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.