Psychological distress among Ethiopian migrant returnees who were in quarantine in the context of COVID-19: institution-based cross-sectional study

Ethiopia is one of the major sources of migrant flows, particularly to the Middle East and South Africa [1]. The number of international Ethiopian migrants is estimated to be one and half million, and each year close to 120, 000 Ethiopians migrate [2]. Migrants from Ethiopia mostly involve in domestic work and other non-professional works [3]; most migrants are young men and women (roughly from early twenties to early thirties) [4]. Ethiopian migrants to the Middle East are mostly women and to South Africa are mostly men [5]. Several studies identified the push and pull factors for migration in Ethiopia, in particular and in Africa in general [2, 3, 6, 7]. Unemployment/underemployment, conflict, poverty, income inequality, household indebtedness, population pressure, lack of good governance, low agricultural productivity and agro-climatic disasters, low wages and insecure informal economic activities are important push factors for people to leave their homes [6, 7]. Attractive working conditions and demand for cheap labor in destinations, the growth of the service industry, aging population in developed countries, booming oil economy in the Middle East and globalization and modernization that have improved communication, transportation and social connection are the important pull factors for migration [8, 9].

Migration, particularly unsafe migration, is found to have impact on migrants physical, psychological, social and economic wellbeing [2, 10]. These include drowning, trafficking, sexual exploitation, labor exploitation, organ harvesting, degrading treatment, discrimination, physical attack and denial of medication [11, 12]. Several qualitative studies among female Ethiopian migrants to the Middle East [8, 13] found experiences of exploitation, enforced cultural isolation, undermining of cultural identity and thwarted expectations. A survey of migrant returnees from the Middle East and South Africa found a high burden of mental health problems resulting from adverse migration experiences, with 27.6% respondents reporting symptoms of common mental disorders [14]. Overall, migrants face a variety of pre-migratory, migratory, and post- migratory stressors that can have lasting impacts on their physical, social and psychological wellbeing [15]. Studies conducted on Ethiopian migrants [13, 16‐18] found diverse problems at the various stages of migration. These include physical and emotional abuse while travelling; poor adaptation to the host culture; physical, emotional and sexual abuse at destination; overwork and salary denial; loss of identity and degrading attitudes of employers; very poor legal support; and lack of psychosocial support. These challenges and problems are strongly associated with different kinds of psychosocial problems, including depression, post-traumatic stress disorder and somatization [19].

In relation to the novel coronavirus (SARS-CoV-2) disease 2019 (COVID-19) pandemic, significant numbers of Ethiopian migrant workers from the Middle East and other countries abroad are returning back to their home country. Some of the migrants are returning voluntarily with their own decision, while many others are coming back through mass deportation particularly from Middle East countries of Lebanon, United Arab Emirates, and Saudi Arabia. The deportation is unexpected for the returnees as well as for the Ethiopian government. This mass, sudden and unexpected return as well as the journey during the COVID-19 pandemic may create additional and heightened level of stress, which is likely to be associated with several psychosocial challenges. Migrant returnees are not prepared psychologically and socially for the rapid movement and transitions. They are faced with uncertainty, chaos, personal danger, and complete disruption of normal life sustaining processes [20]. Although global movements are restricted and social distancing is taken as a major protective factor to COVID-19, considerable numbers of Ethiopian migrants from the various countries of the Middle East have been deported to their country. The concerns of migrant returnees to get infected and infecting significant others together with their possible unpreparedness and likely gloomy future may put them at risk of manifesting various psychological and social problems. On top of these challenges, migrant returnees are required to stay in mandatory quarantine centers for a week or two.

Quarantine is often an unpleasant experience for those who undergo it [21]. There might be severe disruptions of routines, separation from family and friends, loss of freedom, uncertainty over disease status, fear of infection, boredom, shortages of food and medicine, wage loss, and social isolation [21, 22]. Studies found a high prevalence of psychological distress in those who have been quarantined, with some experiencing anxiety for their safety or anger about being involuntarily confined [21, 22]. In addition, thinking to start a new life in the home country after quarantine may be gloomy and difficult. Hence, migrant returnees who experienced quarantine are likely to be worried about reintegrating with the community and their family.

A number of qualitative studies [2, 13, 23] were conducted on the social and psychological problems of Ethiopian migrant returnees, particularly from Middle East countries. A few quantitative surveys [14] also investigated the prevalence and associated factors of psychological distress and disorders among this population group. There are a few studies which investigated the impact of COVID-19 on the general population and particularly to healthcare providers [24, 25]. For instance, a web-based cross-sectional survey in Italy found that COVID-19 pandemic has physical and psychological pressure on general practitioners [26]. Nevertheless, to the best of our knowledge, there are no published studies on the prevalence and associated factors of psychological distress among migrant returnees who were in quarantine in the context of COVID-19. This study, therefore, aimed at investigating the prevalence of psychological distress and its association with sociodemographic, and migration, quarantine and COVID-19 related characteristics among migrant returnees who were in quarantine in Addis Ababa, Ethiopia.

A cross-sectional survey study was conducted. The study attempted to determine the prevalence and associated factors of psychological distress (depression, anxiety and stress) among an institution-based sample of migrant returnees who were in quarantine during the time of COVID-19. The study was conducted from 1st May to 15 June 2020.

