Disparities in mental health among urban and rural populations show a marked gap, which are related to a number of factors ranging from political to anthropological factors. This phenomenon is present in high-income as well as middle- and low-income (LMIC) populations. However, these differences are accentuated in countries with a great proportion of LMIC rural or peri-urban populations, which is a public health problem (1). COVID-19 has shown these differences and has led to more inequity with respect to access to mental health in rural populations (2). Previous studies have demonstrated that anxiety, depression, and suicide levels have been higher in rural populations in comparison with urban populations (3, 4). However, other studies have shown low levels of anxiety and depression in rural populations (5, 6).

The impact of mental health can vary between rural and urban populations due to a combination of factors. Economic characteristics, societal differences, and the specific effects of COVID-19, such as mortality rates and quarantine measures, can contribute to these differences. One significant factor is the limited access to mental health services in rural areas, where there is a scarcity of trained psychologists and psychiatrists and a lack of suitable facilities (7). Moreover, stigma surrounding mental health issues, social isolation, limited social support, socioeconomic conditions, lifestyles, and environmental factors can all play a role in influencing the wellbeing of rural communities (8). It has also been observed that the adoption of protective behaviors against COVID-19 and health literacy during the pandemic differ among different socioeconomic groups in Iran, with lower levels reported in populations of low socioeconomic status (9).

Thus, not all the rural communities have felt the pandemic in the same way, and the neuropsychological impact can vary (10). In general, communities in Latin America face regional challenges, social and political conflicts, and have high levels of violence that can lead to mental disorders (11, 12). Rural populations in Latin America are grouped in the Andes (distributed between Peru, Chile, Colombia, Ecuador, Argentina, and Bolivia), and they suffer inequities that are marked compared to urban populations, characterized by low human development, low level of access to healthcare, economic limitations, and social, religious and cultural issues (13). Hence, COVID-19 can have a kickback effect on rural communities' mental health, where these disruptions have not been quantified.

The objective of this systematic review was to estimate the mental health problems among rural Andean populations in Latin America during the COVID-19 pandemic, highlighting the differences among inter- and intra-population groups.

This is the first systematic review of the literature on mental health problems in the Latin American population of rural areas of the Andes during the COVID-19 pandemic. We identified only 14 articles, which reveal that, in spite of the mental healthcare interventions during the pandemic, there exists an important frequency of symptoms of anxiety, depression, and stress in a limited group of publications on this important subject. Almost all of the articles were cross-sectional studies restricted to analyzing the adult or adolescent population of only one country. In addition, almost half of the documents included in this revision were gray literature from two-fourths of Latin American countries that had studies on rural populations in the Andes during the lockdown.

The main strength of this study is, for the first time, the analysis of mental health in the Andean rural population using gray and black literature. Two recent systematic revisions centered on LMICs have determined that Latin America, after Africa and Asia, has shown the worst overall mental health symptoms (33, 34). However, these meta-analyses have not included the rural or indigenous populations, which may have more deteriorated mental health. This even more deteriorated condition might be due to a mosaic of factors that include a lack of dialogue about sanitary decision-making in the face of COVID-19, which would already precede as a crucial factor (35), lack of access to quality healthcare services, low coverage and disorganization of medical attention (36), limited recourses to extend coverage of mental health programs, and low economic-social sustainability (6, 37).

According to World Bank data, 60% of the LMIC population lives in rural areas (India: 66%, China: 40%, and Sub-Saharan Africa: 59%) (38), communities where the pandemic has worsened in terms of infection and deaths. Other diseases such as the occurrence of cancer in the indigenous population are consequences of the disparities these regions face (39). In addition, the pandemic has accentuated this disparity due to the fact that several health programs are being abandoned or have been limited, which affects the rural population to a greater extent in comparison to the urban population concerning breast (86 vs. 88%) and cervical cancer (77 vs. 82%) screening (40). Taking this context into account, the rural population has been living in a paradox more than ever since health could not become sustainable with local needs, while confinement and the immediate cessation of their social and economic activities invaded their daily thoughts and caused mental conflicts.

Similar to our investigation, multiple studies informed us that mental health had deteriorated during the pandemic, which caused an increase in depression symptoms in Latin American countries (33, 34, 41). Furthermore, the prevalence of depression was reported to be 27% in the general European population (42), similar to our result in the rural population (27.6%). However, our results are different from the symptoms of depression reported in the general population of Southeast Asia (16%) and in Africa (45%) (43, 44). Our results suggested that approximately 45% of the rural population in Latin America has reported anxiety symptoms, showing a significant increase in previous reports in the general population worldwide (42–44). Social, economic, and cultural characteristics are key factors contributing to the different prevalence of depression and anxiety across regions and populations.

