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 Table of Contents  
ORIGINAL ARTICLES
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 24-33

Consequences of COVID-19 pandemic on the mental health of general population in India


1 Department of Physiology, Gayatri Vidya Parishad Institute of Healthcare and Medical Technology, Visakhapatnam, Andhra Pradesh 530048, India
2 Department of General Medicine, Gayatri Vidya Parishad Institute of Healthcare and Medical Technology, Visakhapatnam, Andhra Pradesh 530048, India
3 Department of General Medicine, Government Medical College, Srikakulam, Andhra Pradesh 532001, India

Date of Submission22-Feb-2021
Date of Acceptance31-Mar-2022
Date of Web Publication18-Apr-2022

Correspondence Address:
Suryaveeramani Kartheek Adhikarla
D. No. 14-413, Sri Manikanta Nilayam, Near Naidu Cheruvu Gattu, Gujarathipeta, Srikakulam, Andhra Pradesh 532005
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajoim.ajoim_2_22

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  Abstract 

Background: COVID-19 pandemic poses a challenge to mental health. The perception of stress and its adaptation are determined by individual’s risk perception and coping mechanisms. Aim: The study aimed to evaluate the perceived stress and behavioral responses owing to COVID-19 pandemic. Materials and Methods: The online survey recruited 621 respondents. The survey included (1) sociodemographic variables, (2) Perceived Stress Scale (PSS)-10 item inventory, (3) four items on experience of stress, and (4) eight items on mental health-related lifestyle changes and societal support during the pandemic. Results: Out of 621, majority were females (54.1%) and belonged to the age group of 18–30 years (66.02%). Moderate perceived stress was observed in 67.1% of the respondents. The mean PSS scores were significantly higher among females, age group of 18–30 years, unmarried, educational qualification below undergraduation, and students. Higher perception of work and financial stress were present in 52.67% and 48.3%, respectively. Increased concern about family and vulnerability was confirmed by 89.05% and 54.59%, respectively. Increased work stress was negatively associated with attention toward mental health, emotional support, physical activity, and hobbies. Greater concern for family and vulnerability had showed positive association with attention toward mental health, emotional support, and protective behavior. Conclusion: In COVID-19 pandemic, females, younger age, and students had significantly higher stress perception. Work and financial stress were associated with maladaptive responses, whereas concern about family and feeling vulnerable were accompanied by positive adaptive responses. Thus, evaluating the cognitive and behavioral responses to stressors is imperative to quantify individual’s stress perception during exposure to a stressful situation such as pandemic.

Keywords: Coping mechanisms, COVID-19 pandemic, mental health, Perceived Stress Scale-10, perception of stress


How to cite this article:
Gara HK, Vanamali DR, Adhikarla SK. Consequences of COVID-19 pandemic on the mental health of general population in India. Assam J Intern Med 2022;12:24-33

How to cite this URL:
Gara HK, Vanamali DR, Adhikarla SK. Consequences of COVID-19 pandemic on the mental health of general population in India. Assam J Intern Med [serial online] 2022 [cited 2022 Oct 7];12:24-33. Available from: http://www.ajimedicine.com/text.asp?2022/12/1/24/343430




  Introduction Top


The current COVID-19 pandemic represents an ambiguous challenge marked by persistent health anxiety, risk of virus exposure, forced isolation, limited population mobility, changes in workplace dynamics, increased unemployment, and mandatory adherence to infection prevention and control measures resulting in emotional burnout and psychological distress.[1] Continuous broadcast regarding pandemic development compounded with surge of myths and misinformation and stigmatization of infected individuals also exaggerates misinterpretation of perceived bodily sensations which further fuels “Coronophobia.”[2]

