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COVID-19 knowledge and mental health impact assessment in Haiti

Published online by Cambridge University Press:  29 January 2024

Taehwan Park
Affiliation:
Department of Pharmacy Administration and Public Health, St. John’s University, Queens, NY, USA
Jean Pierre-Louis
Affiliation:
Capracare, Inc., Les Cayes, Haiti
Tachel Jean
Affiliation:
Biomedical Program, College of Pharmacy and Health Sciences, St. John’s University, Queens, NY, USA
Prachurjya Barua
Affiliation:
Biomedical Program, College of Pharmacy and Health Sciences, St. John’s University, Queens, NY, USA
Taheera T. Ilma
Affiliation:
Biomedical Program, College of Pharmacy and Health Sciences, St. John’s University, Queens, NY, USA
Mariana A. Pinanez
Affiliation:
Biomedical Program, College of Pharmacy and Health Sciences, St. John’s University, Queens, NY, USA
Joseph Ravenell
Affiliation:
Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
Chimene Castor
Affiliation:
Department of Nutritional Sciences, Howard University, Washington, DC, USA
Yolene Gousse*
Affiliation:
Department of Pharmacy Administration and Public Health, St. John’s University, Queens, NY, USA
*
Corresponding author: Yolene Gousse; Email: [email protected]
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Abstract

Mental health is a significant public health challenge globally, and one anticipated to increase following the COVID-19 pandemic. In many rural regions of developing nations, little is known about the prevalence of mental health conditions and factors that may help mitigate poor outcomes. This study assessed the impact of the COVID-19 pandemic on mental health and social support for residents of rural Haiti. Data were collected from March to May 2020. The Patient Health Questionnaire subscales for anxiety and depression, and the Perceived Stress Scale were utilized in addition to tailored questions specific to COVID-19 knowledge. Half (51.8%) of the 500 survey respondents reported COVID-19-related anxiety and worrying either daily or across a few days. Half (50.2%) also reported experiencing depression daily or across several days. Most (70.4%) did not have any social support, and 28.0% experienced some stress, with 13.4% indicating high perceived stress. Furthermore, 4.6% had suitable plumbing systems in their homes. The results were immediately actionable, informing the implementation of a mental health counseling program for youth following a loss of social support through school closures. Long-term investments must be made as part of public health responses in rural communities in developing nations, which remain under-studied.

Type
Research Article
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2024. Published by Cambridge University Press

Impact statement

This study presents a first-of-its-kind assessment of the prevalence of mental health outcomes, social support and economic hardship for residents of rural Haiti after the onset of the COVID-19 pandemic. Mental illness is a significant global health issue, and less is known about its challenges in low- and middle-income nations. In Haiti, a confluence of factors, including persistent poverty and limited access to health care, have been exacerbated by the COVID-19 pandemic. Emerging data suggest the pandemic has increased mental health burdens, with the poorest communities being most affected. The study found that half of the 500 survey respondents (51.8%) reported symptoms of COVID-19-related anxiety and depression. Most respondents (70.4%) reported having no social support. Of those reporting some level of stress (28%), 13.4% reported high perceived stress. This demonstrates that the COVID-19 pandemic has had significant impacts on residents of rural communities in lower-income countries, which have not been included in much of the current discourse on the pandemic. Place of stay and facility for washing hands were found to be significantly associated with anxiety, depression and stress, Wilks’ Lambda ≤0.05. The latter has implications for social deprivation factors being the most significant drivers of mental status. Study results were immediately actionable by the participating community-based organization (CBO), which implemented a youth counseling program providing social support and explored additional opportunities to address mental health needs. The study’s outcomes and model can stimulate interest among researchers and CBOs to forge partnerships and design tailored health education initiatives for similar underserved communities worldwide. Public health practitioners must identify unique mental health needs of residents in diverse communities and use insights to develop tailored outreach and intervention programs. It is important that the needs of residents in these low- and middle-income nations do not go unfunded and unresearched during global pandemics.

Introduction

Mental illness is a significant global health burden which, combined with addictive disorders, affects more than a billion people worldwide (Rehm and Shield, Reference Rehm and Shield2019). Individuals experiencing mental illness during their lifetime have a shorter life expectancy by an average of 10.1 years, compared to those without mental illness (Walker et al., Reference Walker, McGee and Druss2015; Deeg et al., Reference Deeg, Comijs, Hoogendijk, van der Noordt and Huisman2018). Worldwide, mental health disproportionately affects certain populations based on factors, including access to services, stigma of seeking care and poverty. In low- and middle-income nations, extreme poverty, lack of educational and economic opportunities, hunger and overcrowded or unsafe living conditions together aggravate and lead to increased rates of mental illness (Lund et al., Reference Lund, De Silva, Plagerson, Cooper, Chisholm, Das, Knapp and Patel2011). Mental illness and poverty often exacerbate a negative cycle in which persons who experience social deprivation are at higher risk for developing mental illness, and those with mental illness are at higher risk for poor daily functioning and lower quality of life (Kumar and Kumar, Reference Kumar and Kumar2020).

