used this as the sampling frame in round 2. In each household, one adult aged 20 or older was interviewed. Because this was a phone survey, participants were limited to those who had access to a working phone (mobile or landline). Households were sampled from each sampling frame and called until we reached the target sample size of 300 for each site (600 per country except for Ghana, which only included 300 adults from a rural area). Figure 1 shows the number of participants sampled, called, and interviewed at each site. Africa Research, Implementation Science, and Education COVID-19 Survey Round 2 participant flowchart for the adult household survey across five countries, 2021. All adults who participated in the round 1 survey in Burkina Faso, Ethiopia, and Nigeria were recontacted to join this survey. We replaced those adults who could not be reached or who declined to participate in the study with new participants from the sampling frame to achieve the target sample size of 300 adults per site. In Tanzania and Ghana, all recruited participants were new because these countries did not participate in the round 1 survey. Trained enumerators conducted all interviews in the local languages of each site using computer-assisted telephone interviewing (CATI). Participant data were collected electronically using a mobile tablet-based data collection system (Open Data Kit) and uploaded to a secure server after each interview. All research staff members were trained on study procedures, including screening, consent, enrollment, and data collection, emphasizing confidentiality and safeguarding the participant’s rights and well-being. A standardized questionnaire assessing sociodemographic information; knowledge, practices, and perceptions of COVID-19; psychological distress; reported disruption of health services due to COVID-19; and knowledge, perceptions, beliefs, and hesitancy related to COVID-19 vaccines was used across all sites, which was developed by subject matter experts across sites. Experts familiar with the context of each site translated the consent script and the questionnaires into the local languages of each country. The questionnaire was pretested at each site, and minor adaptations were made to account for the local contexts in each area. The complete questionnaire is available at (https://africa.harvard.edu/covid-19-resources). The data collectors obtained verbal informed consent from each participant before beginning the interview. Data were reviewed for completeness and quality, cleaned, and pooled for data analysis by a centralized data management team. Informed consent was obtained from all participants in this survey and the study was approved by all necessary ethical review boards in each country, including the Harvard T.H. Chan School of Public Health Institutional Review Board; Nouna Health Research Center Ethical Committee, and National Ethics Committee in Burkina Faso, the Institutional Ethical Review Board of Addis Continental Institute of Public Health in Ethiopia, Kintampo Health Research Center Institutional Ethics Committee in Ghana, the University of Ibadan Research Ethics Committee in Nigeria, and the Muhimbili University of Health and Allied Sciences, University of Dodoma and the National Institute for Medical Research in Tanzania. Survey responses to questions related to sociodemographics, COVID-19 practices and perceptions, psychological distress, and disruption of healthcare access due to COVID-19 were presented descriptively. Means and SDs were presented for continuous variables, medians, and interquartile ranges for skewed variables, and counts and percentages for categorical variables. Demographic characteristics explored included age, gender, occupation, religion, household size, number of children under 5 years, and participant’s role in the household (mother, father, or other). Participants were also asked if they considered themselves to be the head of the household which in this study context referred to the individual who served as the provider of the family (often a senior male in the home).31 Household wealth was defined using a wealth index, constructed using principal component analysis of 10 items describing the household’s asset ownership, housing quality, crowding, and water and sanitation facilities. The wealth index was divided into population tertiles (poor, middle, and rich).32,33 Perceptions and compliance with preventive measures were assessed by asking participants if they complied with the following evidence-based prevention measures: use of masks, handwashing, changing travel plans, and social distancing. In addition, we also assessed some non–evidence-based perceptions and preventive measures such as utilizing saunas, taking vitamins, and drinking tea or consuming ginger as preventive measures for COVID-19. We measured psychological distress using the validated four-item Patient Health Questionnaire for Depression and Anxiety Scale (PHQ-4),34,35 which included four questions related to psychological distress over the past two weeks. This instrument asks participants how often they have been bothered by the following problems over the past 2 weeks: 1) feeling nervous, anxious, or on edge; 2) not being able to control or stop worrying; 3) having little interest or pleasure in doing things; 4) feeling down, depressed, or hopeless. Each question is answered on a scale where 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day. We computed a total score for psychological distress by adding the scores of the four items, ranging from 0 to 12. We further categorized psychological distress as none (total score: 0–2), mild (total score: 3–5), moderate (total score: 6–8), severe (total score: 9–12), and any psychological distress (including mild, moderate, and severe).35 We also created an anxiety subscale (range: 0–6) using the scores of the first two questions and a depression subscale (range: 0–6) using the scores of the last two questions. A subscale score of 3 or greater was considered a high anxiety or depression score.34 The PHQ-4 has previously been proven valid and reliable for screening for anxiety and depression among adolescents and adults in sub-Saharan Africa.35 We also examined access to seven essential health services as reported by the adult community participants. Participants were asked if COVID-19 impacted their access to the following healthcare services: 1) childhood immunization, 2) vitamin A supplementation for children, 3) management of child malnutrition, 4) antenatal care for pregnant women, 5) iron and folic acid supplementation, 6) sexual and reproductive health services, and 7) HIV treatment services. The first three services were grouped as child health services and the second three as maternal and reproductive health services. For each question, participants could respond with yes (scored as 1 point), no (scored as 0 points), not applicable, don’t know, or refuse to answer. Responses were coded as missing and unscored if the services were not applicable or participants refused to answer the question. Answers to each question were summed across all sites to create a total aggregate score. The maximum score for child health services was 3 (1 point each for immunization, malnutrition treatment, and vitamin A). The maximum score for maternal and reproductive health was 3 (1 point each for antenatal care, iron and folic acid supplementation, and sexual and reproductive health services). The remainder, HIV services, had a maximum point of one. A total aggregated score was computed by summing responses to all seven health services questions, ranging from 0 to 7. Each site’s mean total aggregated score was used as a cutoff point to define reduced access to essential health services (below the mean aggregated score indicated reported difficulty in accessing healthcare).36,37 The respective cutoff for Nouna, Ouagadougou, Addis Ababa, Kersa, Ibadan, Lagos, Dar es Salaam, Dodoma, and Kintampo was 0.041, 0.707, 0.211, 0.184, 1.793, 0.603, 0.035, 0.006, and 0.269, respectively. In associational analyses, our primary outcomes of interest were reduced access to essential health services and any self-reported psychological distress, which was selected based on its higher prevalence (19.9%) compared with other psychological distress outcomes (≤ 10%). Potential factors explored for each outcome were site, age, gender, occupation, role in the household, educational status, wealth index, COVID-19 testing availability, ever tested positive for COVID-19, the number of children under 5 years in the household, household size, and effect of COVID-19 on employment. Any psychological distress was also explored as a factor relating to reduced healthcare access and vice versa. Because of the low reported difficulty of healthcare access in Dar es Salaam, Dodoma, Nouna, and Kersa, these sites were excluded in the crude and adjusted analyses for this outcome (reduced access). Modified Poisson regression with robust standard errors38 was used to estimate crude prevalence ratios and adjusted prevalence ratios (aPRs) with 95% CIs and P values to establish statistical significance (α < 0.05). In the crude analysis, variables with a P value < 0.25 were retained for the final model. However, age and gender had P values > 0.25 but were kept in the model because the authors hypothesized these factors were essential to include. Model fitness and collinearity effects were tested using model misspecification and correlation matrices. Missing data were handled using a complete case analysis. Data were cleaned and managed using SAS 9.4 (SAS Institute Inc., Cary, NC) and analyzed using Stata version 16 (Stata Corp LLC, College Station, TX).