Mental health is an integral part of person’s well-being through which he/she gains insight toward his/her coping potential for normal stressors and confers his/her productivity and contribution toward his/her community.[3] Stress is a function of an individual trait and the circumstances around them. The experience of stress is governed by threat appraisal and coping mechanisms.[4] Repeated stress activation shall trigger cognitive shifts to achieve emotional and behavioral changes which may be adaptive or maladaptive in nature.[5] Along with socio-economic, biological, and environmental determinants, coping capacity is partially mediated by one’s risk appraisal, access to medical and psychological aid, self-care, cognitive reconstruction, and avidity for evidence-based updates on pandemic.[6] Lesser risk perception may downplay the significance of pandemic and result in negligence and reduced accountability in recommended health practices. Those who perceive a threat may experience heightened sensitivity to stress resulting in general distress, excessive avoidance, or health-compromising behavior.[7]

Psychological disruption during pandemic can result in tensed family atmosphere, living pressure, and career resistance. Few studies addressing the potential mental health impact of COVID-19 have suggested that in countries without psychological intervention protocol for the outbreak, there has been an emergence and persistence of stress-related disorders.[1],[8] It is important to understand the implications of COVID-19, the disease itself, state of health emergency, and quarantine, on well-being of an individual. Though COVID-19 is a stressor experienced by everyone, there exists a substantial heterogeneity in each one’s stress perception and coping potentials.[7] Hence, the survey was attempted to estimate the prevalence of the perceived stress levels as well as to explore the differential behavioral responses attributed to COVID-19 pandemic.


  Materials and Methods Top


This was an observational, cross-sectional study conducted to assess the psychological impact of COVID-19 pandemic on Indian population from September 23, 2020 to October 18, 2020. The study was initiated after obtaining approval from the Institutional Ethical Committee. The snowball sampling technique was adopted for the survey for recruitment of the initial pool of eligible participants who would further recruit more respondents within their network for participation. An online semi-structured questionnaire with annexed informed consent form was developed as a Google Form in English language. Then the survey link was created and forwarded to the acquaintances of the investigators via various online portals such as e-mails, Facebook, WhatsApp. By clicking on the survey link and after consenting for participation, the participants were auto-directed to secure page to complete the questionnaire. To prevent missing responses to all the items, their responses were mandatory, and the respondents could submit their response if all questions were answered. The participation was voluntary, without any renumeration or incentives. No identifying information was collected to maintain anonymity of participation.

Being an online survey in English, individuals with internet accessibility, age not less than 18 years, and ability to read and understand English were recruited for the survey. The questionnaire consisted of four sections with a set of questions appearing in the sequential order as (1) sociodemographic variables, (2) Perceived Stress Scale (PSS)-10 item inventory, (3) four items concerned with experience of stressful factors during the COVID-19 pandemic with responses “yes” and “no,” and (4) eight items concerned with mental health-related lifestyle changes and societal support during the pandemic with responses “increased,” “decreased,” and “same as before.”

PSS-10 item inventory[9]

This instrument was developed by Cohen, Kanmarch, and Mermelstein, based on conceptualization of psychological stress.[9] It measures the degree to which the situations in an individual’s life are appraised as stressful. The items are general in nature and specific content free and are formatted to assess how unpredictable, uncontrollable, and overloaded the participants see their lives since the past 1 month. It is a self-rated, economic tool with good internal consistency (Cronbach’s α ranging from 0.78 to 0.91) and test–retest reliability.[10] It also has good construct validity as it moderately to strongly corelates with anxiety and depression.

The items in PSS-10 are dichotomized as four positively stated items (items 4, 5, 7, and 8) and six negatively stated items (items 1, 2, 3, 6, 9, and 10). The negative items intend to assess the lack of control and the negative affective behavioral reactions, whereas the positive items assess the degree of coping ability to the existing stressors. The 10 items are easy to administer and understand and deal with the feelings and thoughts regarding the present status of stress experience. The respondent has to score on a 5-point response scale to each item (“0=never,” “1=almost never,” “2= sometimes,” “3=fairly often,” and “4=very often”). The PSS scores of the four positively stated items are obtained by reversing the responses (0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0) and by adding to responses of the six negatively stated items to yield the final PSS scores. The total score ranges from “0” to “40.” Higher PSS scores corelate with a higher perception of stress. Scores ranging from “0 to 13,” “14 to 26,” and “27 to 40” were considered as “low,” “moderate,” and “high” perceived stress, respectively.

