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Abstract
Introduction The SARS-CoV-2 pandemic has caused global devastations in social, economic and health systems of every nation, but disproportionately of nations in Africa. In addition to its grave effects on the global systems, there is continuation or development of new symptoms among individuals who have contracted the virus, with the potential to further stress the health systems on the continent. Therefore, the aim of this scoping review was to collate and summarise the existing research evidence on the prevalence and health effects of post–COVID-19 conditions in Africa.
Methods and analysis Five main databases were thoroughly searched from 1 September 2023 to 10 May 2024 for eligible articles based on the pre-established inclusion and exclusion criteria. These databases included PubMed, Central, Scopus, Dimensions AI and JSTOR. A total of 17 papers were included in the review. The protocol for this review is already published in BMJ Open; doi:10.1136/bmjopen-2023-082519.
Results The prevalence of post–COVID-19 conditions in Africa ranged from 2% to as high as 94.7%. Fatigue, dyspnoea and brain fog were among the commonly reported symptoms of post–COVID-19 conditions. Reduced functional status as well as physical and psychosocial disorders were the main health effects reported by the studies reviewed, but no study yet reported the effects of post–COVID-19 conditions on the health systems in Africa.
Conclusions There is an evidence of high prevalence of post–COVID-19 conditions in the African setting. However, there is limited evidence of the health effects of the post–COVID-19 conditions on patients and health systems in Africa.
Ethics and dissemination This scoping review involved analysis of secondary data; therefore, no ethical approval was needed. Dissemination of the result is being done through international journals and may also be presented at available research conferences.
- COVID-19
- Public health
- Post-Acute COVID-19 Syndrome
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This scoping review provides a comprehensive synthesis of existing evidence on post-COVID-19 conditions in Africa, which may inform healthcare strategies and interventions and public health planning in the continent, and further draws attention to the areas of needed research.
The consultation with diverse stakeholders, including medical professionals and individuals experiencing post-COVID complications, enhances the validity and relevance of our findings.
By including both peer-reviewed articles and grey literature, the study offers a broad overview of the prevalence and health effects of post-COVID-19 conditions in Africa.
Quality appraisal of included studies was not conducted, which potentially limits the robustness of our findings.
The review included studies published in English, potentially excluding relevant literature published in other languages.
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has altered global dynamics, affecting both individual and societal well-being since its outbreak in late 2019 in Wuhan, China.1 The COVID-19 pandemic has posed significant challenges and continues to impact the global healthcare system profoundly.2 The disease has tragically led to approximately 7 million deaths worldwide from an estimated 800 million confirmed infections as of September 2023.3 In Africa alone, there were around 10 million confirmed cases and 175 496 deaths as of 16 February 2024.3
Recent global evidence indicates that many individuals infected with COVID-19 continue to experience symptoms or develop new ones beyond the acute phase of the disease.1 Post-COVID-19 condition, also known as long COVID, is characterised by the persistence or emergence of physiological health symptoms 3 months into the initial infection, lasting for 2 months or more with no other underlying cause apart from the COVID-19 infection.4 Symptoms of post-COVID-19 conditions include fatigue, malaise, altered sense of smell and taste, breathlessness and cognitive impairments.5–7 In some cases, organ damage has also been reported.8
Globally, the prevalence of post-COVID-19 conditions is estimated at 0.43%.2 In the USA, reports indicate that by 2022, 6.9% of adults had experienced post-COVID-19 conditions, with 3.4% still living with these symptoms.9 In the UK, as of February 2023, 2 million people (3.1% of the population) reported post-COVID-19 conditions.10 In Africa, approximately 41% of individuals diagnosed with COVID-19 continue with post-COVID-19 conditions.11 However, these figures may not fully capture the reality in Africa, where under-reporting is likely due to challenges in testing and diagnosis, especially in low-resource settings. This under-reporting complicates efforts to fully understand and appreciate the long-term impact of COVID-19 on individuals across the continent. Consequently, African health systems may find it challenging to plan and manage the healthcare demands posed by post-COVID-19 conditions effectively. The persistence of post-COVID-19 conditions could exacerbate the strain on Africa’s already burdened healthcare systems, potentially impeding socioeconomic and health development across the continent. This scenario underscores the importance of improving diagnostic capacity and support structures for those experiencing post-COVID-19 symptoms to address the broader implications for public health in the continent of Africa.