Haiti is a low- to middle-income nation in the Caribbean with over 11 million residents. Many Haitians experience poor health outcomes, including mental health, due to Haiti’s under-resourced health care system, struggling economy and ongoing political unrest (Quran, Reference Quran2019). The 2010 earthquake in Haiti caused high morbidity and mortality rates, with nearly 57% of deaths attributed to communicable diseases such as tuberculosis, respiratory conditions and diarrheal-related diseases. The aftermath of the earthquake also further exacerbated existing mental health issues in Haiti, including increasing the rate of depression and anxiety (Wagenaar et al., Reference Wagenaar, Hagaman, Kaiser, McLean and Kohrt2012), and of the population experiencing post-traumatic stress disorder (PTSD), and 50% experienced a major depressive disorder (Castle, Reference Castle2020).

Approximately 6.4 million (59%) Haitians live below the poverty line, with nearly a quarter (24%) of the population living in extreme poverty (IFRC, 2019). Furthermore, only 36% of the population has access to electricity, 56% has access to clean water and only 28% has access to basic sanitation (Louis-Jean et al., Reference Louis-Jean, Cenat, Sanon and Stvil2020). These social determinants of health contribute to social deprivation, which represents limited access to society’s resources due to poverty, discrimination, or other disadvantages that are associated with poor mental health outcomes.

In Haiti, as of January 3, 2023, 34.4% of the confirmed COVID-19 cases resulted in death (WHO, 2023), compared to the 1.5% of the confirmed COVID-19 cases dying in early March 2020 (OCHA, 2020), indicating a rapid increase in the COVID-19 mortality rate. Emerging data have shown that the pandemic has increased mental health burden (Panchal et al., Reference Panchal, Saunders, Rudowitz and Cox2020; Lozano et al., Reference Lozano, Rueger, Lam, Louie, Southworth, Maene, Mo, Randal and Kim2021). In low-income countries, the poorest communities were most affected by COVID-19 (Prates and Barbosa, Reference Prates and Barbosa2020) and had a disproportionately high suicide rate (Pirkis et al., Reference Pirkis, John, Shin, DelPozo-Banos, Arya, Analuisa-Aguilar, Appleby, Arensman, Bantjes, Baran, Bertolote, Borges, Brečić, Caine, Castelpietra, Chang, Colchester, Crompton, Curkovic, Deisenhammer, Du, Dwyer, Erlangsen, Faust, Fortune, Garrett, George, Gerstner, Gilissen, Gould, Hawton, Kanter, Kapur, Khan, Kirtley, Knipe, Kolves, Leske, Marahatta, Mittendorfer-Rutz, Neznanov, Niederkrotenthaler, Nielsen, Nordentoft, Oberlerchner, O’Connor, Pearson, Phillips, Platt, Plener, Psota, Qin, Radeloff, Rados, Reif, Reif-Leonhard, Rozanov, Schlang, Schneider, Semenova, Sinyor, Townsend, Ueda, Vijayakumar, Webb, Weerasinghe, Zalsman, Gunnell and Spittal2021). To date, there is little research examining the effects of COVID-19 on mental health in rural communities of low- and middle-income nations, including in rural Haiti. Identifying the mental health and social impacts of COVID-19 on Haitians will be important to accurately inform public health programs and policies designed to address heightened disparities.

In the current study, the authors assessed the impact of the COVID-19 pandemic on mental health, social support and economic hardship and identified areas of need for rural community members in Haiti after the onset of the COVID-19 pandemic. Through a partnership with a CBO, a mental health assessment was implemented for the first time in this community, to the authors’ knowledge. The authors also share strategies to address behavioral health and related social needs based on the study’s supported findings.

Methods

The present study used a cross-sectional survey design developed through a collaborative partnership between capracare Inc., a CBO in Haiti and St. John’s University (SJU) Public Health Program in Queens, New York, in the United States (US). This partnership builds on a 5-year history of research partnership, which has included prior research studies and capracare serving as a fieldwork host site for SJU public health graduate students to develop and implement programs.

The organization capracare, founded in 2009, located in the rural community of Fonfrede, Haiti, provides basic medical and preventive health care for women and children, health education, social services, professional development training and low-threshold mental health counseling. All services delivered by capracare are free or offered at a low cost for community residents. Fonfrede, Haiti, a community located 120 miles outside the capital, Port-au-Prince, has an estimated population of 20,000 residents. In 2009, more than 40% of the Haitian population reported not accessing the health system due to their inability to afford the associated costs (Maselko, Reference Maselko2017). As a result of lack of access to health care, community members have learned to rely on alternative medicine and religious healers to address illnesses and manage diseases (Materu et al., Reference Materu, Kuringe, Nyato, Galishi, Mwanamsangu, Katebalila, Shao, Changalucha, Nnko and Wambura2020).

SJU, founded in 1870, emphasizes strong ties to local communities in Queens and surrounding regions and facilitates national and international initiatives. The SJU faculty member who served as the Principal Investigator for the project was not previously affiliated with capracare’s health care or mental health programs.

All project materials were approved by St. John’s University Review Board (FWA # 00009066).

All data used in this study was collected between March and May 2020.

