Pschycological Impact of Covid-19 Globally: A Multicentric Study.
1Dr. Tanya Singh, 2Dr. Alankrita Chaudhary, 3Dr. Navpreet Kaur, 4Dr. Shrikant Rajput, 5Dr. Abhay Chaudhary, 6Dr.Ajay Kumar Nagpal
1Post Graduate Student, Department of Public Health Dentistry K.D. Dental College &Hospital, Mathura
2Associate Professor, Department of Public Health Dentistry School of Dental Sciences Sharda University Greater Noida, Uttar Pradesh
3Professor And Head, Department of Public Health Dentistry, K.D. Dental College & Hospital, Mathura
4Post Graduate Student, Department of Public Health Dentistry, K.D. Dental College & Hospital, Mathura
5Post Graduate Student, Department of Public Health Dentistry, K.D. Dental College & Hospital, Mathura
6Professor And Head, Department Of Conservative Dentistry And Endodontics, K.D.Dental College
&Hospital, Mathura Corresponding Author: Dr. Tanya Singh ([email protected])
Abstract
Background: COVID-19 has spread all over the world and is listed as a pandemic by the World Health Organization. It started surfacing in China in November 2019 and has been on the rise in all major parts of the world. On 30th January, 2020, the first case of coronavirus pandemic in India was reported. During such state, citizens must stay confined at home with few justified exceptions. This whole situation drastically changed the life of the population, which can cause a wide range of psychosocial impacts. The main aim of the study was to assess psychological impact of covid-19 globally
Method: Cross-sectional, observational, web-based survey conducted during the peak of the pandemic to assess psychological impact of COVID-19 globally. By using Google forms, an online structured questionnaire with annexed informed consent form was developed. The survey link was generated and was sent through online platforms like WhatsApp, e-mails and Facebook to the contacts of the investigators.
Chi square test and multiple logistic regression analysis were used to analyze the data.
Result: The study population comprised total 839 participants including 345 (41.1%) males and 494 (58.9%) females. In this study, we found that about one fourth of participants around the globe showed moderate psychological stress, and about 45.7% participants showed high psychological stress. We also found that females, who were younger and unmarried showed high psychological stress.
Conclusion: Individuals who were younger, female or unmarried, were more vulnerable to psychological distress. The covid-19 pandemic had negative psychological effects globally.
Keyword: psychological, covid-19, stress
Introduction
The COVID-19 pandemic has threatened the health and lives of millions of people across the globe. On 30th January 2020, the World Health Organization declared a public health emergency of international concern.1. On March 11 2020, the WHO upgraded the status of the COVID-19 outbreak from epidemic to pandemic2.The coronavirus disease (COVID-19) pandemic is the greatest public health threat that the world has seen in the last 100 years. 34 It is well known that quarantine/isolation for any cause and in the context of a pandemic (severe acute respiratory distress syndrome/SARS, 2003) had been reported to be associated with significant mental health problems ranging from anxiety, fear, depressive symptoms, sense of loneliness5.The COVID-19 pandemic led to a prolonged exposure to stress. Some segments of the population seem to be more exposed to the risk of anxious, depressive, and post-traumatic symptoms because they are more sensitive to stress.6 The psychological consequences of infectious diseases have been reported to include depressed mood, anxiety, poor sleep, and increased fear and stress level7, 8, with posttraumatic stress disorder (PTSD) and depressive disorders being the most prevalent long-term psychological conditions.9To the best of our knowledge, the psychological impact and mental health of the general population living during the COVID-19 pandemic is unknown. There is an urgent need to deepen
our knowledge about mental global health as a first step to develop psychological interventions, so that the lasting psychological negative consequences of the pandemic can be reduced. This survey was therefore planned to assess psychological impacts of the COVID-19 globally.
Material And Materials
This survey was conducted across the globe in the month of May 2020. Due to the national lockdown, social media was used to conduct the survey across various countries.
Study design and participants
It was a cross sectional, observational web based study in which snowball sampling technique was used to pool the initial eligible respondents who could potentially recruit more respondents from their acquaintances. Study was conducted among general population across the globe.
