COVID-19 pandemic, psychological response to quarantine, and knowledge of the disease among inmates in a Nigerian custodial center

Abstract

This was a cross-sectional study to assess the psychological response to quarantine during COVID-19 pandemic and knowledge level about the disease among inmates of a Custodial Center in Enugu, Nigeria. A total of 66 new prison inmates were assessed for psychological distress using the Kessler Psychological Distress Scale (K10); and inmates’ knowledge about COVID-19 using a COVID-19 Knowledge Questionnaire developed by the researchers.

Participants had a mean age of 28.39±8.71 years; 63 (95.5%) were male inmates and 3 (4.5%) were female inmates. Sixty-one (92.4%) were awaiting-trial inmates, 43 (65.1%) had psychological distress, and 35 (53%) had completed at least secondary school. COVID-19 questionnaire mean score was 3.82±3.33. Thirty-one (21.8%) had adequate knowledge of COVID-19 (7-10 score), while 35 (53%) and 10 (15.2%) had poor (0-3) and average (4-6) knowledge, respectively. Adequate COVID-19 knowledge level was significantly higher among those that completed at least secondary school (48.6%) than those who did not (12.9%). Though not statistically significant, adequate COVID-19 knowledge level was commoner among those without psychological distress (43.5%) than those with psychological distress (25.6%).

Considering responses to specific questions contained in the questionnaire, knowledge about some questions was relatively high. For example, a majority of the participants 45 (68.2%) correctly responded that death can be a complication of COVID-19; whereas half of them 33 (50%) correctly responded that regular hand washing with soap and water can help prevent the spread of the disease. Nevertheless, responses to some questions showed poor knowledge about the disease as 18 (27.3%) correctly answered that COVID-19 can affect the lungs, while 20 (30.3%) correctly responded that COVID-19 is caused by a virus.

Our study highlighted the need to have all quarantined persons educated about the disease for which they are being quarantined. It also provided the opportunity to raise awareness of COVD-19 among the inmates.

Citation

Okoro, J., Odionye, T., Nweze, B., Onuoha, M., Ezeonwuka, C., Owoh, J. and Nkire, J. (2023), "COVID-19 pandemic, psychological response to quarantine, and knowledge of the disease among inmates in a Nigerian custodial center", Emerald Open Research, Vol. 1 No. 2. https://doi.org/10.1108/EOR-02-2023-0008

Introduction

Coronavirus disease 2019 (COVID-19) is a novel viral disease caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), with clinical features including cough, fever, weakness, nasal congestion, difficulty with breathing, diarrhea, lung and other organ damage, and death in some cases (Wang et al., 2020b). While the cause of early cases of the disease has been linked to transmission from animals such as bats and cats, later cases have indicated human to human transmission through respiratory droplet and close contact (Adhikari et al., 2020; Hassan et al., 2020).

According to the World Health Organization (WHO), COVID-19 is a pandemic (World Health Organization, 2020b), and a public health emergency of international concern (World Health Organization, 2020c). Globally, nations have adopted various preventive measures, in line with WHO guidelines, to reduce the spread of the virus. One of such public health control measures is to place people on quarantine (World Health Organization, 2020a), and this is a way of preventing the spread of a disease outbreak by restricting activities or separating people who are not ill but may have been exposed to the disease (Centers for Disease Control and Prevention, 2004).

In addition to the public health concerns raised by the outbreak of COVID-19, the negative mental health effects are tremendous and worrisome. A disease outbreak as well as an infection control measure such as quarantine has overwhelming effects on people’s mental health. Findings in the general population have demonstrated relationship between quarantine, disease outbreak, and psychological distress (Bai et al., 2004; Chatterjee and Chauhan, 2020; El-Zoghby et al., 2020; Taylor et al., 2008).

In one study that assessed the impact of COVID-19 pandemic on mental health and social support in the general population in Egypt, there was a high negative psychological effect of COVID-19 outbreak (El-Zoghby et al., 2020). In another study which was a national survey of the associated factors of psychological responses and distress among Italian people during the COVID-19 pandemic, a high prevalence of psychological distress was associated with quarantine. It was further found that factors such as female gender, being young, detachment and negative affect domains of personality trait, and a history of stressful situation and medical problems contributed to the observed high level of psychological distress (Mazza et al., 2020).

Furthermore, Hawryluck et al. (2004) found that the psychological effects of quarantine range from depression to anxiety and other emotional disturbances. These findings have been replicated in another study in which quarantine was observed to be associated with psychological distress and other behavioural problems (Dong and Bouey, 2020; Robertson et al., 2004).

Though literatures on the mental health effects of quarantine and disease outbreak in custodial centers are scarce, one study found that psychological distress is more prevalent when the quarantine takes place in institutional setting such as custodial centers (Pfefferbaum and North, 2020).

