Results
Study selection: Our preliminary search through selected databases yielded a total of 116 articles. After removing duplicates, 83 remaining papers were reviewed based on their titles and abstracts, regarding our eligibility criteria. We excluded 63 articles and therefore retrieved and appraised the 20 lasting articles based on their full-texts and also considering our selection criteria. Finally, 12 articles [24–35] were systematically reviewed and qualitatively summarized. The PRISMA flow chart showing our study selection process is shown in figure 1.
Study characteristics: The sample size of the 12 included studies ranged from 103 to 2430 participants, with a total of 7,293 participants (2,741 males and 4,552 females, thus giving a female/male ratio of 1.66). The enrolled studies were conducted between March 17, and November 30, 2020. The 12 studies were realized in seven countries, namely Ethiopia (n = 4), Egypt (n = 2), Morocco (n = 2), Liberia (n = 1), Libya (n = 1), Sudan (n = 1) and Tunisia (n = 1). Amid selected studies, 11 were reported as cross-sectional studies, and one as a transversal descriptive study [33]. Data were collected exclusively electronically (online surveys) in 9/12 studies, only with a paper version form in one study[32], both with online and paper forms in one study[29], and through phone calls in one study [26]. Most of studies (7/12) used a non-probabilistic sampling method, 4 studies reported a probabilistic sampling technique, and one article reported no details on the sampling method used. A minimal sample size was calculated in five studies [25,26,30,32,35]. Regarding studies’ participants, the reported mean/median ages varied from 20 to 29 years, and four studies focused on medical/pharmacy students. Studies and participants’ characteristics are summarized in table 3.
Risk of bias in studies: Based on the 10-items questionnaire established by Hoy et al. [23], the overall quality of included studies is moderate. More precisely, we classified four studies as “low risk of bias”, seven studies as “moderate risk of bias” and one study as “high risk of bias”. The table 4 displays details of risk of bias assessment.
Results of individual studies and syntheses: Regarding the main outcome of our systematic review, psychological concerns varied across selected studies and especially included depression (depressive symptoms), anxiety and stress. More specifically, the most screened conditions were depression and anxiety (respectively in 9/12 studies), and were followed by stress (8/12 studies). One research work assessed suicidal ideations, and another one studied non-specific psychological distress.
A diversity of scales/tools were used for the appraisal of these mental health outcomes. For depression, anxiety and stress, the most used screening tool was the Depression, Anxiety and Stress Scale 21-items (DASS-21). This tool was used in 6/12 studies of our review [26,28,31,32,34,35]. All these studies used the followings as respective positive screening cut-off scores for depression, anxiety and stress: ≥ 10, ≥ 08 and ≥ 15. These thresholds respectively corresponding to mild cases of depression, anxiety and stress. Regarding depression, two studies [29,30] used the Patient Health Questionnaire 9-items (PHQ-9) with a positive screening cut-off score of ≥ 05 (mild cases) for one study and ≥ 15 (moderately severe to severe depression) for the other, and one used the PHQ-8 (positive depression screening if ≥ 10) [27]. Concerning anxiety, two studies [29,30] used the Generalized Anxiety Disorder 7-item (GAD-7) scale with one study’s threshold at 15 (severe anxiety) and the other’s one at 05 (mild anxiety), and one used the Beck Anxiety Inventory (BAI) [24]. For the BAI, a score of 0-21 was classified as low anxiety, 22-35 as moderate anxiety, and 36 or above as potentially concerning level of anxiety. To evaluate stress, two studies [25,33] used the Perceived Stress Scale (PSS)-10 (Scores ≥ 25 = high or pathological perceived stress), and the study that assessed non-specific psychological distress used the Kessler distress scale (K-6) [30].
Overall, eight studies reported a frequency for all depression degrees (at least mild). This one varied from 21.3% [26] to 78% [29]. Severe depression prevalence (from six studies) ranged from 9.7% [29,31] to 31.5% [34]. Eight studies reported a prevalence of all anxiety levels (at least mild) ranging from 27.1% [26] to 64.5% [29], with a frequency of severe anxiety (7/12 studies concerned) going from 9.4% [24] to 29.9% [34]. From six of our 12 included studies, the prevalence of mild to severe stress varied between 22.2% [32] and 47.8% [31], with severe cases (4/12 studies synthetized) frequencies varying between 12.8% [35] and 17.5% [34]. The two studies that used the Perceived Stress Scale (PSS)-10 respectively reported frequencies of pathological perceived stress at 35.9% [25] and 49% [33]. Others negative mental health outcomes assessed by some of the selected studies included suicidal ideations [29] and non-specific psychological distress [30], respectively found at 22.7% and 69%. The summarized findings encompassing frequencies of mental health issues as well as risk/associated factors assessed and reported by included studies, are available in table 3. The most reported factors associated with depression/ anxiety/ stress were poor social support, low economic status and female gender.