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Aksunger N, Vernot C, Littman R, Voors M, Meriggi NF, Abajobir A, Beber B, Dai K, Egger D, Islam A, Kelly J, Kharel A, Matabaro A, Moya A, Mwachofi P, Nekesa C, Ochieng E, Rahman T, Scacco A, van Dalen Y, Walker M, Janssens W, Mobarak AM. COVID-19 and mental health in 8 low- and middle-income countries: A prospective cohort study. PLoS Med 2023; 20:e1004081. [PMID: 37023021 PMCID: PMC10079130 DOI: 10.1371/journal.pmed.1004081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/12/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The Coronavirus Disease 2019 (COVID-19) pandemic and associated mitigation policies created a global economic and health crisis of unprecedented depth and scale, raising the estimated prevalence of depression by more than a quarter in high-income countries. Low- and middle-income countries (LMICs) suffered the negative effects on living standards the most severely. However, the consequences of the pandemic for mental health in LMICs have received less attention. Therefore, this study assesses the association between the COVID-19 crisis and mental health in 8 LMICs. METHODS AND FINDINGS We conducted a prospective cohort study to examine the correlation between the COVID-19 pandemic and mental health in 10 populations from 8 LMICs in Asia, Africa, and South America. The analysis included 21,162 individuals (mean age 38.01 years, 64% female) who were interviewed at least once pre- as well as post-pandemic. The total number of survey waves ranged from 2 to 17 (mean 7.1). Our individual-level primary outcome measure was based on validated screening tools for depression and a weighted index of depression questions, dependent on the sample. Sample-specific estimates and 95% confidence intervals (CIs) for the association between COVID-19 periods and mental health were estimated using linear regressions with individual fixed effects, controlling for independent time trends and seasonal variation in mental health where possible. In addition, a regression discontinuity design was used for the samples with multiple surveys conducted just before and after the onset of the pandemic. We aggregated sample-specific coefficients using a random-effects model, distinguishing between estimates for the short (0 to 4 months) and longer term (4+ months). The random-effects aggregation showed that depression symptoms are associated with a increase by 0.29 standard deviations (SDs) (95% CI [-.47, -.11], p-value = 0.002) in the 4 months following the onset of the pandemic. This change was equivalent to moving from the 50th to the 63rd percentile in our median sample. Although aggregate depression is correlated with a decline to 0.21 SD (95% CI [-0.07, -.34], p-value = 0.003) in the period thereafter, the average recovery of 0.07 SD (95% CI [-0.09, .22], p-value = 0.41) was not statistically significant. The observed trends were consistent across countries and robust to alternative specifications. Two limitations of our study are that not all samples are representative of the national population, and the mental health measures differ across samples. CONCLUSIONS Controlling for seasonality, we documented a large, significant, negative association of the pandemic on mental health, especially during the early months of lockdown. The magnitude is comparable (but opposite) to the effects of cash transfers and multifaceted antipoverty programs on mental health in LMICs. Absent policy interventions, the pandemic could be associated with a lasting legacy of depression, particularly in settings with limited mental health support services, such as in many LMICs. We also demonstrated that mental health fluctuates with agricultural crop cycles, deteriorating during "lean", pre-harvest periods and recovering thereafter. Ignoring such seasonal variations in mental health may lead to unreliable inferences about the association between the pandemic and mental health.