Fear, financial stress, work stress (El-Zoghby et al., 2020), loss of freedom, loneliness, strangeness of the disease, uncertainty surrounding the disease, and inadequate information about the disease (Brooks et al., 2020) are some of the unpleasant experiences of disease outbreak and quarantine; and these increase the vulnerability to anxiety, depression, and other symptoms of psychological distress (Brooks et al., 2020; El-Zoghby et al., 2020).

Having knowledge and awareness of a disease outbreak can give a sense of relaxation which may further reduce the psychological distress that may be associated with it (El-Zoghby et al., 2020). This is further supported by Mishra et al. (2016) in which it was found that health care workers have a lower level of psychological distress; and this was attributed to their high level of awareness, knowledge, and attitude during the outbreak. The role of adequate information and knowledge about a disease outbreak in reducing the negative impact of the disease on mental health has been further buttressed in a survey that assessed stress reactions among health care workers involved with the SARS outbreak (Bai et al., 2004).

Studies have also shown that people who have adequate information and knowledge about COVID-19 pandemic are less likely than others to develop psychological distress (Wang et al., 2020a). Similarly, it has been reported that during disease outbreak, inadequate information and knowledge about the disease is associated with psychological distress among quarantined persons (Johal, 2009).

Following the announcement of the index case of COVID-19 in Nigeria on 27^th February 2020, and the increasing spread of the disease, the National Judicial Council suspended all court activities on the 24^th of March 2020, with the exception of cases that are urgent, essential, or time-bound (Nigerian Correctional Service, Enugu Custodial Center Medical Department, 2020; Yahaya, 2020). Therefore, while the nation was on lockdown, a few of these exceptional cases were arraigned in court and then remanded in custody.

Considering that the COVID-19 status or a history of exposure to the disease could not be ascertained among these new inmates, there was a great need for them to be quarantined for 14 days. When it became obviously difficult to effectively and appropriately quarantine new inmates in custodial centers across the nation, the Controller-General of the Nigerian Correctional Service in collaboration with other arms of the justice system, completely suspended the remand of all inmates in the custodial centers on the 8^th of April, 2020. Consequently, new inmates were no longer remanded in Enugu Custodial Center Nigerian Correctional Service).

Objectives

Knowledge about inmates’ psychological responses to quarantine will help in early identification and intervention to those that are vulnerable to developing psychological problems after the quarantine period. Hence the need for this study that aimed at: (1) assessing the level of knowledge about COVID-19 pandemic among quarantined inmates (2) determining the level of psychological distress among quarantined inmates (3) evaluating the relationship between level of Knowledge about COVID-19 and psychological distress (4) and to evaluate the relationship between COVID-19 knowledge and demographic variables.

Methods

Ethical considerations

Permission and approval for this study was obtained from the Nigerian Correctional Service. The objectives of the study were explained to all the participants, and they were assured of confidentiality of their information. They were made to understand that they could withdraw from participation in the study at any time without being victimized. They were then asked to provide their answers voluntarily after giving their consent.

Study design and setting

This was a cross-sectional study conducted in Enugu Maximum Security Custodial Center, located in Enugu metropolis, South East Nigeria. It has a statutory capacity for 638 inmates (Okoro et al., 2018). However, at the time of this research, the number of inmates fluctuated between 2,041 and 2,088, including the 46 female inmates. While two cells were made available for the purpose of quarantining new male inmates, one cell was provided in the female wing for this purpose.

Participants

Two cells in Enugu Custodial Center which were hitherto occupied by old inmates were emptied and reserved for the purpose of quarantining new male offenders remanded in custody. Similarly, one cell was made available for new female inmates. During this period, these new inmates were quarantined and restricted from having contact with other inmates. Hence, two cells were used to quarantine all 63 male inmates, while one was used for all 3 female inmates. All male inmates remanded in custody between 24^th and 31^st March, 2020 were quarantined in the first cell, while those remanded between 1^st and 8^th April, 2020, were quarantined in the second cell. The 14-day count for each cell began on the last day of the week for each quarantine cell (i.e., 31^st March for the first cell, and 8^th April for the second cell).

The three female inmates in this study were remanded between 24^th and 31^st March, 2020. Hence, they were all kept in one quarantine cell in the female wing of the custodial center.

Upon arrival at the quarantine cells, the reason for the quarantine and the number of days (14 days) it would last was explained to the inmates; and at completion of the 14-day quarantine, all the inmates in a particular quarantine cell appeared before the custodial center’s admission board for the usual admission process for all new entrants brought to the custodial center. This process entails the proper documentation of inmates’ information, allocation of cells, and other administrative processes. Thereafter, they were taken to the clinic of the custodial center where the interview was conducted.

