Covid-19 symptom burden, chronic disease, mental health, and executive function: Multi-country evidence from four African countries

Abstract

Abstract Background Evidence 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. Methods Cross-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). Results Executive 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. Conclusions COVID-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.