Inclusion criteria
General population across world
Age 18-60 years & above
Having good understanding of English language
Having access to internet, and
Those who were willing to take part in the survey.
Exclusion criteria
Those who were not willing to take part in the survey.
Ethical committee clearance
Ethical clearance was obtained from Institutional Review Board.
Data collection
By using Google forms, an online semi-structured questionnaire with annexed informed consent form was developed. The survey link was generated and was sent through online platforms like WhatsApp, e-mails and Facebook to the contacts of the investigators. The link was first circulated at 11:00 IST on 1st May 2020 and kept open for responses till 11:00 IST on 31st May 2020. The respondents were motivated to refer links to their contacts for participation. The participants were auto-directed to the survey on clicking the link. The survey questionnaires would take around 5-7 minutes to complete. Total 839 responses were received by the stipulated time.
Questionnaires
As it was an online survey in English, individuals with age ≥18 years, internet access and those who were able to read and understand English were recruited. These online questionnaires contained a total of 41 questions consisting of 4 sections with several questions appearing sequentially in order of (1) General information including age, country, sex, marital status, occupation etc (2) Knowledge of COVID-19 (3) Psychological assessment using Kessler Psychological Distress Scale (4) Ways to cope up with the COVID-19 stress. The main outcome measure reported in this study was nonspecific psychological distress as measured by the Kessler Psychological Distress Scale10. This measure comprised 10 questions that asked respondents how often they had experienced certain symptoms during the preceding four weeks and responses were scored on a scale of 1 to 5 depending on how frequently each symptom was experienced, where 1 = 'none of the time', and 5 = 'all of the time'. Thus, a minimum score was 10, indicating no psychological distress, and a maximum score was 50, indicating the most severe level of psychological distress. Scores on the K10 were subsequently categorized into four levels: low (scores of 10–15);
moderate (scores of 16–21); 'high' (scores of 22–29) and 'very high' (scores of 30–50).
Data analysis
Data was recorded, tabulated, and statistically analyzed using IBM SPSS version 20. Simple binary logistic regression and backward stepwise multiple logistic analyses were performed to identify factors influencing high psychological distress. A binary coding of psychological distress was used in which high psychological distress was a combination of 'high' + 'very high' levels of psychological distress = 1 (i.e.
K10 scores of 22 or greater) and low psychological distress was a combination of 'low' + 'moderate' levels of psychological distress = 0 (i.e. K10 scores of 21 or less). Chi square test were performed to identify prevalence of psychological distress among study participants. All variables were entered into the model initially, with the factors influencing high least significant variables removed one at a time until only significant variables associated with values of p ≤ 0.05 remained.
Results
In total 839 respondents completed the online survey and of these majority of participants were females (58.9%), single (60%) and belonged to 21-30 years of age group. A total of 46.1% of the participants had graduate level of educational qualification and more than half of participants i.e. (55.9%) were belonged from professional background [Table 1]. Knowledge among study participants regarding COVID-19 were listed in Table 2.The prevalence of four level of psychological distress for the whole sample were showed in Table 3. The greatest prevalence of ‘very high’ psychological distress was reported for those in the 21- 30 years age group (22.9%).
With regard to the remaining socio-demographic variables the highest prevalence of 'very high' psychological distress were recorded for those respondents who were married (18.8%), those with family and dependents (20.6%), and those with PhD and above (26.4%) educational qualifications.The prevalence of 'very high' psychological distress was greater for respondents from Europe (32.8%) with prevalence figures being slightly lower for respondents from Africa (23.7%) and lower again for respondents from North America (20.3%) and Asia (15.6%).
Multiple linear regression analysis
All factors’ values in the multiple linear regression analysis were listed in Table 4.