All 66 inmates (34 in the first week, and 32 in the second week) that completed the 14-day quarantine gave their consent to participate in the study after the objectives were explained to them. They were made to understand that they could withdraw from participation in the study at any time without being victimized. In order to minimize frequent contact between the researchers and the participants, the instruments (The socio-demographic questionnaire and K10) were interviewer administered and were read aloud for each participant to indicate the answer as it applied to him/her. Additionally, for the purpose of privacy and confidentiality, this was done for one participant at a time in the consulting room of the clinic.

Inclusion criteria were all new inmates that completed the 14-day quarantine and gave consent to participate in the study. Exclusion criteria were inmates with florid psychosis and those with severe physical illness. However, no participant was excluded for the study as none met the criteria for exclusion.

Variables

The outcome variable in our study was the level of knowledge about COVID-19 which was measured on a continuous scale; whereas demographic variables and psychological distress were the independent variables which were categorical variables.

Measurement

Socio-demographic questionnaire

A socio-demographic questionnaire (see Extended data; Okoro, 2020) designed by the researchers has two sections (A and B) which were used for data collection. Age, marital status, highest level of education, previous prison remand, and the number of days spent in police jail were the variables contained in “Section A” of the socio-demographic questionnaire.

“Section B” contained questions that assessed each participant’s knowledge about COVID-19. The development of the “Section B” was guided by the survey of Zhong et al. (2020). Pilot-testing was done on 10 randomly selected inmates of the custodial center that were not part of the main study. Ambiguous questions noted during the testing were modified to obtain the final version of the COVID-19 knowledge questionnaire. It contains 10 items measuring the respondents’ knowledge about COVID-19 in 6 domains: aetiology (B1 and B2), transmission (B3 and B4), symptoms (B5), complications (B6 and B7), treatment (B8), and prevention (B9 and B10). The responses to each item of the questionnaire are “yes,” “no,” and “I do not know.”

A correct answer has a score of 1, while a wrong or “I do not know” response has a score of 0. Therefore, the total score ranged from 0 to 10; and a higher score indicates a greater knowledge of the disease. Our study further categorized COVID-19 knowledge into three groups of poor knowledge (total score of 0–3), average knowledge (4–6), and adequate knowledge (7–10). A Cronbach’s alpha of 0.89 was obtained on test of reliability (internal consistency) of the questionnaire, and this is within acceptable range.

Kessler Psychological Distress Scale (K10)

This is a 10-item self-reported or interviewer administered questionnaire used to screen for psychological distress. Each item score ranges from 1 (none of the time) to 5 (all of the time); hence, a minimum score of 10 and a maximum of 50 can be obtained. A higher score indicates more psychological distress such that a score of 10–19 means the respondent is likely to be well; 20–24 indicates mild distress, 25–29 indicates moderate distress, while 30–50 indicates severe distress (Andrews and Slade, 2001; Kessler et al., 2002). The K10 scale has been used in the prison population (Ibrahim et al., 2015).

Given that the assessment was for the period of two weeks the participants had stayed in custody, the present study adopted the Kessler Psychological Distress Scale (K10) with a slight modification of the opening sentence to reflect the duration. Therefore, the opening sentence for all the 10 items on the scale started with “In the past two weeks.” This was against the usual opening sentence of “In the past four weeks.”

For example, an item on the scale which read “In the past four weeks, about how often did you feel nervous?” was modified to read “In the past two weeks, about how often did you feel nervous?”

Statistical analysis

Data analyses were done using the Statistical Package for Social Sciences (SPSS) statistical software, version 20. Results were presented in frequency table; and a chi-square-test was used to determine the association between COVID-19 Knowledge Questionnaire and the independent variables. The significant value was set at p<0.05.

Results

Participant backgrounds

Table 1 shows the characteristics of all 66 participants. In total, 63 (95.5%) of them were male inmates, while the remaining 3 (4.5%) were female inmates. The mean age and mean score of COVID-19 knowledge were 28.39 ±8.71 and 3.82 ±3.33, respectively. A total of 35 (53%) of the participants had poor knowledge of COVID-19, while only 21 (31.8%) had adequate knowledge. Of the participants, 14 (21.2%) were recidivists, and 61 (92.4%) were awaiting-trial inmates. A total of 23 (34.9%) had no psychological distress, while 20 (30.3%), 14 (21.2%), and 9 (13.6%) had mild, moderate, and severe psychological distress, respectively.

Participant knowledge about COVID-19

Table 2 shows the responses of the participants to COVID-19 knowledge questionnaire. A majority of the participants (68.2%) correctly responded that death can be a complication of COVID-19. Half of them (50%) correctly responded that regular hand washing with soap and water can help prevent the spread of the disease. A little above one-quarter (27.3%) correctly answered that COVID-19 can affect the lungs, and less than one-third (30.3%) correctly responded that COVID-19 is caused by a virus. Individual-level answers to each question are available as Underlying data (Okoro, 2020).