Recruitment and data collection procedures

Respondents were recruited by capracare staff and Community Health Workers (CHWs) who canvased Fonfrede and Les Cayes in Haiti to identify potential study participants. The door-to-door canvassers knocked on household doors and explained the purpose of the study, identified potentially eligible participants and ensured a representative sample. The eligible study population comprised of persons who identified as (1) adults aged 18 years or older; (2) residents of Haiti at the time of data collection; and (3) those who understood and spoke Haitian Creole. Staff of capracare and CHWs explained the project to potential study participants. Eligible individuals interested in this study were provided with a set of assessment questions before survey deployment. All respondents provided verbal consent prior to being formally enrolled in the assessment.

Face-to-face interviewer-led interviews with enrolled community members were conducted. Participant responses were recorded by interviewers, with periodic checks of interviews conducted to check for completion, accuracy and integrity of survey completion and for interviewer bias. The data were collected and centrally organized and stored to ensure confidentiality and protection prior to analysis.

Survey instruments

The survey instruments used in this study were developed in English by project staff and translated to Haitian Creole by capracare’s team. To establish equivalence, clarity and cultural appropriateness of the survey, the English version was translated to Haitian Creole and then back-translated into English by professional translators proficient in both languages. The survey was pilot tested with a sample of individuals representative of the priority population. The survey comprised both open and closed-ended questions, collecting data on five construct areas: (1) Respondent sociodemographic factors; (2) COVID-19 knowledge and ability to care for persons diagnosed with the virus; (3) Domestic composition and structural factors; (4) Existing social network as a support system and resource; and (5) COVID-19 impact on mental health status.

Sociodemographic factors

The following standard sociodemographic variables (Table 1) were assessed to describe the study sample: age, gender, nativity, region of residence in Haiti, marital status, employment status, educational status and household composition. One additional question asked whether the respondent had received services from capracare (yes/no).

Table 1. Study respondent characteristics (n = 500)

COVID-19 knowledge and isolation strategies

Four questions assessed respondent’s knowledge about the COVID-19 pandemic and isolation strategies. The questions included: (1) Have you heard of COVID-19 before today? (2) If yes, where did you first hear about COVID-19? (3) Can you isolate yourself or a family member sick with COVID-19 in your household? All response options were dichotomous (yes/no).

Domestic conditions and social support network

Multiple variables validated in prior research were included in the survey to measure household living conditions (Dias and de Oliveira, Reference Dias and de Oliveira2018; Table 2). Respondents were asked about their living facilities, facilities for washing hands in their household and type of latrine available in their household. One question with a dichotomous response (yes/no) asked whether respondents had someone who could provide care if they contracted COVID-19. Those who responded ‘yes’ were further asked to specify who could provide the care. The responses to this follow-up open-ended question were categorized based on the relationship to the participant for evaluation purposes (e.g., spouse, parent(s)).

Table 2. Domestic and social network support (n = 500)

Mental health status

To assess mental health status, multiple standardized questionnaires were used, including the Patient Health Questionnaire (PHQ-4) and the Perceived Stress Scale (PSS). Both scales have been broadly used in both clinical and nonclinical settings due to their strong reliability and validity (Kroenke et al., Reference Kroenke, Spitzer, Williams and Löwe2009; Materu et al., Reference Materu, Kuringe, Nyato, Galishi, Mwanamsangu, Katebalila, Shao, Changalucha, Nnko and Wambura2020). In this study, two PHQ-4 subscales were used (anxiety and depression) and summed to create total scores. The PHQ-4 questions used in this study were adapted to be COVID-19 period-specific and were modified with the following language to read: ‘Over the last two weeks (during COVID-19), how often have you been bothered by the following problems?’ (1) Feeling nervous, anxious or on edge due to COVID-19; (2) Not being able to stop or control worrying due to COVID-19; (3) Feeling down, depressed or hopeless due to COVID-19; and (4) Little interest or pleasure in doing things due to COVID-19. Likert responses ranged from not at all to more than half the days. The PHQ-4 total score ranges from 0 to 12, with categories of psychological distress being: none (0–2), mild (3–5), moderate (6–8) and severe (9–12). A total score of ≥3 for the first two questions suggests anxiety. A total score of ≥3 for the last two questions suggests depression (Kroenke et al., Reference Kroenke, Spitzer, Williams and Löwe2009) The PHQ-4 scale is a validated scale with a Cronbach Alpha of α = 0.81 which indicates good internal consistency (Materu et al., Reference Materu, Kuringe, Nyato, Galishi, Mwanamsangu, Katebalila, Shao, Changalucha, Nnko and Wambura2020). No changes to the scoring or scales of the PHQ-4 were made.

The PSS-4 measures the degree to which situations in one’s life over the past month are appraised as stressful. The instrument’s questions were adapted to be COVID-19 period-specific by adding the following language to questions. The PSS-4 questions read ‘In the last month, (1) how often have you felt that you were unable to control the important things in your life due to COVID-19; (2) how often have you felt confident about your ability to handle your personal problems due to COVID-19; (3) how often have you felt that things were going your way due to COVID-19; and (4) how often have you felt difficulties were piling up so high that you could not overcome them due to COVID-19’. Likert responses for each item ranged from never to very often with scores from 0 to 4. Higher scores reflect higher degree and longer duration of perceived stress (Vallejo et al., Reference Vallejo, Vallejo-Slocker, Fernández-Abascal and Mañanes2018). Although the PSS-4 has a Cronbach alpha of <0.7 indicating low internal validity, it is useful and feasible in situations where a short questionnaire is required (Lee, Reference Lee2012). The responses to the PSS-4 questions were summed to generate total PSS scores, which were further categorized into low, moderate and high perceived stress. Neither the PSS-4’s scale nor scoring were changed.