Univariate analysis
Analysis by gender indicated a higher risk for high psychological distress for females (OR=1.00) compared to men (unadjusted: OR = 1.00; 95% CI: 0.66–1.31), however this difference was not significant (p = 0.689). Analysis by age indicated a generally decreasing trend in risk of high psychological distress with age, respondents in the youngest age categories (18-20, 21-30 years) had a higher risk of high psychological distress when compared to all other age groups.According to marital status, married people showed a high psychological distress (adjusted: OR =1.348, 95% CI: 0.006-0.090; p = 0.000) and the results were found to be statistical significant (p=0.000) The respondents having diploma degree had higher psychological distress (unadjusted: OR = 2.420, 95% CI: 0.969-6.046; p = 0.050).Compared to respondents in Europe (unadjusted: OR = 2.011, 95% CI: 0.129-0.678–; p=0.004), Africa (unadjusted: OR
= 1.851, 95% CI: 0.108–0.958; p =0.040), Asia (unadjusted: OR = 1.252, 95% CI: 0.197–0.108.; p =0.000) were at greater risk of high psychological distress than those in Australia (unadjusted: OR = 0.376, 95%
CI: 0.137–1.278; p =0.12) .
Multivariate Analysis
As compared to < 30 years age group, the following age groups: 31-40; 41-50; 51 & above were protective against high psychological distress (adjusted: OR = 1.5, 95% CI: 0.61-3.79; p = 0.365; adjusted: OR = 0.66, 95% CI: 0.21-2.045; p = 0.480; adjusted: OR = 1 respectively). Compared to respondents in North America, respondents in Europe (adjusted: OR = 2.00, 95% CI: 0.124–0.645; p=0.003), Africa (adjusted:
OR = 1.831, 95% CI: 0.368–0.143; p=0.039) and Asia ((adjusted: OR = 1.151, 95% CI: 0.110–0.365;
p=0.000) were at greater risk of high psychological distress, as were respondents in Australia (adjusted:
OR = 0.389, 95% CI: 0.137–1.284; p = 0.000) .Response of participants for intervention questions regarding Psychological Distress Level were shown in Table 5.Psychological distress among different continent were shown by graph in Figure 1.
Table 1: Demographic details of participants (n=839)
Demographic variable N %
Gender Female
Male
41.1 58.9
345 494 Age category (in years) 18-20
21-30 31-40 41-50 51 and above
62 485 193 60 39
7.4 57.8 23.0 7.2 4.6
Marital status Married
Single /unmarried Divorced
321 503 15
38.3 60.0 1.8
Family and dependents Yes No
734 105
87.5 12.5 Educational qualification Diploma
Graduate High school PhD and above Post graduate
33 387 74 72 273
3.9 46.1 8.8 8.6 32.5
Occupation Professional
Semi professional Clerical
Skilled
Unemployed and retired
469 26 2 30 312
55.9 3.1 0.2 3.6 37.2
Continent Africa
Asia Australia Europe
North America
38 639 25 58 79
38 639 25 58 79 Score of Kessler psychological 0-14 (low)
15-25 (moderate) 26-31 (high) 32-40 (very high)
287 212 195 145
34.2 25.2 23.24 17.2
TABLE 2- Knowledge among study participants regarding COVID-19
QUESTIONS RESPONSE RATE N(%)
1. Are you aware of COVID 19? Yes No
839(100%) 0 (0.0%)
2. COVID 19 is Pandemic Epidemic
Don’t know
826(98.4%) 10 (1% ) 3 (0.6%)
3. COVID19 pandemic will have impact on
People contacting the virus
Immediate family of patients
Everyone around the globe
Don’t know
279 (33.3%) 12 (1.9%) 539 (64.3%) 9 (1%)
4. The impact of this pandemic according to you will be
Transient Long lasting Permanent
160(18.8%) 654 (77.6%) 25 (3.6%)
