Prevalence and social determinants of anxiety and depression among adults in Ghana: a systematic review and meta-analysis protocol

Introduction Anxiety and depression pose a significant global health challenge, especially affecting adults in low-income and middle-income countries. In many low-income and middle-income countries, including those in sub-Saharan Africa, social determinants such as access to affordable health services, conflict, food insecurity, and poverty may be associated with the prevalence of anxiety and depression, further contributing to health disparities. To mitigate the burden of anxiety and depression in sub-Saharan Africa, it is essential to develop country-level tailored mental health policies and strategies. For example, Ghana is working towards improving mental health via its 12 year Mental Health policy launched in 2021. However, the prevalence of anxiety and depression among adults in Ghana, along with associated social determinants remains largely unknown, posing challenges for mental health planning, resource allocation and developing targeted interventions. This systematic review seeks to (1) examine the prevalence of anxiety and depression among adults in Ghana and (2) explore social determinants potentially associated with anxiety and depression. Methods and analysis Electronic databases (eg, African Index Medicus, CINAHL, EMBASE, MEDLINE, and PsycINFO) will be searched with all screening steps conducted by two independent reviewers. Secondary search strategies, including grey literature searches, will be used. Studies reporting on the prevalence of anxiety, depression and/or a combined symptom measure (ie, psychological distress) among adults in Ghana, using validated instruments will be included. If data allows, random-effects-meta-analyses will be performed to estimate pooled prevalence rates of anxiety and depression. Potential clinical and methodological moderators will be examined using subgroup analyses and meta-regression. A narrative synthesis will explore social determinants potentially associated with anxiety and depression among adults in Ghana. Ethics and dissemination Ethical approval is not required as no primary data will be collected. Results will be disseminated via a peer-reviewed publication and presentations at academic conferences. Plain language summaries will be provided to relevant non-governmental organisations working in Ghana. PROSPERO registration number CRD42023463078


INTRODUCTION
Common mental disorders, such as anxiety and depression, are among the most prevalent and rising health problems affecting adults worldwide. 1 2Anxiety and depression are leading causes of health-related burden globally, with depression being the second and anxiety being the eighth leading cause of years lived with disability (YLDs) out of 369 diseases and injuries in 204 countries and territories. 1The consequences of anxiety and depression can be severe; resulting in impaired social functioning, increased mortality rates, low productivity, and reduced quality of life. 3Research suggests that anxiety and depression are associated with an increased risk of developing complications or worsening a range of chronic physical

STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ This review, to the best of our knowledge, is the first of its kind, aiming to examine the prevalence of anxiety and depression among adults in Ghana and explore the social determinants potentially associated with anxiety and depression.⇒ The review protocol adheres to quality standards informed by the Preferred Reporting Items for Systematic reviews and Meta-Analysis Protocols checklist, with all screening steps and quality appraisal conducted by two independent reviewers.⇒ The peer-reviewed, comprehensive search strategy will ensure the inclusion of a wide range of relevant studies, reducing the risk of selection bias.⇒ High levels of heterogeneity across studies due to differences in populations, condition measurements and study designs may limit the possibility of conducting a meta-analysis.⇒ Qualitative studies will be excluded therefore limiting an in-depth exploration of the perspectives of adults in Ghana on social determinants associated with their mental health, which may have provided important information to inform future intervention development.
5][6] The economic burden of anxiety and depression is also substantial with costs stemming from healthcare service use, lost productivity, and impact on families, caregivers and wider society. 7 8The burden and impact of anxiety and depression on individuals and societies underscores the critical need to prioritise adult mental health and well-being globally.
The majority of the global burden of mental disorders is located in low-income and middle-income countries (LMICs), 9 where 75% of individuals experiencing common mental disorders do not receive appropriate mental healthcare. 10This treatment gap is particularly pronounced in Africa owing to the limited availability of mental health resources, coupled with healthcare systems that are inadequately equipped to meet the needs of individuals seeking care. 11 12A previous scoping review conducted in 12 African countries found a lifetime prevalence rate of anxiety ranging from 5.7% to 15.8% and depression ranging from 3.3% to 9.8%. 13Within Africa, the prevalence of mental disorders including anxiety and depression is expected to increase by 130% between 2010 and 2050, potentially leading to 45 million YLDs in sub-Saharan Africa (SSA), 14 with major depression predicted to be the largest contributor to disease burden in SSA. 14 Therefore, researchers, global health entities, and advocacy groups are urging actions to address the growing mental health crisis in SSA, 15 advocating for integrating mental health into primary care, establishing national policies, training paraprofessionals, expanding community healthcare, and collaborating with traditional healers. 14 16To further inform these actions, 15 there is a need to better understand the determinants of mental health that may contribute to the development and exacerbation of mental disorders in SSA, particularly in resource-constrained countries in the region.
Determinants of mental health among adults are multifaceted, and can be broadly categorised into biological (eg, genetics, brain chemistry and hormonal imbalances), psychological (eg, cognitive and interpersonal factors), and social (eg, ethnicity, food security and neighbourhood deprivation). 172][23] Within LMICs, including those in Africa, social determinants including diminished social capital, environmental events, food insecurity, forced migration, income inequality, violence, low education, poor housing, poverty and unemployment, [24][25][26][27] may increase vulnerability to experiencing mental health difficulties. 15Ethnicity as a social determinant also requires additional consideration given experiences of discrimination and exclusion, as a result of ethnicity, impact mental health. 22Furthermore, while ethnicity has been established as a social determinant of mental health, the interactions of mechanisms such as norms, differences in cultural interpretations of symptoms, and practices can also impact mental health. 21 22Recognising the over-arching importance of social determinants, the WHO has urged focus on reshaping economic, physical, and social factors to improve mental health and reduce inequalities by accelerating the implementation of the Comprehensive Mental Health Action Plan 2013-2030. 28mportantly, the majority of social determinants such as poor living arrangements and low or worsening socioeconomic status are modifiable, 29 and may be improved by implementing appropriate governmental policies and adopting a multisectoral approach to provide comprehensive mental health and social care services. 7 30In SSA, there is a growing consensus that mental health policies and services should be tailored to the contextual realities of each country in the region, with evidence emphasising the importance of documenting the social determinants specific to each SSA country where mental disorders are experienced. 15 31he focus of the present review is Ghana, an LMIC in SSA with a population of approximately 31 million, with an estimated 13% of adults experiencing mental disorders including anxiety and depression. 32Despite this, only 2% receive treatment. 33Chronic physical conditions like cancer, diabetes and HIV are commonly linked to mental disorders among adults in Ghana 34 35 and the burden of anxiety and depression in Ghana is further worsened by inadequate mental health resources and healthcare disparities. 356][37][38] To the best of our knowledge, there has been no systematic review undertaken to consolidate existing research, examine the prevalence rates of anxiety and depression among adults and explore key social determinants specific to the Ghanaian context.By examining the prevalence of anxiety and depression among adults in Ghana and exploring social determinants potentially associated with anxiety and depression, this review will provide insights into the magnitude of the problem in Ghana, and social determinants influencing their occurrence to inform evidence-based policies and interventions aimed at enhancing mental well-being and overall health of adults in Ghana.The review's findings will also be valuable for countries experiencing similar social determinants as the Ghanaian population.

Research objectives
This systematic review seeks to (1) examine the prevalence of anxiety and depression among adults in Ghana and (2) explore social determinants potentially associated with anxiety and depression.

METHODS
This review protocol adheres to the Preferred Reporting Items for Systematic reviews and Meta-Analysis Protocols (PRISMA-P) checklist 39 (online supplemental appendix 1).The Joanna Briggs Institute (JBI) methodology for systematic reviews on prevalence was used to guide protocol development. 40The protocol has been registered in the International Prospective Register of Systematic Reviews.The study is scheduled to commence on 25 September 2023, with an anticipated completion date of 1 September 2024.Any protocol amendments will be recorded in PROSPERO.