Associations between knowledge of COVID-19 and other measured variables

COVID-19 knowledge was divided into three groups of poor knowledge (total score of 0–3), average knowledge (4–6), and adequate knowledge (7–10). Table 3 shows the relationship between the groups and other variables. Education was significantly associated with COVID-19 knowledge as 17 (48.6%) of those who completed at least secondary school had adequate knowledge of the disease; whereas it was 4 (12.9%) among those who did not complete secondary school.

Ten (43.5%) of those without psychological distress had adequate knowledge, while it was 11 (25.6%) among those with psychological distress. Additionally, 10 (34.5%) of those who were already in police jail before the index case of the disease was announced in Nigeria had adequate knowledge of the disease, while it was 11 (29.7%) among those who were arrested and brought to police jail after the index case.

Discussion

COVID-19 is a high infectious disease that is currently ravaging the world and has led to threat and loss of lives. Its novelty and high transmission rate remain a major concern; as a result, information about it is speedily and recently being gathered through research (Adhikari et al., 2020; Hassan et al., 2020). Our study showed that the overall and specific knowledge about COVID-19 is poor among prison inmates, and this is lower than the knowledge level of COVID-19 among the general population in Nigeria, India and China. (Ayinde et al., 2020; Bhagavathula et al., 2020; Zhong et al., 2020). For example, only 21 (31.8%) of our participants had adequate knowledge about COVID-19, and this is far lower than the knowledge level of 78.6% among health care workers in Nigeria (Ayinde et al., 2020).

Several explanations may be attributed to these differences. First, the participants in our study had lower educational qualification compared to those in India and Nigeria where the participants were health care workers, who unsurprisingly, should have more exposure and access to information regarding COVID-19. Second, the study in China was an online survey, and the participants’ ability to use the internet requires a certain level of intelligence. Hence, it is likely that the participants in the study in China have a higher level of intelligence than our participants.

On the factors associated with adequate knowledge about COVID-19, our study found that adequate knowledge of COVID-19 was significantly higher among those who had higher educational level. This replicates the findings of a study among health care workers in Nigeria in which adequate knowledge of COVID-19 was higher among doctors and nurses when compared with others (Ayinde et al., 2020). This may be explained by the fact that knowledge is believed to be founded upon the gathering of information through education (Bilge and Keskin, 2014; Sani et al., 2016).

Quarantine, together with other factors such as fear of the disease and overcrowding associated with it can result in a high level of psychological distress among people during disease outbreak (Blendon et al., 2004, 2006; Pfefferbaum and North, 2020; Robertson et al., 2004). Psychological distress was found in 43 (65.2%) of our participants, and this is higher than the 34% reported in Australia (Taylor et al., 2008) using the same scale (K10) to measure anxiety. Some of the explanations for the difference are; first, the prison population is associated with overcrowding, fear, and loss of freedom and privacy, which may likely heighten the level of stress, therefore, increasing the rate of psychological distress (Okoro et al., 2018). Second, social support from family members and friends has been found to be protective against psychological distress. The participants in our study lacked complete social support from their family members and friends during the quarantine period as visitors were not allowed into the custodial center during this period; whereas those in the Australian study were not completely separated from their family members.

With respect to the relationship between psychological distress and knowledge about the disease, we found that adequate knowledge about COVID-19 was higher among those without psychological distress than among those with psychological distress. This is similar to previous research findings where adequate knowledge and information about a disease outbreak was associated with better appraisal and emotional response (Blendon et al., 2004; Wang et al., 2020b).

Finally, we observed that those that were already in police jail before the COVID-19 index case in Nigeria were more knowledgeable about the disease than those that were brought to police jail after the index case. With the announcement of the index case and subsequent increase in the spread of the disease, there was great emphasis on decongestion of detention centers. This may have afforded the inmates already in police jail the opportunity of having access to information regarding COVID-19, thus, increasing their knowledge about the disease.

Our findings have several implications including the need for Nigerian Correctional Service to have adequate cells for isolation of contagious diseases, since social distancing is almost impossible in the prison population. There is need for the implementation of alternative to imprisonment such as community service to help reduce the overcrowding in prison. Given that crime is still being perpetrated despite the suspension of court activities, online trial of cases should be considered by the judiciary. Additionally, those offenders that may still be remanded in custody should have testing for COVID-19, and other contagious diseases. Finally, the on-going decongestion of custodial centers by the judiciary should be encouraged and sustained beyond COVID-19 era and effort should be made by the authority to transfer some inmates from congested custodial centers to centers with fewer inmates across the nation.