5. What kind of impact can be seen of COVID 19?
Physical stress Psychological stress Economic stress Social stress All of above
15 (1.9%) 31 3.7%) 13 (1.5%) 20 (2.4%) 759 (90.5
6. Do you think media adds on to people anxiety?
Yes No Sometimes
457 (54.5) 315 (37.6) 67 (7.9%)
Table-3 Prevalence of psychological distress by demographic details Psychological Distress Level (K10 Score) Low
(10-15) (%)
Moderate (16-21) (%)
High (22-29) (%)
Very high (30-50) (%)
Total (%)
p-value
Gender Male
Female
35.4 33.2
24.9 25.7
22.3 23.9
17.4 17.2
100 100
0.909
Age category (in years)
18-20 21-30 31-40 41-50 51 and above
21.0 33.6 30.6 41.7 66.7
35.5 22.9 29.0 33.3 10.3
37.1 20.6 29.0 25.0 2.6
6.5 22.9 11.4 0.0 20.5
100 100 100 100 100
0.000*
Marital status
Married Single Others
32.4 36.4 66.7
25.1 26.3 0.0
25.9 18.5 33.3
16.6 18.8 0.0
100 100 100
0.092
Family and dependents
No Yes
34.6 34.0
20.6 26.1
24.3 23.1
20.6 16.8
100 100
0.582
Education Diploma Graduate High school PhD. &
above Post graduate
27.3 34.6 23.0 38.9 35.9
24.2 24.3 29.7 16.7 28.2
39.4 22.5 29.7 18.1 22.0
9.1 18.6 17.6 26.4 13.9
100 100 100 100 100
0.050*
Occupation Professional Semi professional Clerical Skilled Unemployed and retired
38.4 38.5 50.0 26.7 27.9
25.2 7.7 0.0 30.0 26.9
21.5 26.9 0.0 23.3 25.6
14.9 26.9 50.0 20.0 19.6
100 100 100 100 100
0.107
Continent Africa Asia Australia Europe North America
31.6 39.0 20.0 8.6 19.0
15.8 24.6 40.0 39.7 21.5
28.9 20.8 36.0 19.0 39.2
23.7 15.6 4.0 32.8 20.3
100 100 100 100 100
0.000*
The chi-square test was used to estimate p-values (*<0.05)
Table-4 Factors associated with high psychological distress: Adjusted and Unadjusted Odds Ratios
Unadjusted OR Adjusted OR
OR 95% CI p- value OR 95% CI p-
value Gender Male
Female
0.932 1.00
0.661 1.315 0.689 - - -
Age category (in years)
18-20 21-30 31-40 41-50 51- above
2.803 3.808 1.546 0.682 1.00
1.022 1.581 0.620 0.222
7.685 0.172 3.857 2.094
0.045*
0.003*
0.350 0.504
2.754 3.798 1.525 0.669 1.00
1.007 1.581 0.612 0.219
7.533 9.123 3.797 2.045
0.048*
0.003*
0.365 0.480
Marital status
Married Single Others
1.348 1.024 1.00
0.006 0.097
0.091 1.243
0.000*
0.104
1.351 1.023 1.00
0.006 0.096
0.090 1.214
0.000*
0.097
Family and
dependents Yes No
1.227 1.00
0.745 2.018 0.422 - - -
Education Diploma Graduate High school PhD and above Post graduate
2.420 0.950 1.085 1.829 1.00
0.969 0.643 0.574 0.940
6.046 1.404 2.053 3.559
0.050*
0.798 0.801 0.075
- - - -
- - - -
- - - -
Occupatio n
Professio nal Semiprof essional Clerical/
Shopown er Skilled worker Unemplo yed and others
1.009 4.841 1.222 1.137 1.00
0.696 1.814 0.061 0.454
1.462 12.918 24.689 2.846
0.962 0.002*
0.896 0.783
1.017 4.716 0.982 1.150 1.00
0.704 1.807 0.050 0.461
1.470 12.311 19.181 2.871
0.927 0.002*
0.990 0.765
Continent Africa Asia Australia Europe North America
1.851 1.252 0.376 2.011 1.00
0.144 0.108 0.137 0.129
0.958 0.359 1.278 0.678
0.040*
0.000*
0.126 0.004*
1.831 1.151 0.389 2.00 1.00
0.143 0.110 0.137 0.124
0.952 0.365 1.284 0.645
0.039*
0.000*
0.128 0.003*
OR = odds ratio; CI = confidence interval Multiple logistic regression analysis was used to adjust the ORs for the factors listed in the table.