The sociodemographic variables included age, gender, area of residence, marital status, educational qualification, and profession. The survey tool took approximately 7–10 min to complete.

Sample size calculation

Based on previous study by Wang et al.,[11] 53.8% of the respondents reported moderate-to-severe psychological impact due to COVID-19 outbreak. Based on the central limit theorem, the minimum sample size for the study was calculated as 382 using the following formula:




where Z is the standard normal variate, d is the absolute error or precision, and p is the estimated proportion in the population depending on the previous studies. For our present study, Z=1.96 [at 5% type 1 error (P <0.05)], d=0.05, and P = 0.538.

Data analysis

The data collected were organized into an Excel spreadsheet. The data were quality-checked to ensure its accuracy and completeness. The statistical analysis was performed using SPSS (version 26) software. Descriptive variables were summarized as frequencies (N) and percentages (%). Categorical variables were expressed as mean (M) and standard deviation (SD). The χ2 test was utilized for comparison of group differences. Independent t-tests were applied to analyze the differences of mean values of PSS scores among various groups. Linear regression analysis assessed the association of various demographic variables with PSS scores. Keeping gender, age, educational qualification, profession, and family status as constant variables, the association of positive outcomes with negative predictive variables was determined by the multinomial regression analysis method. The P-value of less than 0.05 was considered to be statistically significant for all analyses.


  Results Top


A total of 621 responses were obtained for the present study. The study comprised 285 (45.9%) male and 336 (54.1%) female respondents. The demographic characteristics of the study participants along with the PSS are listed in [Table 1]. The mean age was 28.8 ± 10.073 years, and the minimum and maximum age of the respondents was 18 and 70 years, respectively. The majority of the participants belonged to the age group of 18–30 years [n = 410 (66.02%)] and urban area of residence [n = 524 (84.4%)]. Majority of the participants had moderate PSS [n = 417 (67.1%)], followed by low and high PSS in 19.6% and 13.2%, respectively. The mean PSS score of the participants was 19.29 ± 6.604.
Table 1: Demographic characteristics and Perceived Stress Scale of the participants (n = 621)

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Analyses between PSS score and various demographic co-variates revealed that the mean PSS score was statistically significantly higher among females (P = 0.007), age group of 18–30 years (P < 0.0001), unmarried individuals (P = 0.008), undergraduate educational status (P = 0.002), and students (P < 0.0001) [Table 2]. Linear regression analyses [Table 3] revealed that the PSS score had a strong positive association with age 18–30 years (P = 0.034) and undergraduates or below educational status (P = 0.042). The negative and positive affects perceived during COVID-19 pandemic are displayed in [Table 4] and [Table 5], respectively.
Table 2: Mean Perceived Stress Scale score of the participants (n = 621)

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Table 3: Linear regression analysis of factors associated with Perceived Stress Scale score (n = 621)

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Table 4: Responses for negative effects during COVID-19 pandemic (n = 621)

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Table 5: Responses for positive effects during COVID-19 pandemic (n = 621)

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Multinominal regression analysis [Table 6] and [Table 7] revealed that higher perceived stress (PSS score >13) had a negative impact on individuals as it was significantly positively associated with decreased attention toward mental health [β=1.388, odds ratio (OR)=4.007, P = 0.006], reduced time for physical activity (β=0.656, OR=1.926, P = 0.018), hobbies (β=0.957, OR=2.604, P = 0.0006), and exploring healthy lifestyle (β=0.931, OR=2.538, P = 0.016).
Table 6: Multinomial regression analyses of negative effect with mental well-being and emotional support during COVID-19 pandemic

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Table 7: Multinomial regression analyses of negative effect with lifestyle changes during COVID-19 pandemic

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Increased stress from work had a significant negative impact on mental health as it showed positive association with lack of emotional support from friends (β=0.651, OR=1.917, P = 0.007) and family (β=1.531, OR=4.626, P = 0.002), reduced caring of family members (β=1.488, OR=4.428, P = 0.006), reduced time for household activities (β=1.056, OR=2.875, P < 0.0001), physical activity (β=0.524, OR=1.689, P = 0.011), hobbies (β=0.747, OR=2.11, P < 0.0001), and exploration for good health (β=0.560, OR=1.75, P = 0.027). Increased financial stress was positively associated with reduced attention toward mental health (β=0.772, OR=2.165, P = 0.005).