Several reviews have explored the risk factors, prevalence and burden of post–COVID-19 conditions in Africa.11–14 However, these reviews often fall short of addressing how post–COVID-19 conditions could further strain Africa’s already overburdened healthcare systems. Although these reviews aim to provide updated evidence on the prevalence of post–COVID-19 conditions, their comprehensiveness may be limited. Methods, such as systematic reviews and meta-analyses,15 include quality appraisals that may exclude relevant records, potentially narrowing the findings. Additionally, given the evolving nature of post–COVID-19 conditions, the evidence provided in these previous reviews11–14 may already be outdated, limiting their ability to capture recent trends in Africa. It remains essential to understand the common post–COVID-19 symptoms, their critical impact on patients and their broader implications for health systems in Africa. Access to accurate, up-to-date information would enable African health systems to respond effectively to these challenges, allowing for improved management in a region with limited healthcare resources.
The challenge is that post–COVID-19 conditions could raise the dependency ratio because of the long-term health effects including the various forms of disabilities. Therefore, there is the need for evidence-based policy, health system restructuring and re-orientation to meet such increasing health demands. Thus, a more comprehensive review like a scoping review is needed to map available evidence on the prevalence, common symptoms, and health effects of long COVID and provide how they affect the health system in Africa. Furthermore, the evidence could improve patients’ well-being and healthcare outcomes and form the bases for future studies, including systematic reviews. This scoping review aimed at providing critical insights into the prevalence of post–COVID-19 conditions, health effects on patients and the implications for the health system in Africa.
Method and analysis
This review adhered to the scoping review methodology outlined by Arksey and O’Malley,16 which includes defining research questions; identifying relevant studies, selecting studies, data extraction, summarising and synthesising results and incorporating consultation. The Arksey and O’Malley framework was chosen for its emphasis on consultation, a crucial component in enhancing the rigour of a scoping review.16 Additionally, findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).17 The protocol for this review is available at doi:10.1136/bmjopen-2023-082519.18
Patient and public involvement
This study is a scoping review, and as such, there was no patient or public involvement in its design and conduct, reporting and dissemination. We rather collated existing evidence into one stop shop, providing a strong evidence.
Research question(s)
Two research questions guided this review
What is the prevalence of post–COVID-19 conditions in Africa?
What are the health effects of post–COVID-19 conditions on patients in Africa?
Identification of relevant literature
Search for the literature started from 1 September 2023 and continued until 10 May 2024 in five main databases, including PubMed, Central, Scopus, Dimensions AI and JSTOR. Additional search was conducted in Google Scholar, Google, ProQuest, WHO library and university online repositories. In consultation with a professional librarian at the Sam Jonah Library, University of Cape Coast, Medical Subject Headings terms together with controlled vocabularies were identified and used to conduct an initial search in PubMed. These search terms were modified to suit searches in the other databases (see online supplemental file 1 for details). Moreover, all identified records were saved into the Mendeley software where they were merged (to remove duplicates) for further screening. See table 1 for the search strategy conducted in PubMed. A librarian at the Sam Jonah Library, University of Cape Coast, was also consulted throughout the literature search process. Table 2 presents the eligibility criteria for the review.
Supplemental material
Search strategy for search in PubMed
Eligibility criteria for screening search results and full-text records
Selection of relevant studies
The selection of articles went through a two-stage screening process. The screening of titles and abstracts was carried out after the duplicate records were identified and merged using the Mendeley software. Titles and abstracts were screened by 15 graduate students under the guidance of authors PKS, MSD and DNB. Five students formed a group (three groups), and these students independently screened the retrieved records. There was cross-over screening, where a group cross-checked the screening done by another group. Any unresolved discrepancies were dealt with by authors EWA and MA. This ensured that all relevant full-text records have been selected into the review. The screening of the titles and abstracts were conducted to select eligible full-text records. In addition, the reference lists of full-text eligible records were searched for additional relevant records. Finally, full-text records were screened by PKS, MSD and DNB against the eligibility criteria to select relevant studies into the review. Figure 1 presents the search, screening and selection process using the PRISMA-ScR flow diagram.
Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews flow diagram.
Data extraction
Data extraction form was designed, tested and used for the charting of the data. Extracted data include author and date, purpose of the study, country of the study, design and sample size used, study population and findings on the prevalence of post-COVID-19 conditions, common symptoms of post-COVID-19 and health effects. The included studies were critically searched, and data were extracted on the stated implications of COVID-19 conditions and their health effects on the health systems in Africa. Two authors (MSD and DNB) performed the data extraction independently. Then, the other two authors PKS and MA reviewed the data extracted by MSD and DNB. The data extraction process ensured that we captured relevant information that are needed to answer the stated research questions. Author EWA led the study and helped to resolve any challenge that ensued during the data extraction phase.
Data summary and synthesis of results
Thematic analysis was employed in reporting the results of this scoping review. The process include systematic coding of the extracted data to identify recurring themes which were then organised and interpreted according to the stated research questions. At the initial stage, authors familiarised themselves with the data through reading. This was followed up by the generation of initial codes to identify specific themes. Subsequently, themes were grouped based on similarities and relationships and were then reviewed and refined iteratively to ensure accuracy and coherence. Each theme was defined and named descriptively to reflect its content and relevance to the research questions. Thereafter, narrative report was generated to present the synthesised themes in a coherent manner. The approach allowed for a comprehensive exploration of the prevalence and health effects of post–COVID-19 conditions on health systems in Africa, which provided valuable insights into the topic under investigation.
Results
Search results
A total of 17 550 records were retrieved from the five main databases, including PubMed=45, CENTRAL=14 848, Scopus=778, Dimmensions AI=1824 and JSTOR=55. Additional 23 records were retrieved from Google, Google Scholar and the other sites; thus, 17 573 records were retrieved and screened. A total of 371 duplicates were merged, and 17 202 records were screened for eligibility. Thus, 17 full-text records were selected for this review. See figure 1 for details.
Characteristics of included studies
The 17 studies included in the review comprised 16 quantitative studies and one qualitative study. Of these, 35% (6 studies) were conducted in Egypt,19–24 24% (4) in South Africa,25–28 12% (2) in Ghana29 30 and 5.8% (1) each in Ethiopia,31 Tunisia,32 Nigeria33 and Libya.34 Additionally, one study (5.8%) was a multicountry investigation that involved Cameroon, Egypt, Nigeria and Somalia³⁴. The designs used in these studies varied, with nine cross-sectional studies,19 20 24 26 29 31 32 34 35 two prospective studies21 27 four retrospective studies22 26 30 33 and two case-control studies.23 25 In total, the studies sampled 14 328 participants. The majority of these studies were published in 2022 (n=7), followed by 2023 (n=6), 2021 (n=3), and one in 2024.
Only three of the studies received funding support, with one funded by a government agency and two by private entities. Furthermore, most articles were published in international journals such as The Lancet Global Health, BMC Public Health, BMC Health Services Research and BMC Infectious Diseases, with only five studies published in African journals.20 21 24 26 30 Online supplemental table 1 provides detailed characteristics of the included studies.
Prevalence of post-COVID-19 conditions and follow-up periods
The prevalence of post–COVID-19 condition was analysed under two themes, namely, prevalence and common symptoms of post–COVID-19 conditions. Reviewed studies reported post–COVID-19 conditions prevalence between 2%29 and 94.7%.34 Table 3 presents information on the prevalence of post–COVID-19 conditions and the respective country for each study.
Prevalence of post-COVID-19 conditions
Where available, we also report follow-up periods for some of the reviewed studies. Time to follow-up ranged from 2 weeks30 33 to 6 months and over.34 See table 3 for details of the follow-up periods.
Common symptoms of post-COVID-19 conditions
Fatigue, dyspnoea or breathlessness, brain fog (characterised by memory problems, lack of concentration or cognitive impairments), headache, insomnia, anosmia, arthralgia, chest pain, depression, and ageusia, among others, were the commonly reported symptoms of post–COVID-19 conditions. Table 4 presents the pooled prevalence of symptoms, and the studies reporting them.