Table-5 Response of participants for intervention questions regarding Psychological Distress Level
Intervention questions
Psychological Distress Level (K10 Score) Low
(10-15)
N (%)
Medium (16-21)
N (%)
High (22-29)
N (%)
Very high (30-50)
N (%)
p-value
Telephonic and online counselling to people can be helpful in this period?
Yes No
Sometimes
189 (35.9) 17 (28.3) 80 (31.7)
120 (22.8) 19 (31.7) 74 (29.4)
117 (22.2) 15 (25.0) 63 (25.0)
101 (19.8) 9 (15.0) 35 (13.9)
0.174
Health apps can help to decrease anxiety and stress?
Yes No
Sometimes
139 (37.1) 49 (31.0) 98 (32.0)
89 (23.7) 41 (25.9) 83 (27.1)
75 (25.0) 37 (23.4) 83 (27.1)
72 (19.2) 31 (19.6) 42 (13.7)
0.133
Meditation and Yoga can help in relieving stress?
Yes No
Sometimes
232 (34.0) 5 (35.7) 49 (34.5)
169 (24.7) 2 (14.3) 42 (29.6)
163 (23.9) 5 (35.7) 27 (19.0)
119 (17.4) 2 (14.3) 24 (16.9)
0.673
Do you feel healthy lifestyle can be helpful?
Yes No
Sometimes
259 (33.3) 6 (50.0) 21 (42.0)
197 (25.4) 3 (25.0) 13 (26.0)
188 (24.2) 1 (8.3) 6 (12.0)
133 (17.1) 2 (16.7) 10 (20.0)
0.385
Do you think music can help in relieving stress?
Yes No
Sometimes
233 (33.6) 12 (31.6) 41 (38.0)
180 (26.0) 8 (21.1) 25 (23.1)
159 (22.9) 9 (23.7) 27 (25.0)
121 (17.5) 9 (23.7) 15 (13.9)
0.811
Spending time with family can help in overcoming stress?
Yes No
Sometimes
252 (35.0) 10 (41.7) 24 (25.5)
179 (24.8) 3 (12.5) 31 (33.0)
167 (23.2) 5 (20.8) 23 (24.5)
123 (17.1) 6 (25.0) 16 (17.0)
0.290
The chi-square test was used to estimate p-values (*<0.05)
Figure 1 Psychological distress among different continents.
Discussion
We found that about one fourth of participants around the globe showed moderate psychological stress, and about 45.7% participants showed high psychological stress. We also found that females, younger and unmarried showed high psychological stress.
Female were found to be more likely to suffer higher psychological distress. This result was consistent with the previous study which also showed that female might associated with the worse psychological status during COVID-19 pandemic 11. Females were more likely to have sleep problems, depressive symptoms12, and more instructive flashbacks as they were more sensitives and resulted in altered immune function and hormonal level 11,13. As of age, the present study showed that younger age reported higher psychological distress than middle age and elderly people in the younger age group as they were usually exposed to financial pressure, problem at work place and personal relationships. Another similar study surveyed by XIO Yang et al14 in China showed that the middle age group participants reported higher stress.We also found that unmarried respondents were more likely suffering high psychological distress than married. Also, a study by John O Elliott et al 15 showed that family cohesion and marriage quality were associated with higher anxiety and depression.In this study, level of education and occupation were associated to psychological distress. Similarly, Rocio Rodriguez- Rey et al 3 showed that low educational level and occupation were associated to high psychological distress. This might be due to reason that during lockdown many employed were forced to stop working or had lost their job during the lockdown.While assessing the knowledge among study participants 100% participants were aware of the COVID-19 which was in accordance with the study conducted by Kaustav Chakraborty et al.5More than half of the participants (54.5%) got more anxious after reading COVID-19 related news or media ads which was in contrast to the study conducted by the Kaustav Chakraborty et al.5 in which only one fourth of the participants got depressed and anxious after reading COVID related news.There were few limitations in our study. Firstly as it was a online survey it was accessible only to those who could use the internet. Secondly, a potential selection bias existed in our online survey, as snowball sampling was adopted due to lockdown which might reduce the generalizability of the findings to general population across the world. And lastly during lockdown the only feasible option for data collection was web based survey. For this reason, response rate was relatively low and the chances of response bias can not be completely ruled out. Further studies are therefore recommended by taking larger size. Also follow up studies are needed to obtain a clear picture of the magnitude of the psychological impact of COVID-19 pandemic.