Greater concern about family showed a significant positive impact on mental health as it had a positive association with increased emotional support from friends (β=0.961, OR=2.614, P = 0.009) and family (β=0.92, OR=2.509, P = 0.003), increased care for family members (β=1.3, OR=3.67, P < 0.0001) and increased time spent for sharing household activities (β=0.662, OR=1.939, P = 0.037), and exploring lifestyle interventions for good health (β=0.78, OR=2.18, P = 0.014). Respondents who felt vulnerable due to pandemic had a significant positive association with increased attention toward mental health (β=0.716, OR=2.046, P = 0.002), increased emotional support from friends (β=0.739, OR=2.095, P = 0.002), and reduced time for relaxation (β=0.914, OR=2.494, P = 0.002) and hobbies (β=0.788, OR=2.2, P = 0.0013).


  Discussion Top


The COVID-19 pandemic and implementation of public health measures have made individuals navigate through unchartered waters of various psychological stressors revolving around skepticism and constant vigilance, thus challenging mental well-being. The study aimed to explore the perception of stress and its associated variables as well as behavioral responses in pandemic.

In the present study, only 20% perceived low stress levels and almost 80% of the participants had moderate-to-high levels of perceived stress, respectively, based on PSS-10, which is a definite concern. In a study across 194 cities in China, moderate-to-severe psychological impact was reported by 53.8% of the respondents.[11] A meta-analysis on stress and anxiety during COVID-19 pandemic highlighted the prevalence of stress, anxiety, and depression in 29.6%, 31.9%, and 33.7%, respectively.[8] Thus, COVID-19 is the cause of not only physical health concerns, but also has consequential impact on mental well-being that might cause subsyndromal psychiatric concerns and need for psychological intervention.[1]

In the present study, females reported significantly higher perception of stress than males during COVID-19 pandemic, similar to the findings by Wang et al.[11] One reason could be gender difference of coping mechanisms for psychosocial and physiological stressors and increased vulnerability to internalizing-spectrum symptoms and depression.[12],[13] Also, the individuals of age group 18–30 years reported significantly higher perception of stress when compared with other age groups. Liang et al.,[14] in their survey among youth, had observed prevalence of COVID-19-related psychological problems in 40.4% of the respondents. A longitudinal cohort study among young adults of Switzerland highlighted increased stress and anger during pandemic than before.[15] COVID-19 pandemic has created a perfect storm for psychological stress attributed to work from home, school closures, social isolation, curtailment in vacation and entertainment options, unavailability of house help, increase in caregiver burden, health risk exposure, etc.

In the present study, significantly higher stress was perceived by students when compared with other professionals, similar to findings by Wand et al.[11] It can be attributed to uncertainty about examinations and interruption in academic activities. Though pedagogy instructions have continued through online portals, apprehension about technology, lack of quintessential social classroom atmosphere, and reduced peer interaction may exacerbate psychological distress among students. Hazma et al.[16] had observed an increase in psychological distress and a reduction in well-being among university students without pre-existing mental health, which could have stemmed from social isolation and loneliness. Owing to parallel responsibilities of work and parenting demands as well as emotional strains, overstressed parents might spillover and depreciate child’s needs and cues.[17] Hence, it is crucial to preserve the sense of safety and support among children and adolescents through positive parenting, especially during the pandemic.

