1. IntroductionThe World Health Organization (WHO) declared the SARS-CoV-2-caused coronavirus disease (COVID-19) a global pandemic on 11 March 2020 [1]. In Ghana, the first two COVID-19 cases were reported a day after this declaration [2]. In parallel, the Government of Ghana embarked on public education campaigns regarding preventive measures recommended by the WHO to reduce person-to-person transmission, with a concurrent herd effect on transmission of other pathogens [3,4]. These included avoiding or limiting physical contact (including handshakes and other forms of usual contact), regular handwashing with soap under running water, rubbing of hands with sanitizers possessing 70% alcohol strength, and reducing/limiting large gatherings (such as funerals, church activities, festivals and conferences) [5]. Similar to what was done elsewhere across the globe, educational institutions and borders were closed for a period of time and a partial lockdown was instituted in Accra and Kumasi, restricting movement and trade. This near-global lockdown was associated with an unprecedented drop in pollution [6].As part of the local COVID-19-related remedial efforts, 137 markets were disinfected in the Greater Accra Region, along with several others in the Eastern, Northern, Northeast, and Savannah Regions [7]. These disinfection processes, together with the partial lockdown and other COVID-19 protocols, might have affected transmission of gastrointestinal and other pathogens.Notwithstanding the gains chalked up from the elaborate interventions, ancillary effects on business activities, the global economy, food safety, health care, education, sports, and leisure have raised concerns about their potential composite impact on mental health [8,9]. For example, upon the onset of the pandemic, the Centers for Disease Control and Prevention (CDC) in 2021 warned that although social distancing is an important public health action to reduce the spread of the virus, it could cause feelings of isolation and loneliness that could increase stress and anxiety. Uncertainties about effective treatment for COVID-19, the large number of deaths, even in countries with high-quality health care services, and the impact on economies are also propagating factors of stress [9,10]. Chronic stress has been associated with an increased risk for development of diabetes, hypertension, and coronary artery disease [11,12]. In individuals with advanced atherosclerosis, short-term emotional stress may trigger cardiac events [13]. In spite of very little documented information on the impact of the pandemic on mental health in sub-Saharan Africa at the time, Semo and Frissa [14] predicted an immense impact on mental health unless sociocultural resilience factors and coping mechanisms were safeguarded. In light of this, stress-related conditions are likely to develop due to fear and anxiety of contracting COVID-19, closure of businesses, and restriction of trade and travel, among others.The noncommunicable disease burden in sub-Saharan Africa has been slated to rise due to urbanization, population growth, and demographic transitions [15]; the incidence of gastrointestinal infections is also likely to be affected by the implemented COVID-19 protocols. Gastrointestinal infections contribute to the burden of infectious diseases worldwide and constitute the second-leading cause of preventable illness in children aged under 5 years [16]. In developing countries such as Ghana, poor hygiene, sanitation practices and poverty-related risk factors have contributed to this development. Evidence of a decrease in incidence will go to strengthen education on infectious disease transmission and the need to sustain hygiene-focused protocols long after COVID-19 is eliminated.This study, therefore, retrospectively investigated differences in prevalence of gastrointestinal infections and stress-related diseases/disorders at a primary health facility in the capital city of Ghana before and during the COVID-19 pandemic. The impact of COVID-19 infection and its protocols on transmission has been assessed on some areas of health care [17,18,19,20,21,22,23,24,25]. However, to the best of our knowledge, this is the first study to have examined the differences in occurrence of both gastrointestinal infections and stress-related diseases/disorders at the same facility, before (pre) and during (after the advent of) the COVID-19 pandemic. It is noteworthy that although the setting for this study was a city, quite a number of the inhabitants have relatively low socioeconomic status.

We hypothesized that during the COVID-19 pandemic, measures such as avoiding or limiting physical contact (including handshakes and other forms of usual contact) and reducing/limiting large gatherings among the general population may lead to an increase in stress-related diseases/disorders, while regular handwashing with soap under running water and rubbing of hands with alcohol-based sanitizers could lead to a reduction in the prevalence of gastrointestinal infections reported at the facility investigated.