Eligibility criteria
Eligibility criteria was developed and defined in accordance with the CoCoPop (Condition, Context, and Population) and type of studies framework. 41pulation Adults (aged≥18 years) living in Ghana will be eligible for inclusion.Studies solely focused on children/adolescents will be excluded.Studies focusing on both adults and adolescents will be excluded if they do not present data separately for adults and adolescents or data cannot be obtained via correspondence with study authors.Studies conducted with specific subpopulations, including individuals with known psychiatric conditions, prisoners, individuals accused of witchcraft and women with fertility or gynaecological disorders, will be excluded due to their unique circumstances, which predispose them to a higher risk or potentially elevate the likelihood of experiencing mental health problems compared with the general population.

Condition
Conditions eligible for inclusion include anxiety and/or depression assessed using a structured diagnostic clinical interview in accordance with the International Classification of Diseases and Related Health Problems (ICD-10 or ICD-11), or the Diagnostic and Statistical Manual of Mental disorders (DSM), third, fourth or fifth edition (DSM-III, DSM-IV or DSM-V) such as the Structured Clinical Interview for (SCID), the Mini-International Neuropsychiatric Interview (MINI) or the Composite International Diagnostic Interview (CIDI).Studies using a self-report, clinician or proxy administered screening tool for anxiety (eg, Beck Anxiety Inventory), depression (eg, Beck Depression Inventory), or psychological distress (eg, Kessler Psychological Distress Scale) will also be eligible for inclusion.Studies reporting point (current), period (timepoint) or lifetime estimates of the prevalence of anxiety, depression, and psychological distress will be included. 42To ensure the reliability and quality of assessment methods, only studies using instruments validated for use in adult populations will be included.Validity will be assessed based on evidence provided in the validation paper(s) of the measurement instrument and/ or evidence of psychometric properties such as construct validity, content validity, criterion validity, and reliability measures including internal consistency, test-retest reliability, and inter-rater reliability.Studies using instruments validated for use in adult samples in Ghana will also be eligible for inclusion.Studies focused on other mental disorders (eg, psychotic disorders and bipolar affective disorders), substance use (eg, alcohol dependence), and neurological disorders (eg, multiple sclerosis) will be excluded.Studies will be excluded if the prevalence of anxiety, depression, and psychological distress cannot be calculated, for example, when reported solely as mean score or due to insufficient data.

Context
This review will include studies conducted in Ghana with adults sampled from the community or clinical settings (eg, primary healthcare facilities and hospitals).Studies conducted in regions that encompass Ghana (eg, West Africa and SSA) will be considered eligible if data on participants living in Ghana can be extracted from the publication or obtained via correspondence with study authors.Studies conducted immediately after conflict (ie, less than four months after the official end date of the conflict), 43 humanitarian crises, or natural disaster will be excluded as we seek to understand the general prevalence of anxiety and depression. 44pes of studies Primary quantitative studies, with observational study designs including longitudinal cohort studies (baseline data only), case-control and cross-sectional studies reporting the prevalence of anxiety, depression and/ or psychological distress among adults in Ghana will be included.Mixed-method studies will be eligible for inclusion only if data from the quantitative component can be clearly extracted.In the case of studies conducted on the same cohort of individuals at the same or different points in time, or where samples overlap, only the study with the largest sample and findings related to the aims of this review will be included to ensure that duplicate data are not included.Studies such as case reports, commentaries, conference proceedings, editorials, letters, opinion papers, qualitative studies, reviews, and theses/dissertations will be excluded.