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Affiliation(s)
- Nursena Aksunger
- School of Business and Economics, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Corey Vernot
- Y-RISE, New Haven, Connecticut, United States of America
| | - Rebecca Littman
- Department of Psychology, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Maarten Voors
- Department of Social Sciences, Wageningen University, Wageningen, the Netherlands
| | | | | | - Bernd Beber
- RWI—Leibniz Institute for Economic Research, Berlin, Germany
| | - Katherine Dai
- Department of Economics, New Haven, Connecticut, United States of America
| | - Dennis Egger
- Department of Economics, University of California, Berkeley, California, United States of America
| | - Asad Islam
- Department of Economics, Monash University, Melbourne, Victoria, Australia
- J-PAL, Cambridge, Massachusetts, United States of America
| | - Jocelyn Kelly
- Harvard Humanitarian Initiative, Cambridge, Massachusetts, United States of America
| | - Arjun Kharel
- Department of Sociology, Tribhuvan University, Kathmandu, Nepal
- Centre for the Study of Labour and Mobility, Kathmandu, Nepal
| | | | - Andrés Moya
- School of Economics, Universidad de los Andes, Bogotá, Colombia
| | | | - Carolyn Nekesa
- Vyxer Research Management and Information Technology (REMIT), Busia, Kenya
| | | | - Tabassum Rahman
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Michael Walker
- Center for Effective Global Action, University of California, Berkeley, California, United States of America
| | - Wendy Janssens
- School of Business and Economics, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ahmed Mushfiq Mobarak
- School of Management, Yale University, New Haven, Connecticut, United States of America
- Deakin Business School, Deakin University, Melbourne, Victoria, Australia
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Solís Arce JS, Warren SS, Meriggi NF, Scacco A, McMurry N, Voors M, Syunyaev G, Malik AA, Aboutajdine S, Adeojo O, Anigo D, Armand A, Asad S, Atyera M, Augsburg B, Awasthi M, Ayesiga GE, Bancalari A, Björkman Nyqvist M, Borisova E, Bosancianu CM, Cabra García MR, Cheema A, Collins E, Cuccaro F, Farooqi AZ, Fatima T, Fracchia M, Galindo Soria ML, Guariso A, Hasanain A, Jaramillo S, Kallon S, Kamwesigye A, Kharel A, Kreps S, Levine M, Littman R, Malik M, Manirabaruta G, Mfura JLH, Momoh F, Mucauque A, Mussa I, Nsabimana JA, Obara I, Otálora MJ, Ouédraogo BW, Pare TB, Platas MR, Polanco L, Qureshi JA, Raheem M, Ramakrishna V, Rendrá I, Shah T, Shaked SE, Shapiro JN, Svensson J, Tariq A, Tchibozo AM, Tiwana HA, Trivedi B, Vernot C, Vicente PC, Weissinger LB, Zafar B, Zhang B, Karlan D, Callen M, Teachout M, Humphreys M, Mobarak AM, Omer SB. COVID-19 vaccine acceptance and hesitancy in low- and middle-income countries. Nat Med 2021; 27:1385-1394. [PMID: 34272499 PMCID: PMC8363502 DOI: 10.1038/s41591-021-01454-y] [Citation(s) in RCA: 539] [Impact Index Per Article: 179.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/28/2021] [Indexed: 02/08/2023]
Abstract
Widespread acceptance of COVID-19 vaccines is crucial for achieving sufficient immunization coverage to end the global pandemic, yet few studies have investigated COVID-19 vaccination attitudes in lower-income countries, where large-scale vaccination is just beginning. We analyze COVID-19 vaccine acceptance across 15 survey samples covering 10 low- and middle-income countries (LMICs) in Asia, Africa and South America, Russia (an upper-middle-income country) and the United States, including a total of 44,260 individuals. We find considerably higher willingness to take a COVID-19 vaccine in our LMIC samples (mean 80.3%; median 78%; range 30.1 percentage points) compared with the United States (mean 64.6%) and Russia (mean 30.4%). Vaccine acceptance in LMICs is primarily explained by an interest in personal protection against COVID-19, while concern about side effects is the most common reason for hesitancy. Health workers are the most trusted sources of guidance about COVID-19 vaccines. Evidence from this sample of LMICs suggests that prioritizing vaccine distribution to the Global South should yield high returns in advancing global immunization coverage. Vaccination campaigns should focus on translating the high levels of stated acceptance into actual uptake. Messages highlighting vaccine efficacy and safety, delivered by healthcare workers, could be effective for addressing any remaining hesitancy in the analyzed LMICs.