To supplement the PSS-4, four questions were developed to capture the levels of and changes in stress experienced during the pandemic. One question was intended to compare perceived stress during the pandemic to that before the outbreak. Answer choices for this question were categorical, including ‘More stress than usual; same level of stress as usual; or less stress than usual’. Respondents who indicated ‘more stress than before’ were asked for more explanation. Four questions (yes/no response) examined the type of stress, including ‘worry about overall financial state’; ‘the ability to afford food’; ‘worry about becoming sick with COVID-19’; and ‘worry about family member becoming sick with COVID-19’.

Statistical analyses

All variables included in the study were examined using descriptive statistics. Bivariate Chi-square tests were used to measure associations of perceived stress, anxiety and depression with the explanatory variables in the study. The study respondents were first described in terms of socio-demographics using univariate statistics. The sample was then further described in terms of COVID-19 experiences, social support, household conditions and COVID-19 knowledge. Mental health scores were derived for each element of stress and examined using Chi-square tests in association with all explanatory factors. In addition, Generalized Linear Model (GLM) Multivariable analysis was performed to analyze the relationships between multiple independent factors to assess their effect on mental health status (anxiety, depression and perceived stress). All statistical analyses were performed using IBM SPSS at the α < .05 level.

Results

The study sample comprised 500 adults aged 18–85 years with a mean age of 39 (sd = 17). Table 1 describes the respondents’ sociodemographic characteristics, prior treatment at capracare and current knowledge of COVID-19. Nearly all study respondents (99%) were born in Haiti; 61.4% were females. The majority lived in Kay or Les Cayes in Haiti (89.6%), were single (71.6%) and unemployed (78.4%). Approximately 70% of the respondents did not complete high school and 17% completed a 2-year college or vocational/technical training school. Most (86.6%) reported living with someone such as a spouse, parents, grandparents, aunt and/or children. Over half of the study respondents (59.8%) had received services at capracare.

Almost all respondents (97%) reported having prior knowledge of COVID-19. The majority reported learning about the pandemic via radio/television (66.8%) or through social media (17%). Approximately 60% reported that they had the means to isolate themselves if they contracted COVID-19 and had knowledge of how to care for someone sick with COVID-19.

Domestic and social network support

The domestic characteristics and social network support available to the respondents are presented in Table 2. While the majority (81.2%) indicated they lived in their own home, 10.2% were homeless. When asked about the availability of an in-home washing facility, 49.8% reported using a makeshift container or bucket to store water and wash hands, 24.4% reported using unfiltered water from a well and 20.80% reported relying on public taps or a public community well. Only 4.6% reported that having a suitable plumbing system in their home, while the large majority (88%) indicated using an outdoor latrine facility or an outhouse.

Over a quarter of respondents (28.4%) reported having a supporting social system in case of a COVID-19 infection. Most (70.4%) did not have any familial or social support available. The support system comprised of parents (33.6%), spouses (18.7%), and children, siblings and/or friends (47.7%).

Mental health during the COVID-19 pandemic

PHQ-4 questions and the respondents’ scores on mental health status are shown in Table 3. When asked about feelings of helplessness or anxiety due to the pandemic, nearly one-third reported experiencing anxiety for several days and 20% reported feeling it nearly every day. In addition, while 43% of the respondents reported ‘no worry’, 30.4% were worried for a few days and approximately 21.4% were worried almost every day. When asked about feeling depressed or hopeless, nearly one-third (29%) were depressed for several days and 21.2% were depressed nearly every day. Furthermore, about 30% experienced a loss of pleasure for several days and 18% reported losing pleasure nearly every day.

Table 3. Mental health status – PHQ-4 and perceived stress during COVID-19 (n = 500)

Depression and anxiety scores

The majority (64.2%) were not depressed, but over one-third (33.8%) scored ≥3 on the PHQ-4 Depression Subscale, suggesting some level of depression (Kroenke et al., Reference Kroenke, Spitzer, Williams and Löwe2009; Materu et al., Reference Materu, Kuringe, Nyato, Galishi, Mwanamsangu, Katebalila, Shao, Changalucha, Nnko and Wambura2020). Similarly, most respondents (68.4%) scored ≤3 on the anxiety subscale, while nearly one-third (30.6%) scored ≥3 on the PHQ-4 anxiety, suggesting some level of anxiety.

Perceived stress

The PSS-4 questions distribution, and analysis scores are reported in Table 3, along with the four complementary stress questions to gauge stress difference prior to and during the pandemic.

When asked how often they felt unable to control the important things in their life, most (61%) reported never or almost never, while only 28% reported fairly often. Survey respondents were also asked how often they felt confident in handling their personal problems due to COVID-19. Approximately 63% reported that they were always or almost always confident, and only 27% reported feeling confident rarely. When asked how often they felt that things were going their way, 42.4% responded ‘sometimes’, 17.6% reported ‘very often’, and 31.6% responded ‘never’. Similarly, when asked how often they felt that difficulties were piling up beyond their ability, 44.2% reported ‘very often’, while 39.8% reported ‘sometimes’.