Our work is the first study about COVID-19 knowledge and impact among offenders in Africa. It also provides opportunity for educating both the inmates and staff of the custodial center about the disease. We were limited by the fact that the inmates, especially those that had psychological distress on the screening scale, could not be further examined with a diagnostic instrument to confirm any case of Psychological disorder. Another limitation was not assessing the inmates’ exposure and access to information regarding COVID-19 while in police detention cells or prior to that, as this may affect their level of knowledge regarding the disease.

Conclusion

COVID-19 is a highly contagious disease currently affecting the general population as well as the prison population. As much as social distancing is almost impossible in prison because of overcrowding, placing new inmates on quarantine appears much easier and practicable. Considering the low level of knowledge about COVID-19, the high level of psychological distress, and the relationship between high educational level and knowledge about the disease among inmates placed on quarantine; there is a need to regularly educate people before, during and after quarantine. The essence of adequate information about a disease outbreak is its impact on reducing the negative psychological effects the disease may have on people placed on quarantine.

Recommendation

The environment in custodial centers is extremely stressful. Future studies should consider the factors contributing to stress in a custodial center and their associations with psychological distress. Similarly, future studies should consider a longitudinal study that assessed the level of psychological distress among inmates at entry into the quarantine cells and at the end of the 14-day quarantine period.

Data availability

Underlying data

Figshare: COVID-19 pandemic, psychological response, and knowledge of the disease among inmates of a custodial center in Nigeria.sav. https://doi.org/10.6084/m9.figshare.12227543.v2 (Okoro, 2020).

This project contains the following underlying data:

• COVID-19 pandemic, psychological response, and knowledge of the disease among inmates of a custodial center in Nigeria (SAV). (Underlying dataset in SAV format; see Extended data questionnaire for question codes.)

• COVID-19 Pandemic, Psychological Response to Quarantine and Knowledge of the Disease among inmates of a Custodial Center in Nigeria (CSV). (Underlying dataset in CSV format; see Extended data questionnaire for question codes..)

Extended data

Figshare: COVID-19 pandemic, psychological response, and knowledge of the disease among inmates of a custodial center in Nigeria.sav. https://doi.org/10.6084/m9.figshare.12227543.v2 (Okoro, 2020).

File ‘COVID-19 Questionnaire to participants’ contains the questionnaire given to each participant.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Publisher’s note

This article was originally published on the Emerald Open Research platform hosted by F1000, under the Coronavirus (COVID-19) collection.

The original DOI of the article was 10.35241/emeraldopenres.13684.2

Author roles

Okoro J: Conceptualization, Formal Analysis, Methodology, Project Administration, Validation, Writing - Original Draft Preparation, Writing - Review & Editing; Odionye T: Conceptualization, Methodology, Project Administration, Writing - Review & Editing; Nweze B: Conceptualization, Formal Analysis, Writing - Review & Editing; Onuoha M: Conceptualization, Writing - Review & Editing; Ezeonwuka C: Project Administration, Writing - Review & Editing; Owoh J: Conceptualization, Writing - Review & Editing; Nkire J: Conceptualization, Formal Analysis, Writing - Original Draft Preparation, Writing - Review & Editing

Amendments from Version 1

This second version differs from the first one in the following ways: First, the introduction was overhauled to be more specific to the examined variables as contained in the objectives of the study. Second, table 3 was completely replaced; while table 1 was modified to include a row for the categorized COVID-19 knowledge level. In the old table3, COVID-19 knowledge level was not categorized. However, the new table 3 and the modified table 1 show categorization of COVID-19 knowledge level into poor, average and adequate; where poor knowledge is a score ranging from 0-3, average is for score ranging from 4-6, and adequate for a score of 7-10. Third, there was also a major re-writing of the discussion segment to reflect the objectives of the study. Finally, recommendation was included and new references added.

The peer reviews of the article are included below.

Grant information:

The author(s) declared that no grants were involved in supporting this work.

Competing interests

No competing interests were disclosed.

Reviewer response for version 2

Ahmed K. Ibrahim, Community Health School, Faculty of Medicine, Assiut University, Asyut, Egypt

Competing interests: No competing interests were disclosed.

This review was published on 14 January 2020.

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recommendation: approve

Summary: This was a cross-sectional study to assess the psychological response to quarantine during COVID-19 pandemic and knowledge level about the disease among inmates of a Custodial Center in Enugu, Nigeria. A total of 66 new prison inmates were assessed for psychological distress using the Kessler Psychological Distress Scale (K10); and inmates’ knowledge about COVID-19 using a COVID-19 Knowledge Questionnaire developed by the researchers.