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Affiliation(s)
| | | | | | | | - Nina McMurry
- WZB Berlin Social Science Center, Berlin, Germany
| | - Maarten Voors
- Wageningen University & Research, Wageningen, the Netherlands
| | - Georgiy Syunyaev
- WZB Berlin Social Science Center, Berlin, Germany.,International Center for the Study of Institutions and Development (ICSID), HSE University, Moscow, Russia.,Columbia University, New York, NY, USA
| | | | | | - Opeyemi Adeojo
- Busara Center for Behavioral Economics, Lagos, Nigeria.,Department of Sociology, University of Lagos, Lagos, Nigeria
| | - Deborah Anigo
- Busara Nigeria, Lagos, Nigeria.,Agricultural and Rural Development Secretariat, Federal Capital Territory Administration, Abuja, Nigeria
| | - Alex Armand
- Nova School of Business and Economics, Lisbon, Portugal.,The Institute for Fiscal Studies, London, UK
| | - Saher Asad
- Lahore University of Management Sciences, Lahore, Pakistan
| | - Martin Atyera
- Innovations for Poverty Action (IPA) Uganda, Kampala, Uganda
| | | | | | | | - Antonella Bancalari
- The Institute for Fiscal Studies, London, UK.,University of St Andrews, St Andrews, UK.,Redes Peru, Lima, Peru
| | | | - Ekaterina Borisova
- International Center for the Study of Institutions and Development (ICSID), HSE University, Moscow, Russia.,Ghent University, Department of Economics, Ghent, Belgium
| | | | | | - Ali Cheema
- Lahore University of Management Sciences, Lahore, Pakistan.,Institute of Development and Economic Alternatives, Lahore, Pakistan
| | | | - Filippo Cuccaro
- Innovations for Poverty Action (IPA) Sierra Leone, Freetown, Sierra Leone
| | - Ahsan Zia Farooqi
- Institute of Development and Economic Alternatives, Lahore, Pakistan
| | | | - Mattia Fracchia
- Nova School of Business and Economics, Lisbon, Portugal.,NOVAFRICA, Lisbon, Portugal
| | | | | | - Ali Hasanain
- Lahore University of Management Sciences, Lahore, Pakistan
| | - Sofía Jaramillo
- Innovations for Poverty Action (IPA) Colombia, Bogotá, Colombia
| | - Sellu Kallon
- Wageningen University & Research, Wageningen, the Netherlands.,Institute of Public Administration and Management, University of Sierra Leone, Freetown, Sierra Leone
| | | | - Arjun Kharel
- Centre for the Study of Labour and Mobility (CESLAM), Kathmandu, Nepal
| | | | - Madison Levine
- Wageningen University & Research, Wageningen, the Netherlands
| | | | - Mohammad Malik
- Institute of Development and Economic Alternatives, Lahore, Pakistan
| | | | | | - Fatoma Momoh
- Innovations for Poverty Action (IPA) Sierra Leone, Freetown, Sierra Leone
| | - Alberto Mucauque
- Associação NOVAFRICA para o Desenvolvimento Empresarial e Económico de Moçambique, Maputo, Mozambique
| | - Imamo Mussa
- Associação NOVAFRICA para o Desenvolvimento Empresarial e Económico de Moçambique, Maputo, Mozambique
| | | | - Isaac Obara
- Busara Center for Behavioral Economics, Lagos, Nigeria
| | | | | | - Touba Bakary Pare
- Innovations for Poverty Action (IPA) Burkina Faso, Ouagadougou, Burkina Faso
| | | | - Laura Polanco
- Innovations for Poverty Action (IPA) Colombia, Bogotá, Colombia
| | | | - Mariam Raheem
- Centre for Economic Research in Pakistan (CERP), Lahore, Pakistan
| | - Vasudha Ramakrishna
- Yale Research Initiative on Innovation and Scale (Y-RISE), New Haven, CT, USA
| | - Ismail Rendrá
- Associação NOVAFRICA para o Desenvolvimento Empresarial e Económico de Moçambique, Maputo, Mozambique
| | - Taimur Shah
- Centre for Economic Research in Pakistan (CERP), Lahore, Pakistan
| | | | | | - Jakob Svensson
- Institute for International Economic Studies (IIES), Stockholm University, Stockholm, Sweden
| | - Ahsan Tariq
- Institute of Development and Economic Alternatives, Lahore, Pakistan
| | | | - Hamid Ali Tiwana
- Institute of Development and Economic Alternatives, Lahore, Pakistan
| | | | - Corey Vernot
- Yale Research Initiative on Innovation and Scale (Y-RISE), New Haven, CT, USA
| | - Pedro C Vicente
- Nova School of Business and Economics, Lisbon, Portugal.,NOVAFRICA, Lisbon, Portugal
| | | | - Basit Zafar
- Centre for Economic Research in Pakistan (CERP), Lahore, Pakistan.,University of Michigan, Ann Arbor, MI, USA
| | | | - Dean Karlan
- Innovations for Poverty Action (IPA), New York, NY, USA.,Kellogg School of Management at Northwestern University, Evanston, IL, USA
| | - Michael Callen
- London School of Economics and Political Science, London, UK
| | | | - Macartan Humphreys
- WZB Berlin Social Science Center, Berlin, Germany.,Columbia University, New York, NY, USA
| | | | - Saad B Omer
- Yale Institute for Global Health, New Haven, CT, USA.