PSS-4 scores for the sample ranged from 1 to 13. Approximately a quarter (28%) of the respondents experienced some level of stress. The majority (78.6%) had scores between 5 and 9, indicating moderate perceived stress; 13.4% had scores ranging 10–13, indicating high perceived stress. The remaining 8% scored between 1 and 4, indicating low perceived stress.

Comparing prepandemic stress levels to during the pandemic, 34.8% reported less stress, 31% reported the same stress level and 30.8% reported more stress. When asked to elaborate upon their primary source of stress, 22% attributed it to COVID-19, (thought or news of being sick and going to the hospital, lack of healthcare, inability to do personal activities). Another 3.59% indicated suffering from stress unrelated to the pandemic (political unrest) with 1.29% indicating stress due to the lack of security and political climate. Questions related to finance and ability to purchase food showed that the majority (80.4%) were worried about their finances and their ability to purchase food (78%).

Mental health associations

Bivariate associations between characteristics and mental health status were found to be significant (Table 4). A higher proportion of respondents who reported being worried about a family member contracting COVID-19 had anxiety scores of 3 or higher (34.7% vs. 21.3%, χ 2 = 9.19, p = .01). Respondents who had a family member who could provide care had lower depression rates (20.7% vs. 37.9%) and lower anxiety rates than those without (22% vs. 34.2%, χ 2=8.04, p = .02). PSS scores were also associated with education levels (χ 2 = 102.63, p = .01). Furthermore, female respondents reported significantly higher anxiety levels than males (68% vs. 26.1%, reporting a score of 3 or higher) (χ 2 = 6.25, p = .04).

Table 4. Bivariate associations between characteristics and mental health status (n = 500)

Multivariable analysis

Across all the tested covariates we find place of stay (Where do you live or stay most of the time?) and facility for washing hands (What kind of facilities do you have for washing hands in your household?) to be significantly associated with anxiety, depression and stress, each with Wilks’ Lambda ≤0.05.

The facility for washing hands is associated with mild levels of stress (score ~ 5), anxiety (score 3.96 for Makeshift container) and depression (score 3.10 for Makeshift container) and with highest scores for ‘Makeshift container for washing hands’. Similarly, places of stay, specifically those living outside or at work reported high levels of depression (score ≥ 3.0), anxiety (score ≥ 3.0) and mild stress (scores ~5).

Discussion

The present study is one of the first to examine COVID-19 knowledge and the impacts of the pandemic on mental health among community members in rural areas of Haiti. Approximately half of the respondents had received services from capracare Inc., a CBO providing health and social service care to residents of the region. The prevalence of mental health outcomes identified among community members indicates the need for expanded services through community-based organizations to adequately reach remote residents and promote resiliency after the onset of the COVID-19 pandemic.

The study adds new data on mental health and social support prevalence in rural Haiti. Approximately one-fifth of the respondents reported not being able to isolate in their own home, increasing the risk of spreading COVID-19 and other communicable diseases. There is a need for education about preventive measures for COVID-19 and treatment plans in case of infection, tailored to residents of low- and middle-income nations who may not have access to isolation practices found in modernized communities.

Our study found high levels of COVID-19 awareness, indicating that news and health education effectively reach rural populations. This has positive implications for health education and awareness campaigns for COVID-19 and mental health efforts. The study found significant associations between having social support and reductions in both depression and anxiety, with lower rates of both conditions in persons with an identified source of support. Overall, the study respondents indicated moderate to high prevalence of mental health conditions, with a majority indicating moderate stress (78%) and depression (42%). These outcomes are likely further exacerbated by low access to mental health services in rural regions (Tiberi, Reference Tiberi2016; Quran, Reference Quran2019; Castle, Reference Castle2020). However, after controlling for factors in multivariable models, the significant indicators of living outside of the home or at work and using makeshift containers to wash hands point to social deprivation factors being the most significant drivers of mental health status, even during a global pandemic. To date, most of the research on the relationship between social determinants and mental health has focused on higher income countries (Maselko, Reference Maselko2017), leaving out the unique contexts of residents and communities like those in this study who face systemic poverty and barriers to accessing adequate resources, including both basic health care needs as well as mental health services.

The pandemic response in rural regions of low- and middle-income nations must consider unique challenges facing the communities, with CBOs being trusted and integral resources to this endeavor. While studies in developed nations have highlighted the efficacy of telehealth services in reducing rural–urban gaps in mental health access and quality of services (American Farm Bureau Federation, 2020; Patel et al., Reference Patel, Huskamp, Busch and Mehrotra2020). Low- and middle-income nations such as Haiti may need to implement infrastructural changes first, to allow access to sanitary conditions and basic needs before considering telehealth care or other digital interventions. The outstanding need for broader poverty reduction strategies, including sanitation, clean water access and quality housing in these communities cannot be discounted when considering public health interventions.