Participants had a mean age of 28.39±8.71 years; 63 (95.5%) were male inmates and 3 (4.5%) were female inmates. Sixty-one (92.4%) were awaiting-trial inmates, 43 (65.1%) had psychological distress, and 35 (53%) had completed at least secondary school. COVID-19 questionnaire mean score was 3.82±3.33. Thirty-one (21.8%) had adequate knowledge of COVID-19 (7-10 score), while 35 (53%) and 10 (15.2%) had poor (0-3) and average (4-6) knowledge, respectively. Adequate COVID-19 knowledge level was significantly higher among those that completed at least secondary school (48.6%) than those who did not (12.9%). Though not statistically significant, adequate COVID-19 knowledge level was commoner among those without psychological distress (43.5%) than those with psychological distress (25.6%).

Methods:

1. No sample size calculation, the small sample can't reflect robust findings 

2. No Reliability/validity assessment of the Knowledge scale which the author claimed to develop

3. The study design is inappropriate to fulfill the objectives 

4. Using univariate analysis to infer adjusted relationships are invalid 

5. Multiple confounders should be accounted for before getting to conclusion "i.e. mental state of prisoners, crime type etc.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

No

Is the study design appropriate and is the work technically sound?

No

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Behavioral (public health and community) medicine

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

Reviewer response for version 2

Paolo Roma, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy

Competing interests: No competing interests were disclosed.

This review was published on 25 June 2020.

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recommendation: approve

The authors adequately responded to the suggestions provided in the first round of reviews, at least by including criticisms of the study's limitations.

The article deserves for the particularity of the population, even if the research design could have been studied more accurately.

I suggest accepting it, just taking into account the specificity of the population examined.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

No source data required

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

1) Clinical Psychology 2) Mental Health 3) Forensic Psychology 4) Correctional Psychology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Reviewer response for version 1

Paolo Roma, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy

Competing interests: No competing interests were disclosed.

This review was published on 05 June 2020.

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recommendation: approve-with-reservations.

“COVID-19 pandemic, psychological response to quarantine, and knowledge of the disease among inmates in a Nigerian custodial center” is a simple yet interesting study, considering the population of interest.

Introduction and Objectives.

This section, as it stands, is too generic and should be reformulated taking into account the examined variables. For instance, regarding lockdown measures it would be useful to cite already published study on the general population. Among the others, my suggestions are: a) Mazza et al. (2020)¹; b) El‐Zoghby et al. (2020)²

Study design.

In the study design, two variables, which I believe are extremely important in light of the obtained results, are missing: a) an assessment – even an approximate one – of the inmates’ intellectual level, which clearly can impact their level of understanding regarding COVID-19: b) an assessment of inmates’ exposure to information regarding COVID-19, that is inmates’ opportunity to hear or obtain information regarding COVID-19 pathology. This element is particularly discriminant regarding COVID-19 knowledge and, furthermore, it is important since some inmates, even before the quarantine in the maximum-security prison, had already spent a period in a police jail. Authors should add these variables or properly explain their absence.

In the study design, the assessment of the actual problematic that is causing stress for inmates is also missing. In other words, inmates’ stress is primarily deriving from what? The start of the detention? The absence of contacts with family? Quarantine conditions? Prison overcrowding? Something else? Stress needs to be qualified. Authors should add this variable or properly explain its absence

Results.

Regarding COVID-19 knowledge, it would be important to look into a frequency analysis of total scores in order to understand whether inmates with little to no knowledge regarding COVID-19 interfere significantly with the total score. In other words, the inmates’ group could be divided in: little to no knowledge, average knowledge, full or almost full knowledge.

At pag. 6 (also Table 3), results indicate that inmates with low education have less knowledge regarding COVID-19. This result, without the aforementioned variables (intellectual level and exposure to information regarding COVID-19), does not say anything substantial. Moreover, in the study design, it would have been useful to explore if having no knowledge regarding the virus was linked to stress.

Regarding stress analysis, it would be very useful to conduct correlation analyses and not just mean differences between groups. For example, the total knowledge could be correlated with the years of education and with age.

Discussions.

Discussions should be reformulated in light of the aforementioned suggestions. Furthermore, there is again mention of the low level of knowledge regarding COVID-19 among inmates. However, this data can’t be taken as an absolute, since it is not compared with a population outside the prison. Authors should revise their discussions focusing on what knowledge inmates are lacking and what it would be useful for them to know regarding COVID-19.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

No source data required

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

1) Clinical Psychology 2) Mental Health 3) Forensic Psychology 4) Correctional Psychology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

References

1. Mazza C, Ricci E, Biondi S, Colasanti M, et al.: A Nationwide Survey of Psychological Distress among Italian People during the COVID-19 Pandemic: Immediate Psychological Responses and Associated Factors. International Journal of Environmental Research and Public Health. 2020; 17 (9).

2. El-Zoghby SM, Soltan EM, Salama HM: Impact of the COVID-19 Pandemic on Mental Health and Social Support among Adult Egyptians. J Community Health. 2020.

Johnson Okoro, Nigerian Correctional Service, Nigeria

Competing interests: The authors declare that there was no conflicting interest

This review was published on 09 June 2020.

