Study design
A center-based cross-sectional survey was conducted among migrant returnees who were in mandatory quarantine in Addis Ababa, Ethiopia in the context of COVID-19. The study aimed at identifying common coping strategies migrant returnees employ and factors associated with them. The study was conducted from 1st May to 15 June 2020.
Study context and setting
The first case of the COVID-19 outbreak in Ethiopia was announced on March 13, 2020, two days after the WHO officially declared the disease as a global pandemic. The Federal Ministry of Health (MoH) proactively organized the COVID-19 Public Health Emergency Operations Center (PHEOC) on January 27 under the supervision of the Ethiopian Public Health Institute (EPHI). Over the following months, the MoH and EPHI worked in tandem to educate the public about the pandemic and implement firm precautionary measures to contain the spread of the virus.
Among the preventive measures taken were closing of schools and universities, the shutting down of night clubs and similar entertainment centers, the prohibition of sporting, religious and similar public gatherings, the closing of all international borders, the suspension of Ethiopian Airlines flights to over eighty destinations, and the imposition of a mandatory fourteen-day quarantine for all incoming international passengers. In addition, the government postponed the general election initially scheduled for August 2020. In order to further strengthen the protective measures, the government took more robust actions in the following months with the proclamation on April 8 of a state of emergency for a period of five months and imposed restrictions including a ban on meetings of more than four people, a reduction of passenger numbers on public transport vehicles by fifty percent, and the mandatory wearing of face masks in public places. These preventive measures were strictly implemented particularly in the early phase of the pandemic.
However, the concerted effort by the government to prevent the spread of COVID-19 was seriously challenged by the unexpected repatriation of many numbers of Ethiopian migrant workers from several Middle East countries. The Government was seriously challenged in ensuring a safe environment to receive the returnees and to support their psychosocial and economic rehabilitation and reintegration. As a preventive measure, the government arranged COVID-19 quarantine centers and requires all returnees to stay for 14 days with their expenses covered. The quarantine centers were established in hospitals, primary healthcare centers, schools, university campuses and convention centers. The current study was conducted in quarantine centers established in university campuses in Addis Ababa. The centers were student dormitories with basic facilities such as a separate room for each returnee, bed, blanket, and shared toilet and shower. Security forces were overseeing to make sure that no one is contacting with another in the center. Returnees were not allowed to go out and have physical contact with others in the center.
Participants and sampling
We conducted the study in seven conveniently sampled quarantine centers established in three university campuses in Addis Ababa. We selected five centers (the Main Campus, College of Business and Economics Campus, College of Natural Sciences Campus, Lideta Campus, and Technology Campus) from Addis Ababa University, one center from Addis Ababa Science and Technology University, and another center from Ethiopian Civil Service University. In these seven quarantine centers there were about 6500 migrant returnees during the time of this study (2850 in the different quarantine centers in Addis Ababa University, 3060 in Addis Ababa Science and Technology University Center, and 590 in Ethiopian Civil Service University Center).
We approached 416 migrant returnees to take part in the study (182 from Addis Ababa University Centers, 38 from Ethiopian Civil Service University Center and 196 from Addis Ababa Science and Technology University Center). The inclusion criteria were being an Ethiopian migrant returnee during the time of COVID-19, stayed in one of the seven quarantine centers for at least ten days, being an adult (age 18 years or older), able to answer the survey questions in Amharic and able to give verbal informed consent. We retrieved 405 questionnaires yielding a response rate of 97.4%.
Measures
Socio-demographic, quarantine, COVID-19 and migration related characteristics
We developed a structured questionnaire to collect data about the socio-demographic, migration related, quarantine related, and COVID-19 related characteristics of participants (see Additional file 1). The questionnaire consisted of 22 closed-ended items related to returnees’ socio-demographic characteristics (4 items), migration experiences (5 items), quarantine experiences (10 items) and COVID-19 related characteristics (3 items). The questionnaire was reviewed by experts who have experience on questionnaire development and scale adaption and those who have research experience on migration and health. We pilot tested the questionnaire with respondents having similar attributes as the main study participants. Based on the findings of the pilot study, we amended questions that were less understandable, sensitive and less acceptable.
Coping strategies
We used the Brief COPE Scale [48] to measure migrant returnees coping strategies. The Brief-COPE is a 28-item abridged form of the full COPE (Coping Orientation to Problems Experienced) scale that is designed to measure the extent to which individuals respond to a broad range of stressors. It consists of 14 specific strategies, with two items each. The 14 strategies can be grouped into three higher order coping strategies: problem-focused, emotion-focused, and dysfunctional coping [48]. The problem focused coping contains strategies of active coping, instrumental support, and planning. The emotion focused coping includes strategies of acceptance, emotional social support, humor, positive reframing, and religion. The dysfunctional coping, on the other hand, consists of cognitive and behavioral disengagement, denial, self-distraction, self-blaming, and substance use and venting strategies [34].