This mental health assessment study was the first of its kind to be delivered in the Fontfrede region of Haiti and had meaningful implications for mental health care delivery in the community. In response to the survey findings, capracare staff developed and implemented a new mental health program for youths. The study helped identify that the youth were significantly impacted by the COVID-19 pandemic and lost many resources and support systems previously found in schools. Community partnerships like the one used in this study will be essential for COVID-19 response, resiliency and preparedness for future public health emergencies in Haiti. We recommend that public health professionals and policymakers identify and prioritize community partnerships with existing, trusted organizations. Just as respondents indicated high levels of awareness of the COVID-19 pandemic, additional health education around prevention and control measures should be communicated through these channels. In rural areas where there are fewer CBOs, the existing and trusted organizations must be partnered with to identify additional effective communication channels and approaches to engage community residents. In some cases, these trusted organizations may be appropriate settings for future health interventions.

Additionally, new research must be funded and developed in low- and middle-income nations in the future, not just during emergencies, and should be embedded in trusted community organizations. Traditional academic research methods may not be appropriate nor effective in reaching the priority population in these communities (Reese and Vera, Reference Reese and Vera2007). Using community members as lay researchers will provide opportunities to residents in this area in terms of economic opportunity and can promote social engagement in areas where isolation may be a challenge. This may be a beneficial way to promote community-level social support as community engagement has been found to strengthen social networks (Shalowitz et al., Reference Shalowitz, Isacco, Barquin, Clark-Kauffman, Delger, Nelson, Quinn and Wagenaar2009). Based on the demonstrated effectiveness of health education and health promotion when delivered by peers and members of one’s own community, this approach should be prioritized and funded in rural communities.

Conclusion

This study is the first to provide insights into mental health outcomes after the onset of the COVID-19 pandemic for community members in Les Cayes, a rural region in Haiti. Community members reported lower rates of depression and anxiety when simultaneously having social support. This study may inform public health programs and policies designed to address mental health care and community-embedded health education in rural Haiti and may be further extended to other rural low- and middle-income nations.

Open peer review

To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2024.10.

Acknowledgments

The authors would like to thank the Capracare, Inc. staff and clients for their contributions to this work. The program described was supported by New York University Behavioral Sleep Medicine (BSM) PRIDE Grant # R25HL105444.

Author contribution

Y.G. was responsible for conceiving the study and design, acquisition and interpretation of data, drafting of manuscript, critical revision and final approval of the manuscript. T.P. contributed to the data analysis, interpretation of data and final approval of the manuscript. J.P.-L., T.J., P.B., T.T.I., M.A.P., C.C. and J.R. contributed to critical revision, interpretation of data and final approval of the manuscript. All authors are accountable for all aspects of the work.

Financial support

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Competing interest

The authors report there are no competing interests to declare.

Ethics statement

The study was approved by the St. John’s University Institutional Review Board (FWA # 00009066).

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Figure 0

Table 1. Study respondent characteristics (n = 500)

Figure 1

Table 2. Domestic and social network support (n = 500)

Figure 2

Table 3. Mental health status – PHQ-4 and perceived stress during COVID-19 (n = 500)

Figure 3

Table 4. Bivariate associations between characteristics and mental health status (n = 500)

Author comment: COVID-19 knowledge and mental health impact assessment in Haiti — R0/PR1

Comments

March 24th, 2023

Cambridge Prisms: Global Mental Health

Subject: Submission of research article:

COVID-19 Knowledge and Mental Health Impact Assessment in Haiti

Dear Prof. Belkin and Editorial Board:

Please find enclosed the research article, “COVID-19 Knowledge and Mental Health Impact Assessment in Haiti,” for consideration with Cambridge Prisms: Global Mental Health. Our manuscript is first to examine COVID-19 knowledge and mental health outcomes in rural communities in Haiti following the COVID-19 pandemic. These communities have long been under-studied, despite being at high risk for many of the world’s epidemics due to the intersection of high-poverty and rapid infectious disease spread. To our knowledge, our study is the first, and to-date only, to examine the mental health and social support impacts of COVID-19 in rural communities in Haiti.

Herein, we describe and report on a study of over 500 participants at a community-based organization in a rural community in Haiti; communicable disease and mental health issues are unique in these communities due to confluences of sanitation, environmental, and political unrest factors faced by residents. We used validated instruments, including the Patient Health Questionnaire (PHQ-9) and Perceived Stress Scale (PSS-4), and included tailored supplemental questions specific to COVID-19 knowledge. Findings revealed notable mental health and social support concerns reported by participants, in this first of its kind study, underpinning the need for investment in community mental health and social programs in rural communities in developing nations. As a direct result of this study, the participating community-based organization implemented a youth mental health counseling program, in response to the identified loss of social connection due to school closures.

Our manuscript aligns with the mission and scope of Cambridge Prisms: Global Mental Health by reporting on the application of mental health assessment in community and real-world settings in a low-income country. These findings will be immediately relevant to the journal’s international readership.

We confirm that this manuscript and results have not been published elsewhere nor are they under consideration with another journal. All authors have approved the manuscript’s content and its submission to Cambridge Prisms: Global Mental Health.

Thank you for your time and consideration of our manuscript. Please do not hesitate to contact me with any questions regarding the research article.