Symptoms of post-COVID-19 condition
Health effects of post-COVID-19 conditions
Two reviewed studies22 32 reported on the health effects of post–COVID-19 conditions on patients, highlighting reduced functional status²¹ and various physical and psychosocial impacts.32 Reduced functional status ranged from 1.2% to 35.3%: 31% of patients reported negligible limitations, 24.1% light limitations, 8.8% moderate limitations and 1.2% severe limitations.22 Physical effects included itching, facial discolouration, coughing that made speaking difficult, forgetfulness, hand tremors, inability to perform daily activities and olfactory dysfunction.32 Psychosocial effects included suicidal ideation and social isolation.32 Unfortunately, none of the included studies addressed how post–COVID-19 conditions are impacting the health systems in Africa, a gap that need urgent research attention.
Discussion
Summary of findings
Our review indicates that the prevalence of post–COVID-19 conditions in Africa ranged from 2% in Ghana to 94.7% in Libya. Fatigue, dyspnoea, brain fog, headache, insomnia, arthralgia and anosmia were the commonly reported symptoms of post–COVID-19 conditions. Reduced functional status as well as physical and psychosocial disorders were the main patents’ health effects reported by the studies reviewed.
Prevalence of post-COVID-19 conditions
Our study found that the prevalence of post-COVID-19 conditions ranged from 2% to 94.7%. This wide variation likely reflects differences in definitions of post-COVID-19 conditions, as well as diverse methodological approaches used by the studies reviewed in this scoping review. Similar variability has been reported, with Muller et al 13 documenting a prevalence range of 2% to 86% in their systematic review. Most studies in our review reported prevalence between 31% and 40%, aligning closely with the pooled global prevalence of 45% documented by O’Mahoney et al.36 These findings also align with the prevalence of 48.6% and 41% from previous systematic reviews focused on Africa.11 14 This consistency across studies suggests a convergent understanding of post-COVID-19 prevalence despite methodological differences, lending reliability to the findings and underscoring the importance of addressing post-COVID-19 conditions in clinical practice with relevant public health strategies.
Several studies reported exceptionally high prevalence of post-COVID-19 conditions20 26 27 34 which may result from methodological differences such as study design, follow-up period, sample size and definitions of post-COVID-19 symptoms. For example, both Buzgia et al 34 and Galal et al 21 used a cross-sectional design with 323 and 430 participants, they reported prevalence of 94.7% and 86%, respectively. In contrast, Dryden et al 27 employed a prospective observational cohort design and reported a prevalence of 66.7%. The definition of post-COVID-19 conditions also appear to play a significant role. Galal et al,21 with a prevalence of 86%, defined post-COVID-19 conditions broadly to include symptoms affecting various bodily systems following recovery from acute COVID-19. Dryden et al,27 however, defined post-COVID-19 conditions as symptoms persisting for at least 3 months after COVID-19 onset and lasting for at least 2 months, with no other explanation, with which they reported a lower prevalence, of 66.7%. These variations in definition and study design likely accounted for the disparities in prevalence observed across the studies. Thus, we define post-COVID-19 condition as the persistence or manifestation of new physiological and psychological health symptoms after the initial infection(s) beyond the initial successful diagnosis and treatment, with no other underlying cause apart from the COVID-19 infection. This definition encompasses post-COVID-19 condition to include both physiological and psychological health symptoms.
Beyond our current definition, we further recommend a more standardised approach to defining post-COVID-19 conditions in future research, such as the WHO’s definition.4 Standardising definitions would facilitate more consistent measurement across studies and improve comparability of findings. The variations in the prevalence underscore the importance of clear, uniform criteria for understanding the burden of post-COVID-19 conditions, aiding healthcare systems in identifying and managing these conditions effectively. Establishing consistent methodologies in research on post-COVID-19 conditions would enhance the reliability of data and inform strategies for clinical and public health interventions.
