Abstract:

This study aimed to assess the prevalence and variables related to perceived stress associated with the COVID-19 pandemic in a sample of Colombian adults using a designed online cross-sectional survey. Adults answered a version of the Perceived Stress Scale (PSS-10) modified for COVID-19 (PSS-10-C), with Cronbach alpha equal to 0.86. In total, 406 individuals aged between 19 and 88 years (M = 43.9; SD = 12.4) agreed to participate in the survey: 61.8% were females, 90.6% had a university degree, 44.1% were health professionals, and 45.7% considered public health policies for preventing the spread of the disease inconsistent with scientific recommendations. PSS-10-C scores ranged from 0 to 36 (M = 16.5; SD = 7.3); 58 individuals (14.3%) scored for high perceived stress (cut-off point = 25). The inconsistency between policies and scientific evidence was significantly related to high perception of stress associated with COVID-19 (OR = 2.36; 95%CI: 1.32-4.20), after adjusting for gender. We concluded that the study group presented the prevalence of perceived stress associated with COVID-19 at high levels, arising from the inconsistent strategies developed by health authorities in view of scientific recommendations. Further researches must address the psychosocial aspects of epidemics.

Keywords:
COVID-19; Quarantine; Psychological Distress; Cross-Sectional Studies

Resumen:

El objetivo de este estudio fue conocer la prevalencia, y algunas variables asociadas con el estrés percibido relacionado con la epidemia de COVID-19, en una muestra de adultos colombianos. Los autores diseñaron una encuesta transversal en línea. Los adultos respondieron una versión modificada de la Escala de Estrés Percibido (Perceived Stress Scale, por su siglas en inglés PSS-10); relacionado con la COVID-19 (PSS-10-C) y su alfa de Cronbach fue 0,86. Un total de 406 encuestados aceptaron participar. Las edades de los encuestados oscilaban entre los 19 y los 88 años (M = 43,9; DE = 12,4). Un 61,8% eran mujeres, un 90,6% con educación universitaria, un 44,1% trabajadores del sector salud, y un 45,7% de los participantes consideraron que las políticas públicas de salud para prevenir la propagación de la epidemia no se adecuaron a las recomendaciones científicas. El PSS-10-C tuvo una puntuación entre 0 y 36 (M = 16,5; DE = 7,3); un total de 58 participantes (14,3%) obtuvieron una puntuación para alto estrés percibido (punto de corte en 25). La inconsistencia entre las políticas tomadas y las evidencias científicas estuvo significativamente asociada con un alto estrés percibido, en relación con el COVID-19 (OR = 2,36; 95%CI: 1,32-4,20), tras realizar un ajuste por sexo. En conclusión, es alta la prevalencia del estrés percibido relacionado con el COVID-19 en esta muestra de personas colombianas. El estrés alto está relacionado con la percepción de inconsistencia entre los acuerdos de las autoridades de salud y las recomendaciones científicas. Asimismo, se necesitan más investigaciones enfocadas en los aspectos psicosociales de la epidemia.

Palabras-clave:
COVID-19; Cuarentena; Distrés Psicológico; Estudios Tranversales

Resumo:

O estudo teve como objetivo conhecer a prevalência e algumas variáveis associadas à percepção de estresse relacionado à pandemia da COVID-19 em uma amostra de adultos colombianos. Os autores desenharam um estudo transversal. Os adultos responderam a uma versão modificada da Perceived Stress Scale para a COVID-19 (PSS-10-C), que apresentou alfa de Cronbach de 0,86. Um total de 406 adultos concordou em participar. A idade dos participantes variava de 19 a 88 anos (M = 43,9, DP = 12,4). 61,8% eram mulheres, 90,6% tinham bolsas de estudo, 44,1% eram profissionais de saúde e 45,7% achavam que as políticas de saúde pública para prevenir a propagação da epidemia não estavam de acordo com as recomendações cientificas. A pontuação da PSS-10-C variava entre 0 e 36 (M = 16,5; DP = 7,3); um total de 58 participantes (14,3%) tiveram pontuação alta para estresse percebido (ponto de corte de 25). A inconsistência entre as políticas adotadas e as evidências científicas mostraram uma associação significativa com alta percepção de estresse relacionado à COVID-19 (OR = 2,36; IC95%: 1,32-4,20), depois de ajustar para o gênero. O estudo conclui que havia alta prevalência de estresse percebido relacionado à COVID-19 nessa amostra de adultos colombianos. O estresse alto está relacionado à percepção de inconsistência entre as propostas das autoridades sanitárias e as recomendações científicas. São necessários mais estudos para tratar dos aspectos psicossociais das epidemias.