Sincerely,

Yolene Gousse, DrPH, MPH

Associate Professor

St. John’s University | College of Pharmacy & Health Sciences

175-05 Horace Harding Expressway

Fresh Meadows | NY 11365

Email: [email protected]

Review: COVID-19 knowledge and mental health impact assessment in Haiti — R0/PR2

Conflict of interest statement

No competing interests

Comments

The psychological impact of the COVID 19 pandemic in resource-constrained low- and middle-income countries has received less research attention than in high income countries. This paper reports an original investigation in Haiti a severely under-resourced country to establish prevalence of symptoms of depression, anxiety, and other common mental health problems. The authors argue appropriately that their evidence is of relevance to policy makers and program providers in this setting. This study does make an original contribution to knowledge, but in my opinion, there are some significant flaws i in this account of what was done and what was learnt that require revision.

• Careful consideration needs to be given to language use. In particular, it is no longer accepted practice to refer to ‘developing’ countries or nations. This term fails to recognise the deep and sophisticated history that many low- and middle-income countries have. Using the World Bank or other country classification is preferred.

• Line 5 – it was not following the pandemic. In March to May 2020 the pandemic was active and in its early stages and the protections of vaccines were not yet available. The whole paper needs to be read carefully to ensure that it is not conveying the notion that this was a recent assessment. It needs to be acknowledged that what was observed might have been adjustment phenomena that were widespread at the beginning of the pandemic.

• Line 11 – as the assessment did not use a diagnostic measure, the authors cannot say that participants were experiencing depression. I suggest this is replaced with – were experiencing ? some or moderate or clinically significant depressive symptoms.

• Lines 49 – 53. The prevalence data are presented completely uncritically. There is no engagement with how they were generated and the potential impact of methodological differences. In one place they say that prevalence of depression in Haiti has doubled to 5.82% and a line later they say that 50% were depressed. There needs to be much more comprehensive engagement with these disparities and what they mean. Detailed discussion is needed of how the data were generated and whether any of the of the psychometric properties of the instruments had been formally validated against a gold standard. If not this should be added as a significant study limitation.

• Line 62 refers to disparities in health in Haiti, but the reader is not told what these are, including in mental health and what they are attributed to. This needs to be added.

• Line 62 Raw numbers are not helpful to people who do not know Haiti – population fractions are more comprehensible. Please convert these to percentages or fractions.

• Line 69 reports, without describing the evidence that the least advantaged people had the highest rates of death by suicide during the COVID pandemic. The authors must provide the evidence to support this assertion and where and how the data were derived.

• Line 78 – 80 – the authors need to explain what the comparator is otherwise they cannot claim that it is linked to COVID-19.

• Line 98 – makes causal assertions about infections being attributable to lack of access to care. This is probably not a causal relationship – the infections occur, but it is lack of access to treatment that contributes to the burden ? of untreated infections and communicable diseases. More detailed engagement with causal pathways, including of the impact of poor quality and crowded housing, is needed.

• Line 111 – The Methods need to be described with sufficient precision and detail to enable replication. This would not be possible from the account provided here. Please describe in detail what ‘canvas[ing]’ in Fonfrede and Les Cayes to identify potential participants actually involved and how participants were identified and invited to join the study.

• Line 121 – it is not clear what ‘Instrumentation’ means. Please describe how the survey instrument was developed, whether the questions were standardised or study-specific. How was comprehensibility established and culturally verified?

• Line 155 Please provide a reference for the ‘PHQ-4 subscales’ and for any evidence of local validation. It appears that the PHQ was altered to make it COVID specific. Please describe this process.

• Line 167 Please spell out the name of the PSS in full and provide a reference for it. Please describe how it was adapted to be COVID specific

• There is no ‘Procedure’ section and therefore no description of how the data were collected and, if not self-reported, by whom. This needs to be added.

• The analysis is at a basic level, please seek the advice of a biostatistician and undertake a multivariable analysis

• Line 255 ‘never unconfident’ the double negative makes it difficult to know what is being said. Please rephrase so that there is one dimension.

• Cannot attribute the direction of an association in a cross-sectional survey. The authors need to offer both directions of this associations – that the psychological distress was a consequence of COVID or the alternative that more psychologically distressed people experienced the pandemic in a different way to those who were not distressed.

• Although they cite Lund’s evidence about the social determinants of mental health problems, they do not question the use of the term ‘mental illness’ to describe psychological distress arising in the context of severe adverse circumstances or acknowledge that it could be construed as a normal response to adversity

Recommendation: COVID-19 knowledge and mental health impact assessment in Haiti — R0/PR3

Comments

No accompanying comment.

Decision: COVID-19 knowledge and mental health impact assessment in Haiti — R0/PR4

Comments

No accompanying comment.

Author comment: COVID-19 knowledge and mental health impact assessment in Haiti — R1/PR5

Comments

RE: Manuscript Review - GMH-23-0071 “COVID-19 Knowledge and Mental Health Impact Assessment in Haiti”

Dear Review Committee Members,

I hope this email finds you well. I am writing to express my sincere gratitude for the time and effort the journal review committee has dedicated to reviewing our manuscript titled “COVID-19 Knowledge and Mental Health Impact Assessment in Haiti,” which we submitted to Cambridge Prisms: Global Mental Health.

We truly appreciate the insightful comments and constructive feedback provided by the esteemed reviewers. Your thoughtful observations have proven invaluable in improving the quality and clarity of our research. As requested, we have thoroughly reviewed all the comments and have addressed each one meticulously in the revised manuscript.

We believe that the revised version of our manuscript now reflects a stronger and more impactful contribution to the knowledge base surrounding the intersection of COVID-19 and mental health in Haiti.