In this institution-based cross sectional study among migrant returnees who were in quarantine during the time of COVID-19, we found a very high level of psychological distress. More than half of the participants had depressive symptoms; 22.0% had severe or extremely severe symptoms of depression. Nearly half of the participants had anxiety symptoms, with 26.1% sever or extremely severe anxiety symptoms. More than a third of the participants had stress symptoms, with 13.4% sever or extremely severe stress symptoms.

These findings are consistent with previous studies which showed that the prevalence of psychological distress is higher in the migrant population compared to the native population in countries of destination as well as the population in the countries of origin [19, 42‐46]. Qualitative studies conducted among Ethiopian migrant returnees from different Middle East countries showed that migrants experience symptoms of psychological distress as they are exposed to different forms of abuse [2, 13, 23]. A cross-sectional survey conducted among a large sample of Ethiopian migrant returnees found a higher prevalence of symptoms of depression, anxiety and somatization [14]. The prevalence of common mental health problems reported in the current study is found to be higher than reports from prevalence studies conducted in the general population in Ethiopia [47‐49]. This might be because participants of this study passed through multiple life challenges such as unexpected deportation, novel mandatory quarantine experience, and facing all COVID-19 related challenges in a relatively brief period of time. However, to the best of our knowledge, there are no published studies on the prevalence of psychological distress in the general population as well as among migrant returnees in Ethiopia during the time of COVID-19 to compare our findings with.

Studies in other countries show that the population level prevalence of psychological distress has significantly increased during the time of the COVID-19 pandemic [25, 50‐52]. For instance, a nationwide survey among Chinese people during the time of COVID-19 [25] found that almost 35% of the respondents experienced psychological distress. In a study conducted among the general population in China during the initial stage of the COVID-19 pandemic, 16.5% of respondents reported moderate to severe depressive symptoms; 28.8% of respondents reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels [53]. A systematic review and meta-analysis of studies conducted in the general population on the prevalence of stress, anxiety and depression during the COVID-19 pandemic found 29.6, 31.9 and 33.7%, respectively [52]. However, the studies included in the review were from Asia (China, Iran, Iraq, Japan and Nepal), Europe (Spain and Italy) and the UK. There are a few studies which found significant impact of COVID-19 on the mental health of healthcare providers. For instance, a cross-sectional survey in Italy [26] found that general practitioners, who are COVID-19 frontline workers, reported moderate to severe depressive symptoms and very severe anxiety and insomnia. The study further highlighted the urgent need to provide continuity of care for patients at the community level, adequate personal protective equipment to general practitioners and a clear guidance from public health institutions. Experiencing quarantine, fear of infection and uncertainties about the future all contribute to the increased level of psychological distress during the time of COVID-19 pandemic [21]. Hence, COVID-19 pandemic and experiencing mandatory quarantine can be considered as double risk to the mental health of migrant returnees.

In this study gender is found to be an important factor significantly associated with depressive and anxiety symptoms. We found significantly higher prevalence of anxiety and depressive symptoms among women than men. Several previous studies also consistently found that depressive and anxiety symptoms are higher among women than men [54, 55]. This may be associated with biological, socio-cultural and economic factors [55, 56]. Empirical studies indicated that international migration in Ethiopia, particularly to the Middle East, is gendered [3, 8]. Ethiopian migrants to the different Middle East countries are mostly women who have lower level of education [1]; most of them are from rural areas [7] and are disadvantaged in terms of family, economic and socio-cultural factors [23].

We found that fear of being infected with COVID-19, fear of discrimination after the quarantine, and experiencing COVID-19 like symptoms, such as headache, sore throat, and breathing difficulty are significantly associated with increasing depressive, anxiety and stress symptoms. Although studies are scarce in this area, a few previous studies conducted in China [25] and Italy [24] found consistent results with our study. Increased fear at the beginning of the COVID-19 pandemic, particularly among people who were in quarantine, is likely to contribute to distress [52]. People are afraid to stay in quarantine as this was a highly stigmatizing experience [21]. If a person is quarantined, they are considered by other people as infected with the virus; and this was particularly the case during the time of the current study. It is also very likely for a person to worry and get panic when they experience COVID-19 like symptoms, such as headache, sore throat, breathing difficulty and increased level of body temperature.

Overall, the study shows that there is a very high prevalence of depressive, anxiety and stress symptoms among migrant returnees who are experiencing quarantine in association with COVID-19. The prevalence of psychological distress is found to be significantly higher among women than men. Quarantine and COVID-19 related factors, including fear of being infected with the virus, fear of discrimination after the quarantine, and experiencing COVID-19 like symptoms were significantly associated with increasing prevalence of depressive, anxiety and stress symptoms.

The findings of this study suggest implementing mass screening of psychological distress in this population for proper intervention and referral. Suitable mental health interventions need to be in place in quarantine centers and for migrant returnees in order to address the huge and double burden of mental health problems in this group. Mental health services need to be integrated with medical and other psychosocial and socioeconomic support services. There may be a few severe cases of mental disorders in quarantine centers, especially among migrant returnees. Hence, effective and efficient referral system should be instituted. Prospective longitudinal studies to determine change in the prevalence and severity levels of psychological distress after quarantine are warranted.