Palavras-chave:
COVID-19; Quarentena; Angústia Psicológica; Estudos Transversais

Introduction

Since the first case, in early December ¹1. Bonilla-Aldana DK, Villamil-Gómez WE, Rabaan AA, Rodríguez-Morales AJ. A new viral zoonosis of global concern: Coronavirus COVID-19 disease in 2019. Iatreia 2020; 33:107-10., the perceived vulnerability to coronavirus infection (COVID-19) has radically changed in all countries. In Colombia, it switched from a distant threat to a real problem when the country reported the first infected, in March 2020 ²2. Rodriguez-Morales AJ, Bonilla-Aldana DK, Tiwari R, Sah R, Rabaan AA, Dhama K. COVID-19, an emerging coronavirus infection: current scenario and recent developments: an overview. J Pure Appl Microbiol 2020; 14:6150..

Based on other countries’ experiences, both scientific organizations and the media demanded public health decisions that were consistent with the best available evidence to control the spread of the infection ¹1. Bonilla-Aldana DK, Villamil-Gómez WE, Rabaan AA, Rodríguez-Morales AJ. A new viral zoonosis of global concern: Coronavirus COVID-19 disease in 2019. Iatreia 2020; 33:107-10.^,22. Rodriguez-Morales AJ, Bonilla-Aldana DK, Tiwari R, Sah R, Rabaan AA, Dhama K. COVID-19, an emerging coronavirus infection: current scenario and recent developments: an overview. J Pure Appl Microbiol 2020; 14:6150.. However, for financial interests, decisions were taken late ³3. Simon PA, Fielding JE. Public health and business: a partnership that makes cents. Health Aff (Millwood) 2005; 25:1029-39.. Data suggest that public health policies often underestimated scientific evidence and responded to political and capitalist interests ⁴4. Campo-Arias A. The applicability of health research findings in Colombia. Duazary 2010; 7:179-80..

On March 20th, the Colombian National Government decided to prevent COVID-19 transmission: the President of the Republic decreed a quarantine ⁵5. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395:912-20.. Quarantines have negative psychological effects, often deemed as marginal, including symptoms related to anxiety, depression, acute stress, and even manifestations of post-traumatic stress disorder ⁶6. Taylor MR, Agho KE, Stevens GJ, Raphael B. Factors influencing psychological distress during a disease epidemic: data from Australia's first outbreak of equine influenza. BMC Public Health 2008; 8:347..

The restriction of mobility can act as a psychosocial stressor ⁷7. Folkman S, Lazarus RS. Stress, appraisal, and coping. New York: Springer Publishing Company; 1983. due to prolonged confinement, difficulties in obtaining daily-life necessary supplies, potential financial losses, and access to conflicting and inadequate information on the Internet ⁶6. Taylor MR, Agho KE, Stevens GJ, Raphael B. Factors influencing psychological distress during a disease epidemic: data from Australia's first outbreak of equine influenza. BMC Public Health 2008; 8:347.^,88. Reinecke L, Aufenanger S, Beutel ME, Dreier M, Quiring O, Stark B, et al. Digital stress over the life span: the effects of communication load and internet multitasking on perceived stress and psychological health impairments in a German probability sample. Media Psychol 2017; 20:90-115.. Yet, few studies have quantified perceived stress during quarantines. In Australia, Taylor et al. ⁶6. Taylor MR, Agho KE, Stevens GJ, Raphael B. Factors influencing psychological distress during a disease epidemic: data from Australia's first outbreak of equine influenza. BMC Public Health 2008; 8:347. evaluated the frequency of and factors associated with psychosocial stress; by applying the Kessler Psychosocial Distress Scale during the equine influenza epidemic they observed that 34% of participants presented high levels of perceived distress, compared to 12% of the general population. They also reported that the psychosocial distress was significantly higher for those residing closer to infection outbreaks, workers in the equine sector, and younger and less educated people ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213..

Similarly, for the current COVID-19 pandemic, 52,730 people in China responded to the COVID-19 Peritraumatic Distress Index, which includes symptoms of anxiety, depression, related to stress and specific phobias, as well as physical symptoms reported during the last week. Researchers found that 35% of participants scored high for psychological distress, more frequent among women, people aged between 18 and 30 years, participants with higher education level and residents near affected areas ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213.. They observed that psychological distress was associated with local availability of medical services, regional health system efficiency, and measures to control the epidemic ¹⁰10. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002; 32:959-76..

Political decisions may affect emotional health; thus, measures should consider the perceived stress of citizens in emergency situations ¹⁰10. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002; 32:959-76.. These decisions seem relevant in countries like Colombia, where mistrust in public institutions explains most of the limited social capital ¹¹11. Kunitz SJ. Social capital and health. Br Med Bull 2004; 69:61-73.. This study aimed to assess the prevalence and variables related to perceived stress associated with the COVID-19 pandemic in a sample of Colombian adults.

Method

The authors performed a cross-sectional study approved by the Ethics Research Committee of the University of Magdalena (Act 002-2020). The research was based on the Declaration of Helsinki and Colombian legislations.

The study was formed by a nonprobability sample. Professors and students from a public university in Santa Marta, Colombia, and health professionals were invited to participate via email. The recipients could forward the link to friends and acquaintances, in a snowball strategy. We expected at least 386 people to engage in the survey and a 50% prevalence of perceived stress associated with the COVID-19 pandemic at high levels. Inclusion criteria were: Colombian individuals, over 18 years old, and able to respond online questionnaires.