Information sources
Searches will be conducted in accordance with PRISMA 2020 guidelines. 45Electronic database searches will be carried out in African Index Medicus (AIM), African Journals Online (AJOL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), Ghana Medical Journal (GMJ), Health Sciences Investigation (HIS), MEDLINE (PubMed), PsycINFO, and SCOPUS.Electronic databases will be searched from inception up to 25 September 2023, and updated study searches will be conducted within 3 months to submitting the results manuscript.Reference lists of included studies will be manually checked Open access and forward citation checks of included studies will be performed.Reference lists of relevant systematic reviews conducted in SSA, including Ghana will also be manually checked.Grey literature will be searched in Agency for Healthcare Research and Quality (AHRQ), Google Scholar, Health Systems Trust, Open Grey (http://www.opengrey.eu/),and the WHO Institutional Repository for Information Sharing (WHO IRIS).Researchers and non-governmental organisations working in the area of adult mental health in Ghana will be contacted to identify unpublished or ongoing studies.

Search strategy
The search strategy has been developed in collaboration with Mattias Axén, a librarian at Uppsala University Library and was reviewed by Alkistis Skalkidou and Lene Lindberg, following the PRESS Peer-Review guidelines 46 (online supplemental appendix 2).The search was constructed using terms related to (1) mental disorders and (2) Ghana (see online supplemental appendix 3).Electronic databases will be searched using Medical Subject Headings when possible and free text words in title and abstract word searches.No date restriction will be imposed and only studies published in English and Ghanaian languages (eg, Fante, Ga, and Twi) will be considered for inclusion.

Study selection
Studies retrieved from searches will be uploaded into Endnote V.20 with duplicates identified and removed.Two reviewers will independently screen titles and abstracts in Rayyan, 47 followed by full paper checks of potentially eligible studies.Studies not meeting the eligibility criteria will be excluded.Overall reasons for exclusion will be documented and reported using the PRISMA flow chart and detailed reasons for exclusion, in accordance with the eligibility criteria, will be presented in a table.If study data/information required to determine eligibility is missing, authors will be contacted at most twice over a 1-month period via email for additional information.If the authors do not respond, the study will be excluded.Any disagreement between reviewers will be resolved by discussion and/or involvement of a third reviewer.

Data extraction
Data from included studies (see online supplemental appendix 4) will be extracted by one reviewer independently into a standardised Microsoft Excel data extraction form, and crosschecked by a second reviewer for accuracy.The following data will be extracted:

Quality assessment
The methodological quality of all included studies will be independently assessed by two reviewers using the standardised JBI Critical Appraisal Tool for Prevalence Studies. 48The JBI Critical Appraisal Tool for Prevalence Studies comprises nine items including appropriateness of sampling frame and sampling technique, adequacy of sample size, coverage of identified sample, description of study subjects and setting, validity of condition identification methods, standard and reliable measurement of condition, statistical analysis and adequacy of response rate to assess the methodological quality and/ or risk of bias of sampling, analysis and measurements in primary studies.The total score ranges from 1 to 9 for individual studies, 49 with the total number of 'yes' scores for individual studies averaged to appraise studies as low (≤3 score), moderate (4-6 points) or high quality (≥7 points). 50Any disagreement between reviewers will be resolved by discussion and/or involvement of a third reviewer.

Data analysis and synthesis
Quantitative data synthesis If data allow, a meta-analysis with prevalence data from eligible studies will be conducted using Comprehensive Meta-Analysis software. 51Data on the proportion of adults with anxiety, depression, and psychological distress and their respective sample size will be extracted separately from individual studies to generate pooled estimates with exact binomial test and associated 95% CIs.Data will be transformed to their logits before meta-analysis to stabilise variances. 52Due to expected heterogeneity in individual studies, the random-effect model will be used to generate pooled prevalence estimates for anxiety, depression, and psychological distress, respectively. 51Heterogeneity across studies will be estimated using Cochran's Q statistic.The I 2 statistics will be used to measure the proportion of total variability due to between-study

