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Mental Health Among Ebola Survivors in Liberia, Sierra Leone and Guinea: Results from a Cross-­Sectional Study

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Mental Health Among Ebola Survivors in Liberia, Sierra Leone and Guinea: Results from a Cross-­Sectional Study Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-035217 on 26 May 2020. Downloaded from Mental health among Ebola survivors in Liberia, Sierra Leone and Guinea: results from a cross- sectional study Andrew Secor ,1,2 Rose Macauley,1 Laurentiu Stan,3 Meba Kagone,4 Sidibe Sidikiba,4 Sadou Sow,4 Dana Aronovich,5 Kate Litvin,5 Nikki Davis,5 Soumya Alva,5 Jeff Sanderson5 To cite: Secor A, Macauley R, ABSTRACT Strengths and limitations of this study Stan L, et al. Mental health Objectives To describe the prevalence and correlates of among Ebola survivors in depression and anxiety among adult Ebola virus disease ► Depression and anxiety were evaluated using well Liberia, Sierra Leone and (EVD) survivors in Liberia, Sierra Leone and Guinea. Guinea: results from a cross- validated, widely used tools (the Patient Health Design Cross- sectional. sectional study. BMJ Open Questionnaire-9 and Generalised Anxiety Disorder-7 Setting One- on- one surveys were conducted in EVD- 2020;10:e035217. doi:10.1136/ questionnaires), standardising assessment across affected communities in Liberia, Sierra Leone and Guinea bmjopen-2019-035217 the three countries and allowing for comparison to in early 2018. other studies using the same tools. ► Prepublication history for Participants 1495 adult EVD survivors (726 male, 769 ► Where possible, Ebola virus disease (EVD) survivors this paper is available online. female). To view these files, please visit acted as enumerators, hopefully reducing response Primary and secondary outcome measures Patient the journal online (http:// dx. doi. bias associated with EVD-rela ted stigma. Health Questionnaire-9 (PHQ-9) depression scores and org/ 10. 1136/ bmjopen- 2019- ► Due to use of survivor registries for sampling, our Generalised Anxiety Disorder-7 (GAD-7) scores. 035217). sample is likely biased towards survivors who are Results Prevalence and severity of depression and connected with advocacy groups and healthcare Received 23 October 2019 anxiety varied across the three countries. Sierra Leone services. Revised 21 March 2020 had the highest prevalence of depression, with 22.0% of ► This was a cross-sectional study, precluding causal Accepted 15 April 2020 participants meeting the criteria for a tentative diagnosis inference between mental health and covariates of of depression, compared with 20.2% in Liberia and interest. 13.0% in Guinea. Sierra Leone also showed the highest http://bmjopen.bmj.com/ prevalence of anxiety, with 10.7% of participants meeting criteria for generalized anxiety disorder (GAD-7 score ≥10), compared with 9.9% in Liberia and 4.2% in Guinea. INTRODUCTION Between one- third and one- half of respondents reported During the unprecedented 2014–2016 Ebola little interest or pleasure in doing things in the previous outbreak, Liberia, Sierra Leone and Guinea 2 weeks (range: 47.0% in Liberia to 37.6% in Sierra Leone), and more than 1 in 10 respondents reported experienced more than 28 000 cases of Ebola ideation of self- harm or suicide (range: 19.4% in Sierra virus disease (EVD), leaving an estimated © Author(s) (or their 1 2 Leone to 10.4% in Guinea). Higher depression and anxiety 10 000 survivors. The unprecedented on September 25, 2021 by guest. Protected copyright. employer(s)) 2020. Re- use permitted under CC BY- NC. No scores were statistically significantly associated with each number of survivors has raised questions commercial re- use. See rights other and with experiences of health facility- based stigma about long-term health complications of EVD and permissions. Published by in all three countries. Other associations between mental survivorship and the capacity of local health BMJ. health scores and respondent characteristics varied across systems to meet these needs. 1JSI Research and Training countries. Prior and emerging research has shown Institute Inc, Monrovia, Liberia Conclusions Our results indicate that both depression EVD survivorship to be associated with 2Department of Global Health, and anxiety are common among EVD survivors in Liberia, myriad sequelae, including musculoskel- University of Washington, Sierra Leone and Guinea, but that there is country- level Seattle, Washington, USA etal pain, ocular conditions and mental 3 heterogeneity in prevalence, severity and correlates 3–7 JSI Research and Training of these conditions. All three countries should work to health issues. Recent studies from the Institute Inc, Freetown, Sierra make mental health services available for survivors, West Africa outbreak have found that many Leone 4 and governments and organisations should consider survivors suffer from