4. DiscussionIn a bid to limit the spread of the COVID-19 pandemic following its onset, various countries, including Ghana, implemented interventions such as upscaling of hand hygiene practices and education as well as restrictions on movement and social interactions. Although associated with a significant decrease in infectious disease morbidity, these alongside the stress induced by the pandemic may have resulted in an increase in mental health disorders, such as anxiety, depression, and other diseases that are exacerbated by stress [30]. This study investigated whether there was a change in the prevalence of gastrointestinal infections and stress-related diseases during the COVID-19 pandemic, using de-identified data obtained from the Korle Bu Polyclinic in Accra, Ghana.Contrary to expectations that given the implemented WHO-recommended interventions [4], the prevalence of gastrointestinal infections may reduce in the COVID-19 era relative to the pre-COVID-19 era, the findings revealed the reduction to be statistically nonsignificant at the single-center studied. In contrast, a significantly lower gastrointestinal infection prevalence was reported by Amar et al. [30] and Tanislav and Kostev [31] for the COVID-19 era compared to the pre-COVID-19 era in their studies carried out in Israel and Germany, respectively. Ahn et al. [32], on the other hand, reported a non-significant decrease in the incidence of viral gastrointestinal infections. The hypothesis the researchers proffered for their observation was that while the transmission of viral gastrointestinal infections required a more direct contact, that of bacterial gastrointestinal infections were mainly through food [32].The comparable gastrointestinal infection prevalence between the pre-COVID-19 and COVID-19 eras in the current study could be due to a number of reasons. First, in some parts of Ghana, adherence to COVID-19 protocols was poor, probably stemming from misconceptions that no case of COVID-19 infection had yet occurred in the country and/or that people from the tropics were immune to the virus [33,34]. Also possible is the contribution of the easing of restrictions towards the latter part of 2020, during which the euphoria associated with large gatherings may have caused laxity in adherence to the safety protocols. Moreover, the prevalent economic hardships and concurrent hikes in prices during the pandemic may have resulted in more individuals purchasing ready-to-eat foods from vendors, with little or no regard for the microbial safety of these foods, potentially predisposing the consumers to gastrointestinal infections [5]. Furthermore, difficulties in accessing hand sanitizers, face masks, and other items crucial to the prevention of COVID-19 transmission may have negatively impacted adherence. These factors may have, to varying degrees, blurred the behavioral adjustments that would have significantly driven down the gastrointestinal infection prevalence in the COVID-19 era.The parallelism in the overall gastrointestinal infection prevalence notwithstanding, fewer cases of gastrointestinal infection were recorded early in the COVID-19 era relative to analogous periods in the pre-COVID-19 era. This observation could possibly be attributed to the implementation of measures recommended by the WHO to reduce person-to-person transmission [4]. Also, fewer cases recorded during the early part of the pandemic period than the pre-pandemic period may have been fueled by the fear that some probably entertained about contracting COVID-19 from hospital visits; such fears may have resulted from reports of COVID-19-positive cases involving personnel of some health care centers [2]. Conversely, the higher number of gastrointestinal infection cases recorded during the latter part of the COVID-19 era could be explained by the possibility that people might have relaxed in the adherence to the recommended safety protocols. In addition to these, some individuals may have felt more comfortable reporting to the hospital with gastrointestinal infections than with flulike symptoms, owing to the fear that they may potentially be quarantined should they be confirmed to be having COVID-19 infection. However, as explained earlier, the findings reported in this study originate from a single health care facility, warranting caution in their generalization to all health care facilities in the country or in other geographical locations.The higher number of gastrointestinal infection cases involving females than males in both the pre-COVID-19 and COVID-19 eras could be due to the probability that females in the catchment area might have better health-seeking behavior than the males, leading to more frequent hospital visits, as has been reported elsewhere [35,36].The statistically significant increase in the prevalence of anxiety disorders seems to support our hypothesis that the restrictive measures implemented during the COVID-19 era may lead to increased stress-related diseases/disorders. Likewise, Santabárbara et al. [37] and Santomauro et al. [38] demonstrated an increase in the proportions of individuals with anxiety disorders during the pandemic. The rapid spread of the virus, the high mortality rate associated with the disease, and fear of contracting the virus may have contributed to the increasing prevalence of anxiety disorders. It has been shown that exceptional situations like isolation can aggravate psychological disorders [39]. The feelings of isolation brought on by the restrictions placed on movement may have also worsened symptoms in those who already had anxiety disorders. This observation is noteworthy, since individuals with anxiety disorders experience significant impairment in how they function in their social, occupational, and physical domains [40], in such circumstances. The negative impacts of anxiety on various functional domains of life have been emphasized by earlier studies, eventually contributing to a poorer overall quality of life [41,42,43,44].The lower mean age recorded for those reporting to the health care facility with anxiety disorders during the pandemic compared to that observed for the pre-pandemic period agrees with the study by Santomauro et al. [38], which estimated a higher prevalence of anxiety disorders among younger age groups than in the older ones due to closure of schools, restriction of social interactions, and economic crises brought on by the pandemic. In contrast, a study by Wang et al. [40] reported no association between age and stress levels, and hence anxiety. The break from school or work hectic schedules and the periods of rest that accompanied the social restrictions may have served as a relaxation period for some students and working adults. The observed higher number of anxiety cases involving females agrees with studies that have demonstrated a general predisposition of females to anxiety and other mental health conditions [36,45]. It is, however, in contrast to what was reported by Wang et al. [40]—that there was no association between gender and stress levels during the pandemic.That insomnia prevalence