Common symptoms of post-COVID-19 conditions
Similar to findings from other reviews in Africa,11–14 our review identified fatigue, dyspnoea, brain fog, headache, insomnia, arthralgia and anosmia as the most common post-COVID-19 symptoms. Fatigue emerged as the most frequently reported symptom, aligning with previous African studies.11–14 It is crucial for clinical investigations to explore the factors and dynamics contributing to fatigue in post-COVID-19 patients, as it may result from a range of causes, including potential organ damage.37 Likewise, neurological symptoms such as headache, brain fog and anosmia were commonly reported, mirroring findings in other African reviews.11–13 Multiple factors may underlie these neurological symptoms, including direct viral effects on the nervous system, neuroinflammation from the immune response, cerebrovascular complications, hypoxia-induced brain injury and psychological stress.37 Individual variations, such as immune response differences, genetic predispositions, pre-existing health conditions and the severity of the initial COVID-19 infection, might further contribute to the prevalence of neurological symptoms.38
Although COVID-19 was initially identified as a respiratory pathogen,37 it can impact various systems throughout the body, including the nervous system. While the virus may not directly invade brain cells extensively, neurological effects likely arise from immune activation, neuroinflammation and cerebral blood vessel impairment.39 This highlights the importance of examining cytokine networks in post–COVID-19 patients, as the cytokine storm experienced during the acute phase of infection might persist and contribute to these lasting symptoms.22 Addressing these issues may be particularly challenging in many African countries, where diagnostic and treatment options for complex conditions such as cytokine dysregulation are limited, potentially exacerbating the complications linked to post–COVID-19.
Neuropsychiatric disorders, including insomnia, depression and anxiety, were the second most frequently symptom reported in our review. This aligns with global trends, where the prevalence of anxiety and depression increased by 25% in the first year of the pandemic.40 Our findings are also consistent with prior African reviews.11 13 14 Stressors like isolation, social distancing and stigma associated with COVID-19 may contribute to depression and anxiety among survivors.40 In addition, the virus’s neurotropic effects and the associated neuroinflammation could disrupt mood regulation and sleep patterns.39 The pandemic’s broader psychological impact—including fear of infection, social isolation, economic instability and grief from loss of loved ones—may exacerbate pre-existing mental health conditions or induce new ones among patients in Africa.40 41 In low-resource countries, where access to mental health services is limited, these symptoms may be further intensified.40 Factors like disrupted routines, limited access to mental health support and COVID-19-related stigma could also increase psychological distress, explaining the high prevalence of neuropsychiatric symptoms observed in our review, consistent with global trends.39 Therefore, COVID-19 patients would benefit from psychological interventions, yet such resources remain scarce in Africa, compounding the pandemic’s mental health burden in the continent.42
Health effects of post-COVID-19 conditions
The reduced functional status identified in this review may be influenced by the duration and severity of post-COVID-19 infection, as well as pre-existing health conditions in patients.21 For instance, persistent symptoms such as fatigue, dyspnoea and cognitive impairment can significantly hinder patients’ ability to perform daily activities, limiting their participation in social and occupational roles.37 Additionally, underlying conditions like obesity, diabetes, cardiovascular diseases and respiratory disorders may further impair functional capacity, as these comorbidities can exacerbate the effects of COVID-19 on multiple organ systems, prolonging recovery and intensifying functional limitations.22 The psychological impacts of COVID-19, including anxiety, depression and PTSD, may also contribute to reduced motivation, diminished self-efficacy and limited engagement in rehabilitation, all of which impede functional recovery.39 40 These factors together highlight the importance of addressing both physical and psychological aspects in managing post-COVID-19 recovery.
Physical effects such as facial discolouration, speech difficulties, hand tremors and olfactory dysfunction, as observed in this review, align with findings by Wang et al 41 from China. These symptoms are likely to result from the systemic inflammatory response induced by the virus, leading to tissue damage and functional impairments across various organ systems in African COVID-19 patients.41 The diverse presentations of COVID-19—ranging from mild respiratory symptoms to severe multiorgan dysfunction—illustrate the broad spectrum of clinical sequelae that can manifest during both acute and postacute phases of the disease.41 This diversity underscores the need for healthcare providers to remain vigilant and responsive to a wide array of post-COVID-19 symptoms, enabling timely recognition, treatment, and rehabilitation of affected individuals.
Such comprehensive attention to post–COVID-19 conditions can bolster patients’ confidence in the African healthcare systems, encouraging healthcare-seeking behaviours and improving health outcomes.41 Acknowledging and addressing the extensive impact of post–COVID-19 conditions through early intervention and holistic management will not only aid patients’ recovery but also reinforce trust in the healthcare infrastructure across the continent, contributing to better long-term public health outcomes.