symptoms associated JSI Research and Training 3 8–13 Institute Inc, Conakry, Guinea the intersection between EVD- related stigma and with mental health conditions. A 2015 5JSI Research and Training mental health when designing programmes and training study among EVD survivors in Sierra Leone Institute Inc, Arlington, Virginia, healthcare providers. found that 48% showed symptoms of anxiety USA or depression, and 76% showed symptoms 8 Correspondence to of post-traumatic stress disorder (PTSD). Mr Andrew Secor; In Guinea, 15% of survivors met criteria for amsecor@ gmail. com psychological suffering,3 and in Liberia 13% Secor A, et al. BMJ Open 2020;10:e035217. doi:10.1136/bmjopen-2019-035217 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-035217 on 26 May 2020. Downloaded from of survivors presented with symptoms of depression and/ using a diagnostic algorithm to generate a tentative diag- or anxiety.9 nosis of major depressive disorder or other depressive The impacts of EVD infection are far- reaching. In addi- disorder, as a continuous summary score, or as a severity tion to health complications, many survivors also experi- scale.17 In this study, the PHQ-9 had a Cronbach’s alpha enced loss of friends and family, as well as stigmatisation of 0.82, suggesting high internal reliability. and ostracisation in their communities and at health facil- ities, leading to further degradation of traditional social Generalised Anxiety Disorder-7 support structures and the ability or willingness to engage Similar to the PHQ-9, the Generalised Anxiety Disorder-7 with care.14 15 One study in Sierra Leone found that 67% (GAD-7) is a self- administered screening tool based on of survivors had witnessed the death of a family member the seven DSM criteria for GAD and has been validated in to EVD, and 32% experienced stigma in their commu- several sub- Saharan African countries and among vulner- nities after returning home from the Ebola treatment able populations.21 Questions ask about experience of unit.10 These experiences and issues can have long- term each criterion in the past 2 weeks and are scored on a impact on the survivors’ well-being and the ability of the 4- point Likert scale of frequency (eg, ‘more than half health system to respond to their health needs. the days’), with an overall range of 0 to 21. The score The aims of this study are to describe the prevalence can be interpreted using a validated cut-point of 10 for a and correlates of depression and anxiety among adult tentative diagnosis of GAD or as a continuous summary EVD survivors in Liberia, Sierra Leone and Guinea, in score.22 In this study, the GAD-7 had a Cronbach’s alpha order to better understand the health needs of this popu- of 0.83, suggesting high internal reliability. lation and to inform further health programmes and policies. This research is particularly salient considering Stigma the current Ebola outbreak in the Democratic Republic Liberia and Guinea used the same stigma questions while of Congo. Sierra Leone used a modified questionnaire. The Liberia and Guinea surveys asked about experience of five types of stigma at a health facility in the last year: refusal of METHODS service due to survivor status, longer wait times for services Design and sample than non- survivors, receiving less care or attention than This was a cross- sectional survey conducted in USAID non- survivors, providers gossiping about survivor status, EVD- priority regions in Liberia, Sierra Leone and Guinea and providers being nervous to treat them due to their as part of the Ebola Transmission Prevention & Survivor survivor status. Additionally, participants were asked if Services (ETP&SS) programme, a USAID-funded, EVD- they had avoided or delayed seeking care due to fear survivor focused programme implemented between 2016 of stigma. The Sierra Leone survey included four ques- http://bmjopen.bmj.com/ and 2018. Data collection was conducted in early 2018. tions on health facility-based stigma and five questions The final sample size was 1495 (Guinea=531, Liberia=213, on community- based stigma, including questions on Sierra Leone=751). Randomised samples stratified by disclosure of EVD status (health facility), denial of health administrative region and sex were drawn from survivor services (health facility), verbal insult (community) and registries in each country. Representatives from local physical assault (community). Stigma was analysed as survivor associations played an essential role in facili- continuous scores disaggregated by setting (community tating the research by contacting and mobilising partici- vs health facility). Cronbach’s alphas ranged from 0.45 pants. Inclusion criteria were: verified EVD survivor status (Guinea, health facility) to 0.75 (Sierra Leone, commu- on September 25, 2021 by guest. Protected copyright. and age 18 or over. Data collectors received 3–7
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