Open access
heterogeneity.The prediction interval (T 2 ) will be used as an estimate of between-study variance in true effects observed in eligible studies.Sensitivity analyses will be performed to explore the impact of individual studies on the overall prevalence estimate of anxiety and depression.This will be conducted, for example, by removing studies conducted during COVID or studies of lower quality individually from the overall analysis to ascertain if their removal causes any substantial change to overall prevalence estimates.Egger's regression statistic and funnel plots will be used to assess the presence of any publication bias.In the case of significant publication bias, 53 the trim and fill method will be used to identify and correct the asymmetry of the funnel plot to yield a corrected pooled prevalence.

Subgroup analysis
If data allow, we will explore sources of heterogeneity via subgroup analysis of the moderating effects of the following factors on prevalence: ► Chronic physical conditions (eg, long-term lifethreatening conditions such as cancer, diabetes, emphysema, hypertension, HIV/AIDS, ischaemic heart disease and stroke, and chronic conditions such as arthritis, asthma, back problems of any kind, chronic bronchitis, gall bladder diseases, joint pain, osteoporosis, and stomach ulcers). 54► Method of mental health assessment (eg, structured clinical interview or screening tool).► Sample size (eg, <100 vs ≥100).► Study design (eg, case-control study, cross-sectional studies and longitudinal cohort study).► Study quality (low, medium, or high-quality studies).► Prevalence type (point, period, and lifetime).► Time period of data collection or publication year (eg, <2013 vs ≥2013 or <2020 vs ≥2020).Patient and public involvement Public contributors were not involved in the development of this protocol and will not be involved in the conduct of the review due to time and resource limitations.We will seek to involve public contributors in cowriting plain language summaries to be provided to non-governmental organisations working in the area of adult mental health in Ghana.

DISCUSSION
To the best of our knowledge, there is currently no comprehensive review examining the prevalence and social determinants of anxiety and depression among adults in Ghana.This review will extend existing epidemiology literature on mental health 36 55 56 by providing a comprehensive summary of prevalence estimates of anxiety and depression among adults in Ghana, as well as social determinants potentially influencing their occurrence.The review has a number of strengths including a peer-reviewed, comprehensive search strategy ensuring the inclusion of a wide range of relevant studies, and reducing the risk of selection bias.By considering comorbidities, the review recognises that mental health difficulties often co-occur with physical conditions, contributing to a better understanding of the overall health and mental well-being of adults in Ghana.Comorbidity between anxiety and depression is frequent and if data allows, the prevalence of comorbid anxiety and depression will be documented.The review protocol also adheres to quality standards informed by the PRISMA-P checklist, 39 with screening, selection and quality appraisal assessed by two independent reviewers.While there are several strengths, there are also limitations.Qualitative studies will be excluded, limiting an in-depth exploration of the perspectives of adults in Ghana on social determinants associated with their mental health, which may have provided important information to inform mental health intervention development.High levels of clinical and methodological heterogeneity across studies due to factors such as differences in populations, condition measurements and study design may limit the possibility of conducting a meta-analysis.This situation may warrant the need for narrative synthesis.
Despite these limitations, the significance of this review is highlighted by the widespread global attention on mental health, with initiatives such as the WHO Comprehensive Mental Health Action Plan 2013-2030 and the United Nation's SDGs highlighting the importance of mental healthcare equity, prevention, treatment and promotion. 57While Ghana is working towards improving mental health via its revised 12 year Mental Health Policy launched in 2021, 35 a comprehensive review examining the prevalence of anxiety and depression among adults in Ghana can facilitate the planning and allocation of Open access for mental healthcare. 35Addressing the social determinants is also crucial for achieving broader development targets, such as SDG 1 for no poverty, SDG 5 for gender equality and SDG 4 for quality education, among others. 22Findings may be used to inform future research, mental healthcare planning and the development of culturally responsive interventions aimed at improving the mental well-being and overall health of adults in Ghana.