Also, we are submitting the response to reviewers' comments, and two (in tracked changes and clean) versions of the revised manuscript incorporating all the changes and updates based on your valuable feedback.

Thank you for your continued support, and we look forward to hearing from you soon.

Best regards,

Yolene Gousse, DrPH, MPH

Review: COVID-19 knowledge and mental health impact assessment in Haiti — R1/PR6

Conflict of interest statement

Reviewer declares none.

Comments

The revision of this paper has addressed some of the concerns raised in the first round of reviews, but some have not been addressed and other problems have been introduced.

The authors write with sensitivity about the impact of poverty on mental health and describe the extremely difficult circumstances of peoples’ lives in Haiti well. The impacts of the pandemic on household livelihoods and incomes are evoked vividly.

I have several concerns, most about the methods of the study and the unqualified confidence with which the findings are presented. There are aspects of the methods that could not be replicated from the account provided here:

• Haiti is a lower-middle income country by the World Bank classification. This needs to be corrected from ‘low to middle’ throughout and the appropriate reference to the World Bank Group country classification added.

• The Introduction needs to end in a clearly stated aim or aims and not with a statement of what was done, this needs to be corrected.

• Line 149 It is not clear what ‘domestic composition and structural factors’ mean? – please provide a definition

• Please describe the inclusion criteria and recruitment strategies specifically in the Methods and, on the basis of these, consider potential selection biases and their implications in the Discussion.

• What does ‘recorded completely’ mean – were the interviews audio recorded, or documented in field notes? Please describe this process precisely?

• The authors say that no changes were made to the PHQ-4 , but the phrasing of the questions were altered to link them to COVID – this is a non-standardised change and it cannot be assumed that the psychometric properties are the same or directly comparable to its standard use, this limitation and its potential impact on the findings needs to be acknowledged and considered in detail in the Discussion.

• No effort is made to compare the characteristics of the study sample to the general population of Haiti. Accepting that this might be difficult, it is crucial for consideration of generalisability. Please add a table making these comparisons or explain that it is not possible.

• Line 289 never or almost …? a word missing here

• Concludes legitimately that there is a need for more services, but does not elaborate on what these might be ? provision of food, housing, access to sanitation and income-generating work and not only to mental health care. Please provide a more elaborated account here

• Makes claims without supporting evidence that the interventions provided by the CBO are effective. Please provide the evidence to support these claims.

Recommendation: COVID-19 knowledge and mental health impact assessment in Haiti — R1/PR7

Comments

No accompanying comment.

Decision: COVID-19 knowledge and mental health impact assessment in Haiti — R1/PR8

Comments

No accompanying comment.

Author comment: COVID-19 knowledge and mental health impact assessment in Haiti — R2/PR9

Comments

Dear Dr. Belkin and Editorial Board:

I am writing to express my sincere gratitude for your favorable decision to publish our article and the time and effort the journal review committee has dedicated to reviewing our manuscript titled “COVID-19 Knowledge and Mental Health Impact Assessment in Haiti”.

As requested, please find attached two copies of the manuscript. The first version is in tract changes and addresses the reviewers’ revisions; and the second version is a final clean copy to advance the paper for printing and publication.

Thank you for your continued support.

Best regards,

Yolene Gousse, DrPH, MPH

Review: COVID-19 knowledge and mental health impact assessment in Haiti — R2/PR10

Conflict of interest statement

I have no competing interests

Comments

Thank you for responding to the suggestions in the reviews. This account of the study is considerably improved.

Minor amendments are still required:

The study is referred to as a ‘pilot’ only at the end of the Discussion. It appears to be substantial - 500 participants and is not referred to as a pilot elsewhere in the paper. Please either remove this descriptor or explain early in the paper that it is a pilot with an elaborated description of what it is a pilot for. Early in the paper (Line 159) we are told that the survey was pilot tested before implementation so the study as a whole does not appear to be accurately described as a pilot.

This research identified social factors as the main risks for the mental health problems that were documented. However, the only implication that is drawn out of the findings is for increases in mental health care and counselling. It is imperative that the need for strategies for poverty reduction, improvement of housing quality, access to clean water and promotion of social connections are considered and discussed because individual counselling is very unlikely to have an impact on these.

Recommendation: COVID-19 knowledge and mental health impact assessment in Haiti — R2/PR11

Comments

No accompanying comment.

Decision: COVID-19 knowledge and mental health impact assessment in Haiti — R2/PR12

Comments

No accompanying comment.

Author comment: COVID-19 knowledge and mental health impact assessment in Haiti — R3/PR13

Comments

Dear Editorial Team:

We appreciate the close review to our manuscript ‘COVID-19 Knowledge and Mental Health Impact Assessment in Haiti.’ Please find enclosed a revised manuscript and below responses to reviewer comments. We believe the revisions should adequately address the outstanding comments.

Please do not hesitate to be in touch with any additional questions regarding the manuscript.

Sincerely,

Yolene Gousse, DrPH, MPH

Recommendation: COVID-19 knowledge and mental health impact assessment in Haiti — R3/PR14

Comments

No accompanying comment.

Decision: COVID-19 knowledge and mental health impact assessment in Haiti — R3/PR15

Comments

No accompanying comment.