In the present study, individuals with educational qualification of undergraduation or below perceived significantly higher stress compared with those with higher educational qualification, similar to findings in the study by Liang et al.[14] Majority of healthcare workers (HCW) also perceived moderate-to-severe stress during pandemic. The possible causes could be direct contact with COVID-19 patients, psychological breakdown while using personal protective equipment, exposure to patient’s negative emotions, being quarantined, discrimination isolation, and higher exhaustion.[18] A systematic review of 13 studies on mental health on HCWs synthesized the pooled prevalence of anxiety of 23.3%, depression 22.8%, and insomnia 38.9%, thus demanding timely early interventions to mitigate acute and long-term consequences on mental well-being of HCWs.[19] To promote positive behavior among citizens, telephonic mental rehabilitation helpline “KIRAN” (1800-500-0019) has been developed by the Department of Empowerment of Persons with Disabilities, Ministry of Social Justice and Empowerment, Government of India.[20]

The present study revealed perception of increased stress form work as well as financial stress in almost 50% of the respondents. Overlapping of personal and professional spaces and juggling responsibilities in an unhealthy way may translate into reduced engagement, dissatisfaction, and emotional burnout.[13] Increase in work stress had a negative impact on compassion toward family, emotional support, and recreation. Thus, perception of negative effects was associated with depleted coping mechanisms, thus demanding leverage of technology and accessible, equitable mental wellness support now more than before.

In the present study, nearly 40% of the respondents reported reduction in time for exercise and hobbies during the pandemic. The moderate perceived stress level was negatively associated with attention toward mental health and time spent on physical activity and hobbies. Also, a similar study in UK public during COVID-19 times highlighted a negative association between physical activity (in hours) and poor mental health.[21] Enhanced perception of stress may impede resilience and decision-making adroitness.

In the present study, majority of respondents has increased inclination toward family in terms of emotional support, sharing household activities, and active search of information pertaining to health and infection. Connectivity with peers and family can act as a potential buffer to feelings of anxiety, depression, and social isolation. Also, a positive relationship was observed between perception of vulnerability and engagement in protective behavior in our study, similar to the findings by Yıldırım et al.[22] Vulnerability may act as motivating force toward behavioral interventions and compliance with positive health outcomes. Cognitive reconstruction like spending time with family, increased compassion, self-care, recreational activities, seeking psychological support can be regarded as effective adaptive coping strategies to reduce stress.[1],[5] Resilience and tolerance to negative effect have a positive impact on psychological well-being.[23] Thus, positive adaptation and endeavor to defy negative experience shall make an individual proactive to deal with life stressors.

Thus, it is clear that COVID-19 has substantial repercussions on mental health. The emotional, social, and cognitive adaptation to stress are procedural in nature and it changes as the stressor persists over a period of time. Long-term negative impact may effectuate as hypersensitivity to stressor, emotional numbness, vivid intrusive reminiscences, and abated coping competency.[6],[7] Hence, it is essential to extrapolate the nexus between stressors and psychosocial behavior to plan comprehensive crisis prevention and design culturally sensitive egalitarian interventions and rehabilitation services. Cognizance about adaptation and symptomatic/somatic reactions to stress may instigate public to seek medical help as per need.[24] Also, regular tailored assessments shall encourage people to assimilate realistic information about disease and to adopt protective behavior for pandemic containment.

The study has few limitations. The findings in the study are based on self-reported data, which may have the potential of reporting bias. Data collection by snowball technique had an opportunistic approach as it relied on voluntary recruitment and resharing via social networking, thus introducing selection bias. Exclusion of individuals who were not on social network as well lack of English language proficiency limits its generalization to total population. The study did not include other potential factors such as social isolation, neighborhood profile, status of infection in the family, and access to resources, which can also influence the stress perception among the individuals during the COVID-19 pandemic. As the study is cross-sectional in nature, the perceived stress was measured at one point of contact. The temporal relationship between perceived stress levels and the potential stressors cannot be determined. So, a prospective follow-up study may accomplish this goal. However, the present study results on mental health in the community may serve as a snapshot of perception of stress and coping mechanisms during the COVID-19 pandemic.


  Conclusion Top


In the present study, more than 50% of the respondents had moderate perception of stress which requires urgent attention. Females, younger age (18–30 years), and students had significantly higher perception of stress. Work and financial stress were associated with maladaptive responses, and concern about family and feeling vulnerable were accompanied by positive adaptive responses and protective behavior. As COVID-19 pandemic results in repeated activation of psychological stressors, it is imperative to identify vulnerable individuals and provide them with psychological support to preserve mental well-being.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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