Conclusion
Our study suggested that in the general population, individuals who were younger, females or unmarried, were more vulnerable to psychological distress. The COVID-19 pandemic had negative psychological effects globally.
References
1.Shanaya Rathoda, Saseendran Pallikadavath, Allan H. Youngc, Lizi Graves, Mohammad Mahbubur Rahman, Ashlea Brooks et al. Psychological impact of COVID-19 pandemic: Protocol and results of first three weeks from an international cross-section survey - focus on health professionals. Journal of Affective Disorders Reports 2020;1:100005.
2.Shankar Das. Mental Health and Psychosocial Aspects of COVID-19 in India: The challenges and responses. Journal of Health Management 2020;22(2):197–205.
3. Mariagrazia Di Giuseppe, Sigal Zilcha-Mano, Tracy A. Prout, John Christopher Perry, Graziella Orrù and Ciro Conversano. Impact of Coronavirus Disease 2019 among Italians during the first week of lockdown.
Front. Psychiatry 2020; 11: 576597.
4.Rocio Rodriguez -Rey, Heelna Garrido Hernansiz and Siliva Collado. Psychological impact and associated factors during the initial stage of the Coronavirus (COVID-19) Pandemic Among the General Population in Spain. Front. Psychol. 2020;11:1540.
5.Kaustav Chakraborty, Moumita Chatterjee. Psychological impact of COVID-19 pandemic on general population in West Bengal: A cross-sectional study Indian J Psychiatry 2020; 62:266-72.
6.Valeria Saladino, Davide Algeri and Vincenzo Auriemma. The psychological impact and social impact COVID-19 : New perspectives of life. journal Frontiers in Psychology 2020; 11:577684
7. Caiyun Zhang, Maolin Ye , Yunwei Fu , Minyi Yang, Fen Luo, Jinhua Yuan, and Qian Tao et al. The Psychological Impact of the COVID-19 Pandemic on Teenagers in China Journal of Adolescent Health 2020; 67: 747755 .
8. Su TP, Lien TC, Yang CY, et al. Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured SARS caring unit during outbreak: A prospective and periodic assessment study in Taiwan. J Psychiatry Res 2007; 41: 119-30.
9. Mak IWC, Chu CM, Pan PC, et al. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiat 2009;31:318-26.
10. Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al. Screening for serious mental illness in the general population. Kessler Psychological Distress Scale (K10) Arch Gen Psychiatry. 2003 Feb;60(2):184-189.
11. XTT L, AK D, T J, QN N, HT L, TTT D, et al. Evaluating the psychological impacts related to COVID- 19 of Vietnamese people under the first nationwide partial lockdown in Vietnam. Frontiers in Psychiatry.
2020; 11: 824.
12. Yang X, Yang X, Kumar P, Cao B, Ma X, Li T. Social support and clinical improvement in COVID-19 positive patients in China. Nursing Outlook. 2020; 68(6) :830-837.
13. Soni M, Curran VH, Kamboj SK. Identification of a narrow post-ovulatory window of vulnerability to distressing involuntary memories in healthy women. Neurobiol Learn Mem. 2013; 104:32–38.
14. Xiao Yang, Zhenzhen Xiong, Zhixiong Li, Xiao Li, Weiyi Xiang, Yiwen Yuan, Zhe LiI. Perceived psychological stress and associated factors in the early stages of the coronavirus disease 2019 (COVID-19) epidemic: Evidence from the general Chinese population. PLoS ONE 2019; 15(12) :0243605.
15. Elliott JO, Charyton C, Sprangers P, Lu B, Moore JL. The impact of marriage and social support on persons with active epilepsy. Journal of Epilepsy & Behavior. 2011;20(3):533-8.
