COVID-19 Symptom burden, chronic disease, mental health, and executive function: Multi-Country evidence from four African countries"

BackgroundEvidence from high-income countries suggests that COVID-19 may adversely affect cognitive functioning, yet population-based data from African countries remain scarce. Understanding how COVID-19 symptom burden, chronic disease, and mental health intersect to shape cognitive outcomes is critical in low-resource settings disproportionately affected by structural and health system constraints. MethodsCross-sectional data were collected from 3,058 adults (M_age = 27.2 years) in Botswana, Ghana, Nigeria, and Tanzania between April 2020 and November 2022 using the Sonde Health platform. Participants self-reported sociodemographic characteristics, COVID-19 symptoms, chronic disease diagnoses, mental health symptoms, physical activity, and sedentary behavior. Executive function was assessed using the Stroop Color-Word interference score. Multivariable linear regression models estimated adjusted mean differences in executive function associated with COVID-19 symptom burden and chronic disease, controlling for sociodemographic, health, mental health, and behavioral factors. Effect modification by country was evaluated using interaction terms (p < 0.10). ResultsExecutive function declined with increasing COVID-19 symptom burden, with Stroop scores decreasing from 0.14 among participants reporting no symptoms to 0.07 among those reporting three or more symptoms (p < 0.001). Being symptom-free was associated with better executive function in Ghana (adjusted mean difference = 0.06; 95% CI: 0.00, 0.11) and Nigeria (adjusted mean difference = 0.07; 95% CI: 0.02, 0.12), but not in Botswana or Tanzania. Lower chronic disease burden was associated with better executive function in Nigeria (adjusted mean difference = 0.16; 95% CI: 0.06, 0.26). Higher educational attainment was consistently associated with better executive function across countries. ConclusionsCOVID-19 symptom burden and chronic disease were associated with poorer executive function across the four African countries studied, with substantial cross-country variation. Education emerged as a consistent protective factor. These findings highlight the importance of integrated, context-sensitive approaches that address both physical and mental health to support cognitive well-being during and beyond public health crises.