The brief COPE has been used in various cultural contexts with diverse participants and demonstrated sound psychometric properties [49,50,51,52,53,54]. It has also been used in LMIC contexts, including in Ethiopia [28, 55]. The Brief COPE has been validated in Ethiopia in two studies among women with postpartum depression symptoms in rural Ethiopia [55] and among women labor migrant returnees from the Middle East countries [28]. In both of these studies, the COPE was reported to be valid and reliable. Confirmatory factor analysis has supported the three dimensions of coping (problem-focused, emotion-focused, and dysfunctional) [55].
In the current study, the brief COPE is translated into Amharic language, the official language in Ethiopia, by four members of the research team, who are fluent Amharic speakers and trained at masters’ or PhD degree level, following standard procedures [56, 57]. Senior members of the research team, who have training and experience in scale adaptation and validation, evaluated the relevance, cultural equivalence, acceptability and clarity of each item of the Amharic version of the scale. Participants rate each item on a Likert scale, ranging from 0 “I haven’t been doing this at all” to 3 “I’ve been doing this a lot.” Sample items from the scale include: ‘Thinking hard about what steps to take’ for problem-focused coping, ‘Trying to find comfort in my religion or spiritual beliefs’ for emotion-focused coping, and ‘Doing something to think about it less, such as watching TV, reading, daydreaming, or sleeping’ for dysfunctional coping. For this study, the internal consistency reliability coefficients for problem-focused, emotion-focused, and dysfunctional coping sub-scales were 0.74, 0.70, and 0.71, respectively.
Data collection procedure
The process of data collection was executed by two masters level trained and experienced members of the research team. These members of the research team were also in charge of coordinating and supervising the quarantine centers employed by the Ethiopian Federal Ministry of Peace and Ministry of Health. The other three senior members of the research team supervised and coordinated the data collection process. The senior members of the research team trained those who executed the data collection, oversee participant recruitment and data collection and involve in checking and controlling data quality. A half-day orientation was delivered for those who executed the data collection on the purpose of the study, the contents of the data collection instruments, ethical matters, and on how to recruit and approach participants.
Data collection was carried out in quarantine centers (house-to-house) where migrant returnees were available via the guidance of key informants. Data collectors provided the questionnaire to those who gave consent and collected back the completed questionnaires after three days. For participants who were not literate, we administered the questionnaire in a face-to-face interview format. The senior members of the research team closely followed-up the data collection process.
Data management and analysis
We entered and analyzed the data using the IBM Statistical Packages for the Social Sciences (SPSS) version 24 software. Data were checked for completeness and consistency before analysis began. We then conducted both descriptive and inferential statistical analyses to address the research questions. We used descriptive statistics to summarize the socio-demographic and other pertinent characteristics of the participants and determine the extent of use of coping strategies by migrant returnees.
We carried out simple and multiple regression analyses to examine the association of socio-demographic, migration related, quarantine related and COVID-19 related characteristics with migrants’ coping strategies (problem-focused, emotion-focused, and dysfunctional), separately. Factors that were associated with the outcome variables in the univariate models with P value < 0.2 were included in the corresponding multivariable models in order to limit the potential risk of over adjusting without compromising identification of potential predictors for the outcome variables. Standardized regression coefficients (β) (both crude and adjusted), with the corresponding 95% confidence interval, were used to estimate the strength of association between potential associated factors and the outcome variables. All statistical tests were set at α = 0.05 for significance.
Ethical considerations
The study protocol was reviewed and approved by a committee established by the Office of the Vice President for Research and Technology Transfer (VPRTT) at Addis Ababa University. We secured a support letter from the VPRTT to collect data from the quarantine centers. We obtained permission to collect data from the coordinators of the quarantine centers by presenting a cooperation letter written from Addis Ababa University. Participation was voluntary and verbal informed consent was obtained from all the participants after the nature of the study was fully explained to them. We preferred verbal informed consent to written informed consent just to put respondents at ease since informants may not be comfortable to put their signature on paper in the Ethiopian socio-cultural context. Respondents were informed that they could withdraw at any time from the study and cease to respond to any question they felt uncomfortable. Information obtained from all the participants was anonymized and confidentiality was assured throughout the data collection process. Data collectors and field coordinators were urged to stick to all of the COVID-19 preventive measures.