significantly increased during the COVID-19 era agrees with what was reported in the study by Cénat et al. [41]—a higher prevalence of insomnia was reported among populations affected by COVID-19 than in the general population. The observed increase in prevalence has important clinical implications, since insomnia negatively affects the quality of life [46,47], which is further worsened by comorbid conditions [48,49]. Scalo et al. [50] reported that diagnosed insomnia was associated with consistent decreases in both physical and mental health-related quality of life scores. The increase in insomnia prevalence recorded in this study may have been as a result of fear of contracting the virus and the economic crisis that came with the pandemic [9]. A study conducted in Bangladesh by Hasan et al. [48], however, found that the prevalence of insomnia decreased during the second wave of the pandemic. The researchers attributed this to the fact that their target population may have adapted to the stressful pandemic situation, hence reducing their risk of mental health problems. That a higher number of the insomnia cases recorded during the pandemic involved females may be due to the higher vulnerability of females to mental health conditions compared to their male counterparts [51]. Females have also been reported to have higher knowledge and fear of the COVID-19 pandemic [48], and hence the increased anxiety. In contrast, a study by Pizzonia et al. [49] did not find any association between gender and insomnia symptoms. The lower mean age recorded for those reporting to the health care facility with anxiety during the pandemic compared to the pre-pandemic period may be due to the younger age groups being more stressed than the older.The observed reduction in the prevalence of depression during the pandemic is contrary to what has been reported in other studies, and may be attributable to poor health seeking behavior, probably leading to less frequent hospital visits [38,44]. To illustrate, more individuals are expected to be depressed during the pandemic owing to the resultant minimal social interaction from the implemented restrictions [9]. Another possible reason for our observation could be that the break from work or school made the general population more relaxed, and hence less depressed.Similar to the hypothesis provided for the higher number of anxiety cases involving females, that more of the depression cases occurring during the pandemic involved females could be attributed to the higher vulnerability of females to mental health conditions [51]. Additionally, females are more likely to report to the hospital with such symptoms than males [51]. That the prevalence of psychosis changed insignificantly during the COVID-19 era somewhat contrasts the report of O’Donoghue et al. [52] emanating from Australia. The researchers demonstrated an increase in first-episode psychosis during the pandemic, although not statistically significant [52]. Again, this change may have been due to increased relaxation time during the pandemic.The significant increases in the prevalence of headaches and migraines (both of which can be triggered by stress) during the pandemic is consistent with what was reported by Tudor and Sova [53]. The researchers estimated an excess occurrence of headache of 4.53% relative to expected levels in normal times. Headaches have been found to both worsen quality of life for all age groups and place a significant burden on society [54]. According to Al-Hashel [55], among chronic pains experienced in childhood and adolescence, headaches are staggeringly the most prevalent, and can significantly lead to debilitated cognitive, emotional, and recreational functioning in all areas of life, ranging from homes to scholarly activities. Therefore, the observed significant increase in the prevalence of headache during COVID-19 period may have a critical clinical significance.That the cases of headaches and migraines that were recorded during the pandemic involved individuals with a lower mean age is understandable, as individuals of the younger age groups are more likely to be stressed in the stressful pandemic situation [48,52]. Similarly, that more females accounted for the cases of headache than did males corroborates the findings of Wieckiewicz et al. [54], who reported a similar outcome. It is also possible that the longer periods that mothers spent caring for their children at home during the pandemic (because schools had been closed down) resulted in increased stress levels and to some extent accounted for the increased prevalence of headaches among the females.Some studies have shown an elevation of blood pressure immediately after a disaster [56] due to the physical and mental stress these disasters induce. In the study of Elnaem et al. [57], 77% of hypertensive persons were reported to have had good blood pressure control during the pandemic. This is in line with the findings of this study, which showed a 3.3 per 1000 case reduction in hypertension cases recorded at the hospital. Apart from the likelihood that people were more relaxed because of time afforded them during lockdowns and closure of certain public places, those suffering from hypertension were more likely to have been adherent to their medications due to reports that individuals with co-morbidities had poorer prognosis when they acquired COVID-19. That more female cases of hypertension were recorded than were male cases in both pre-COVID-19 and COVID-19 eras is consistent with previous studies. For instance, the prevalence of hypertension has been reported to be higher in males than in females until menopause, after which there is a more rapid rise in women [58].Regarding angina and stroke, the observed male preponderance is similar to what was found by Adeloye et al. [59]. Other studies have, however, not found a significant association between gender and cardiovascular disease and stroke [60,61]. Generally, though, the observed statistically nonsignificant changes in the prevalence of cardio- and cerebrovascular diseases like hypertensive heart disease, angina, and CVA/stroke during the COVID-19 era, as compared to the pre-COVID-19 era is at odds with previous reports [62,63]. Narita et al. [62] for instance, reported an increase in hypertension-related diseases immediately after a disaster until living conditions improved. Zhang et al. [63] also reported that anxiety status was associated with an increased risk of incident cardiovascular events during the COVID-19 pandemic. Interestingly, other studies reported a decline in stroke admission in centers all over the world [64,65]. This has been attributed to the possibility that those who had mild strokes decided to manage themselves at home instead of reporting to the hospital due to their fear of contracting the virus at the health care institutions [66]. Nonetheless, it is difficult to tell if this explanation specifically holds for the participants whose data were analyzed in this study. Indeed, the research findings are best interpreted in the context of the single facility studied.