Implications for health systems in Africa
Healthcare systems across Africa face a complex array of challenges, spanning across institutional, human resource, financial, technological and political domains. Many African countries struggle to meet the basic requirements for building robust healthcare systems.43 As a result, the additional burden of managing post–COVID-19 conditions could significantly disrupt the provision of quality healthcare services, exacerbating health inequalities in the continent.29 The healthcare workforce may see declines in productivity due to post–COVID-19 conditions affecting healthcare workers who previously contracted COVID-19, while the demands of managing post–COVID-19 cases with limited diagnostic and treatment knowledge will likely add to workforce stress.44
Given that post–COVID-19 conditions present over 200 different symptoms, the capacity of the health workforce must be strengthened for accurate diagnosis and management. Health services will need to adapt at primary, secondary and tertiary care levels to support post–COVID-19 patients effectively. This may necessitate the establishment or adaptation of specialised health facilities dedicated to treating these conditions.44 Furthermore, health technology for diagnosing post–COVID-19 conditions and essential medicines to treat them must be made readily available and accessible. Establishing protocols for data collection on post–COVID-19 conditions is also essential to enhance monitoring and management. These protocols should ensure equitable access and support broader research efforts to understand and address these emerging health challenges comprehensively.44
Increased financial resources will be critical to enable African health systems to meet the demands posed by post–COVID-19 conditions effectively. Managing this responsibility will require strategic policy frameworks, effective oversight, and coalition-building from leadership to ensure that financial and human resources are allocated and use judiciously. Such coordinated action would support improved health service delivery to patients across the continent, enabling a more resilient response to the growing healthcare demands in Africa.44
Limitations and recommendations for future research
This review included only studies published in English language; thus, there may be useful studies published in other languages that were not included in our review. Moreover, we acknowledge that the inherent biases in the included studies may affect our findings. In addition, gendered analysis of the prevalence and health effects of post–COVID-19 conditions was not conducted in this review because only one study, out of the 17 studies reviewed, did gender-based analysis. Irrespective of these limitations, the authors collated relevant studies from five major databases and two online sources. The authors also consulted a professional librarian in search of relevant studies on post–COVID-19 conditions in Africa. Only one study assessed the effects of post–COVID-19 conditions on patients’ functional status. That is, future studies should assess the effects of post–COVID-19 conditions on functional status of patients and the health systems in Africa. It is also recommended that gendered analysis of the prevalence and health effects of post–COVID-19 conditions be conducted in future studies.
Conclusion
This review has highlighted a relatively high prevalence of post–COVID-19 conditions in Africa, with reported rates ranging from 2% to 94.7%, though most studies reported prevalence between 31% and 40%. Frequent symptoms identified included fatigue, dyspnoea, brain fog, headache, insomnia, arthralgia and anosmia, with neurological symptoms being particularly prevalent. Key health impacts included reduced functional status and psychological effects like suicidal ideation. However, a significant limitation in the existing literature is the lack of focus on the health system implications of post–COVID-19 conditions, leaving a gap in understanding how these conditions may further burden the already strained healthcare resources in Africa. This study’s findings suggest that post–COVID-19 conditions will likely impose additional financial and operational pressures on African health systems, necessitating reorientation and restructuring to meet these emerging demands. Nevertheless, this review also has limitations, including the exclusion of non-English language studies, which may limit the comprehensiveness of our findings. Further primary research across diverse African settings is essential to capture more detailed picture of the health and systemic impacts of post–COVID-19 conditions. Additionally, greater investment in research funding for African scholars is crucial to develop context-specific strategies to address this ongoing health challenge effectively.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
We acknowledge the tremendous assistance rendered to us by Dr Diana Atuase of the Sam Jonah Library University of Cape Coast throughout the review process. We also thank our postgraduate students who helped in screening the papers.
References
Footnotes
Contributors EWA conceptualised the study, PKS, MSD, DNB and MA designed, collected and analyse data and wrote the draft report of the study. EWA led and supervised the team throughout the review process, is responsible for the overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.