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Egger D, Miguel E, Warren SS, Shenoy A, Collins E, Karlan D, Parkerson D, Mobarak AM, Fink G, Udry C, Walker M, Haushofer J, Larreboure M, Athey S, Lopez-Pena P, Benhachmi S, Humphreys M, Lowe L, Meriggi NF, Wabwire A, Davis CA, Pape UJ, Graff T, Voors M, Nekesa C, Vernot C. Falling living standards during the COVID-19 crisis: Quantitative evidence from nine developing countries. Sci Adv 2021; 7:7/6/eabe0997. [PMID: 33547077 PMCID: PMC7864564 DOI: 10.1126/sciadv.abe0997] [Citation(s) in RCA: 133] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/18/2020] [Indexed: 05/19/2023]
Abstract
Despite numerous journalistic accounts, systematic quantitative evidence on economic conditions during the ongoing COVID-19 pandemic remains scarce for most low- and middle-income countries, partly due to limitations of official economic statistics in environments with large informal sectors and subsistence agriculture. We assemble evidence from over 30,000 respondents in 16 original household surveys from nine countries in Africa (Burkina Faso, Ghana, Kenya, Rwanda, Sierra Leone), Asia (Bangladesh, Nepal, Philippines), and Latin America (Colombia). We document declines in employment and income in all settings beginning March 2020. The share of households experiencing an income drop ranges from 8 to 87% (median, 68%). Household coping strategies and government assistance were insufficient to sustain precrisis living standards, resulting in widespread food insecurity and dire economic conditions even 3 months into the crisis. We discuss promising policy responses and speculate about the risk of persistent adverse effects, especially among children and other vulnerable groups.
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Affiliation(s)
- Dennis Egger
- University of California, Berkeley, Berkeley, CA, USA
- The World Bank, Washington, D.C., USA
| | - Edward Miguel
- University of California, Berkeley, Berkeley, CA, USA
| | | | | | | | - Dean Karlan
- Innovations for Poverty Action, Washington, D.C., USA
- Northwestern University, Evanston, IL, USA
| | | | - A Mushfiq Mobarak
- Yale University and Y-RISE, New Haven, CT, USA.
- Deakin University, Melbourne, Australia
| | | | | | | | - Johannes Haushofer
- Stockholm University, Department of Economics; Research Institute of Industrial Economics, Stockholm, Sweden
- Max Planck Institute for Collective Goods, Bonn, Germany
- Jain Family Institute, New York, USA
| | - Magdalena Larreboure
- Princeton University, Princeton, NJ, USA
- Busara Center for Behavioral Economics, Nairobi, Kenya
| | | | | | | | | | - Layna Lowe
- University of California, Berkeley, Berkeley, CA, USA
| | | | | | - C Austin Davis
- Yale University and Y-RISE, New Haven, CT, USA
- American University, Washington, D.C., USA
| | - Utz Johann Pape
- The World Bank, Washington, D.C., USA
- University of Goettingen, Göttingen, Germany
| | | | - Maarten Voors
- Wageningen University & Research, Wageningen, Netherlands
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