Responses to questions from the second reviewer

(1) Reviewre’s comment on Introduction and Objectives.

This section, as it stands, is too generic and should be reformulated taking into account the examined variables. For instance, regarding lockdown measures it would be useful to cite already published study on the general population. Among the others, my suggestions are: 

a) Mazza et al. (2020) 1; b) El‐Zoghby et al. (2020) ²

Response from authors: The introduction has been re-written to be more specific of the examined variables and to include more references such as Mazza et al and El-Zoghby et al. as suggested.

(2a) Reviewer’s comment on Study design.

In the study design, two variables, which I believe are extremely important in light of the obtained results, are missing: a) an assessment – even an approximate one – of the inmates’ intellectual level, which clearly can impact their level of understanding regarding COVID-19: b) an assessment of inmates’ exposure to information regarding COVID-19, that is inmates’ opportunity to hear or obtain information regarding COVID-19 pathology. This element is particularly discriminant regarding COVID-19 knowledge and, furthermore, it is important since some inmates, even before the quarantine in the maximum-security prison, had already spent a period in a police jail. Authors should add these variables or properly explain their absence.

Responses from authors: These have been included as some of the limitations of the study.

(2b) Reviewer’s comment on the study design. The assessment of the actual problematic that is causing stress for inmates is also missing. In other words, inmates’ stress is primarily deriving from what? The start of the detention? The absence of contacts with family? Quarantine conditions? Prison overcrowding? Something else? Stress needs to be qualified. Authors should add this variable or properly explain its absence.

Response from authors: This has formed our recommendation for future studies.

(3). Reviewer’s comment on Results.

Regarding COVID-19 knowledge, it would be important to look into a frequency analysis of total scores in order to understand whether inmates with little to no knowledge regarding COVID-19 interfere significantly with the total score. In other words, the inmates’ group could be divided in: little to no knowledge, average knowledge, full or almost full knowledge.

At pag. 6 (also Table 3), results indicate that inmates with low education have less knowledge regarding COVID-19. This result, without the aforementioned variables (intellectual level and exposure to information regarding COVID-19), does not say anything substantial. Moreover, in the study design, it would have been useful to explore if having no knowledge regarding the virus was linked to stress.

Regarding stress analysis, it would be very useful to conduct correlation analyses and not just mean differences between groups. For example, the total knowledge could be correlated with the years of education and with age.

Response from authors: The knowledge level has been categorized as suggested. This necessitated a modification of table 1 and a new table 3.

The assessment of sources of stress was not done in our study as it was not part of the objectives of the study. However, it has been added in our recommendation for future studies.

(4) Reviewer’s comment on Discussions.

Discussions should be reformulated in light of the aforementioned suggestions. Furthermore, there is again mention of the low level of knowledge regarding COVID-19 among inmates. However, this data can’t be taken as an absolute, since it is not compared with a population outside the prison. Authors should revise their discussions focusing on what knowledge inmates are lacking and what it would be useful for them to know regarding COVID-19.

Response from authors: The discussion segment has been revised as suggested by the reviewer

(5) Reviewer’s comment on reference being inadequate.

Response from authors: References to Mazza et al and E-Zoghby et al have been made as suggested by the reviewer. More references were also added to address the comment of the reviewer.

(6) Reviewer’s comment on conflict of interest.

Response from authors: The authors declared no conflict of interest. The authors also declared that there was no grant received for the study

Reviewer response for version 1

Li Li, Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, United States

Competing interests: No competing interests were disclosed.

This review was published on 29 May 2020.

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Recommendation: approve-with-reservations.

Thank you for the opportunity to review this manuscript. This is an interesting topic. However, there are many concerns which should be addressed prior to the passing peer review.

My largest concern is the design and interpretation of the study. For example, the scale to assess inmates’ knowledge for COVID. Although it was developed by the authors, it should be compared with other available/similar scales, and validated it. If could not, then it is a limitation. Another concern is that inmates’ psychological status at baseline was not adjusted. Anyone was tested positive for COVID/or any symptoms consistent with COVID? These were missed. What medications are these participants taking? How to covariate these medications in the data analysis? Discussion is somewhat poorly organized and did not discuss/interpret own data well.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Mental health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Johnson Okoro, Nigerian Correctional Service, Nigeria

Competing interests: There was no competing interest

This review was published on 29 May 2020.

(1): Reviewer's concern: My largest concern is the design and interpretation of the study. For example, the scale to assess inmates’ knowledge for COVID. Although it was developed by the authors, it should be compared with other available/similar scales, and validated it. If could not, then it is a limitation.

The questionnaire on COVID-19 knowledge is to some extent similar to what was used by Zhong et al. (Zhong BL, Luo W, Li HM, et al.: Knowledge, attitudes, and practices towards

COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. Int J Biol Sci. 2020; 16(10):1745–1752).