During the pandemic, indigenous and rural populations have highlighted their inequities while adopting health measures that have little dialogue with their social realities, even when knowledge about health and disease prevention is acquired through community interaction (5). As our results suggest, mental health programs do not appear to have an overall impact on the development of anxiety, depression, or stress symptoms in rural populations. In addition, it has been reported that the quality of life of rural and indigenous populations has been affected during the pandemic, so it is important to conduct organized activities to monitor mental issues in order to avoid complications, such as the high frequency of suicide in the rural populations (4).

Several studies have examined mental health on different continents, mainly focusing on urban populations and students. Systematic reviews conducted in Southeast Asian (43), African (44), Latin American (34), and Spanish (45) populations have revealed prevalence rates of anxiety symptoms ranging from 20 to 37%. These findings suggest a lower prevalence of anxiety compared to the results obtained in our study of the rural population. Similarly, our study indicated that 27.6% of the rural Latin American population exhibited symptoms of depression, which contrasts with the reported rates of 16% and 22% in Southeast Asian (43) and Spanish (45) populations, respectively. However, studies conducted in urban African (45%) and Latin American (35%) populations have reported higher prevalence rates (34, 44). These discrepancies may be attributed to the fact that the rural population is exposed to distinct social, economic, and political factors that can impact their mental health and potentially diminish their overall quality of life (8).

Language is an important factor to consider as non–Spanish-speaking populations have shown higher rates of mental health symptoms (34). In rural Latin American communities, where languages such as Quechua are commonly used, language can influence both the comprehension of COVID-19 prevention and control measures and the limited access to mental healthcare services provided in specific languages (7, 46, 47). Additionally, another influential factor is the prevalence of violence within Latin American populations (11, 47). Zhang et al. (34) study demonstrated a higher prevalence of anxiety in urban populations compared to Spanish (45) and Southeast Asian (43) populations. While this review supports our findings, our study indicates a greater burden of mental health problems in the rural population. These communities may face higher levels of violence, which may have been exacerbated during the pandemic, further worsening mental health (48–50). Additional research is needed to explore the role of these factors in mental health outcomes.

This study has limitations that must be acknowledged. First, the heterogeneity of the identified studies precluded meta-analysis, leading to the presentation of results in narrative form. Second, due to the nature of the lockdowns and social isolation during the pandemic in each country, there have been empirical and methodological limitations of each study (i.e., convenience sampling and various data collection tools) that have prevented oversimplification of the findings. Third, we included several gray literature studies that were limited by the varying quality of the documents identified (21–25, 29, 31). However, bias analysis of the studies has reported the risks of each study. Our study findings have revealed an important issue regarding the varying definitions of the rural population across different countries. This variation poses a risk of selection bias and misclassification, potentially hindering the generalizability of our interpopulation analysis. To address this limitation and ensure accurate characterization of the population in future research, it becomes imperative to stratify the population based on specific indicators. Fourth, mental health problems have been addressed differently in each study; thus, only some articles have reported levels of suicide or distress, and, therefore, the findings have not been generalized. Furthermore, most of the studies have been carried out in the adult rural population, but others have included adolescents and the elderly, where not all mental health issues have been evaluated (22, 23, 25, 27, 30, 31).

This is the first systematic review of mental health in the rural population of Latin America during the COVID-19 pandemic. The results identified adults, children, and adolescents with symptoms of anxiety, depression, and stress. Studies are limited and not available for all countries, and prospective designs are required to understand the changes in mental health problems in the epidemiological context of a health emergency and the subsequent sequelae once the pandemic is over. Further regional studies targeting indigenous and rural vulnerable groups are needed to determine the depth of mental illness and quality of life of populations, refine WHO guidelines, and inform the development of evidence-based and tailored mental illness prevention activities adapted to the culture of each population.

As part of future development on mental health in the Andean population, prospective study designs should be implemented to track and analyze changes in mental health problems over time, both during the course of the pandemic and after it has subsided. This will provide valuable information on the long-term impact and consequences of the pandemic on mental health. In addition, multicenter studies in Latin America will allow for a more representative understanding and assessment of the impact of mental illness on the quality of life of vulnerable rural populations, taking into account the specific challenges and circumstances faced by people in these areas and driving better interventions, support systems, and general wellbeing for these communities.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

JM-S, BC, and JM-E completed raw data collection and processing. JM-S, AJ-Q, BC, and HC-P performed the data analysis. JM-S, JM-E, and HC-P wrote and edited the manuscript with input from BC. All authors contributed to writing and finalizing the survey questions and to equally distributing the survey and they approved the final manuscript.