The authors recognized the importance of validating the questionnaire for the population it was to be used on. This necessitated the conduct of a test of reliability (internal consistency) on 10 inmates, that were not part of the study, through a pilot study. The cronbach alpha obtained from the pilot testing was within acceptable range

(2): Another concern is that inmates’ psychological status at baseline was not adjusted. Anyone was tested positive for COVID/or any symptoms consistent with COVID? These were missed. What medications are these participants taking? How to covariate these medications in the data analysis? Discussion is somewhat poorly organized and did not discuss/interpret own data well.

Baseline psychological status and then a follow-up at 15th day (termination of quarantine) would have been lovely. However, it was not done in this study which was a cross-sectional one.

Inmates brought to the custodial center were not suspected, probable, or confirmed cases of COVID-19. They neither had any symptom of COVID-19 nor the disease itself.

They were quarantined and not isolated. The choice of word (quarantine cell and not isolation cell) was carefully used to represent its meaning in the medical parlance.

Isolation is for confirmed cases.

Quarantine is for those without the disease or any of its symptoms, but are needed to stay within the period of the disease incubation time to see if they will manifest the disease

The inmates were quarantined since they could not be tested before remand as suggested in our discussion. Therefore, none of the 66 inmates was expected to be on COVID-19 treatment,

Our discussion has been revised to cover the objectives.

(3) Reviewer’s question : No competing interests were disclosed.

There was no competing interest

Table 1.

Demographic, forensic, and other characteristics of the participants.

Socio-demographic variables	N=66	Percentage	Mean±SD
Mean age			28.39±8.71
Gender Male Female	63 3	95.5 4.5
Marital status Never married Married Separated/divorced/widowed	36 21 9	54.5 31.8 13.7
Level of education primary school is the maximum did not complete secondary school completed sec or tertiary school	17 14 35	25.8 21.2 53.0
Prison category Awaiting-trial inmates Sentenced inmates	61 5	92.4 7.6
Recidivist Yes No	14 52	21.2 78.8
Kessler’s scale well mild distress moderate distress severe distress	23 20 14 9	34.9 30.3 21.2 13.6
Time jailed in Police before COVID-19 index case in Nig after COVID-19 index case in Nig	29 37	43.9 56.1
Time spent in Police jail (days) Minimum Maximum	0 180		32.20±34.41
Knowledge of COVID-19 Poor (score of 0-3) Average (score of 4-6) Adequate (score of 7-10)	35 10 21	53.0 15.2 31.8
Knowledge of COVID-19			3.82±3.33

N=total number of participants; S.D=Standard deviation. Nig=Nigeria

Table 2.

Knowledge of COVID-19 among quarantined inmates in custodial center.

	Questions	Wrong answer n(%)	Correct answer n(%)
B1	COVID-19 is believed to have originated from animal	46(69.7)	20(30.3)
B2	COVID-19 is caused by a virus	46(69.7)	20(30.3)
B3	COVID-19 is transmitted by respiratory droplet and close contact	37(56.1)	29(43.9)
B4	COVID-19 can be transmitted from human to human	35(53.0)	31(47.0)
B5	Cough is one of the symptoms of COVID-19	35(53.0)	31(47.0)
B6	COVID-19 can affect the lungs	48(72.7)	18(27.3)
B7	COVID-19 can lead to death in some cases	21(31.8)	45(68.2)
B8	COVID-19 has a cure	62(93.9)	4(6.1)
B9	COVID-19 can be prevented by regularly washing of hands with soap and water	33(50.0)	33(50.0)
B10	For new entrants (including new inmates) into a community, placing them on quarantine for 14 days may help prevent the spread of COVID-19	45(68.2)	21(31.8)

Table 3.

The association between COVID-19 knowledge level and participants’ variables.

VARIABLES	COVID-19 LEVEL OF KNOWLEDGE			X2	p-value
	poor (0–3) n (%)	average(4–6) n (%)	adequate(7–10) n (%)
Psychological distress No Yes	10 (43.5) 25 (58.1)	3 (13.0) 7 (16.3)	10 (43.5) 11 (25.6)	2.18	0.33
Education pry/sec school drop-out completed sec or tertiary sch	25 (80.6) 10 (28.5)	2 (6.5) 8 (22.9)	4 (12.9) 17 (48.6)	17.94	<0.01
Age (years) Less than 30 30 and above	23 (54.8) 12 (50.0)	7 (16.7) 3 (12.5)	12 (28.5) 9 (37.5)	0.65	0.73
In police jail Before index case After index case	13 (44.8) 22 (59.5)	6 (20.7) 4 (10.8)	10 (34.5) 11 (29.7)	1.84	0.40

n=number; pry=primary; sec=secondary; sch=school; %=percentage.