Participants filled out demographic information on age, gender, education level, marital status, employment, and socioeconomic status. They were further asked to answer yes or no to: whether they were health professionals; suffered from a chronic condition (comorbidities such as diabetes); followed the precautionary measures; and considered the public health policies for preventing the spread of the disease consistent with scientific recommendations.

The Perceived Stress Scale (PSS-10) indicates stress as perceived by participants during the last month ¹²12. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983; 24:385-96.. The researchers adapted the PSS-10 to specify the stress associated with COVID-19 (COVID-PSS-10). The modified items are in Supplementary Material (http://cadernos.ensp.fiocruz.br/site/public_site/arquivo/supply-e00090520_7096.pdf). Each item provides five response options: never, almost never, sometimes, fairly often, and very often. Items n. 1, 2, 3, 6, 9, and 10 are scored from 0 to 4; items n. 4, 5, 7, and 8 are scored reversely, from 4 to 0 ¹²12. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983; 24:385-96.. The scores range between 0 and 40. In this study, scores equal to or higher than 25 were deemed as high perceived stress associated with COVID-19. Previous Colombian studies have used this cut-off point in college students ¹³13. Campo-Arias A, Bustos-Leiton GH, Romero-Chaparro A. Internal consistency and dimensionality of the Perceived Stress Scale (PSS-10 and PSS-14) in a sample of female university students in Bogotá, Colombia. Aquichan 2009; 9:271-80.^,1414. Campo-Arias A, Oviedo HC, Herazo E. The psychometric performance of the Perceived Stress Scale-10 on medical students from Bucaramanga, Colombia. Rev Fac Med (Bogotá) 2014; 62:407-14..

Several Colombian studies have used the previous Spanish version of the PSS-10, which has shown acceptable internal consistency, with Cronbach alpha between 0.65 and 0.86 ¹⁵15. Bustos GJ, Romero A, Campo A. Association between stress perception and risk of an eating disorder. Salud Uninorte 2011; 27:25-30.^,1616. Campo-Arias A, Villamil-Vargas M. Riesgo de trastorno del comportamiento alimentario (TCA) en estudiantes de medicina en Colombia. Rev Colomb Psiquiatr 2012; 41:328-39.. In our study, the COVID-PSS-10 presented a high internal consistency, with Cronbach alpha equal to 0.86.

Between 8:00p.m. on March 21 and 8:00p.m. on March 23, 2020 (the first weekend of the quarantine in Colombia), the leading researcher sent 60 emails among his contacts. The questionnaire was disclosed by email, Facebook, and WhatsApp.

In the descriptive component, frequencies and percentages were computed for categorical variables, and mean (M) and standard deviation (SD) were calculated for quantitative variables. Table 1 shows all dichotomized variables. To establish the crude associations between the quantified variables and high perceived stress associated with COVID-19, odds ratios (OR) were estimated with a 95% confidence interval (95%CI). Associations were adjusted using logistic regression. The IBM-SPSS Statistics 23.0 (https://www.ibm.com/) helped in the analysis.

Results

In total, 407 people received the email, and one disagreed to participate (0.2%). Participants were aged between 19 and 88 years (M = 43.9; SD = 12.4) (Table 1); 179 participants (44.1%) reported working with healthcare; 94 (23.2%) suffering from medical morbidity; 397 (97.8%) following precautionary measures for COVID-19 infection; and 222 (54.7%) considering public health policies for preventing the spread of the disease consistent with scientific suggestions.

Regarding high perceived stress associated with COVID-19, scores ranged between 0 and 36 (M = 16.5; SD = 7.3); 58 participants (14.3%) scored for high perceived stress, which was significantly related to the inconsistency between adopted policies and scientific evidence. After adjusting for gender, the relationship remained significant (OR = 2.36; 95%CI: 1.32-4.20). Table 2 presents other associations.

Discussion

In total, 15% of the participants scored for high perceived stress associated with COVID-19, which was significantly related to participants’ perception on the inconsistency between scientifically-verified recommendations and adopted public health measures by the government authorities.

In this study, the prevalence of high perceived stress was relatively lower than in previous studies. In Australia, Taylor et al. ⁶6. Taylor MR, Agho KE, Stevens GJ, Raphael B. Factors influencing psychological distress during a disease epidemic: data from Australia's first outbreak of equine influenza. BMC Public Health 2008; 8:347. found that 34% of participants reported high perceived distress during an equine influenza quarantine. Qiu et al. ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213. reported that 35% suffered from high psychological distress during the last week of the current COVID-19 epidemic. The discrepancy in prevalence may be explained by the spectrum of symptoms explored by each research instrument and the epidemic context ¹⁷17. Cooch EG, Conn PB, Ellner SP, Dobson AP, Pollock KH. Disease dynamics in wild populations: modeling and estimation: a review. J Ornithol 2012; 152:485-509..

In our research, high perceived stress was solely associated with the perceived inconsistency between government arrangements and scientific recommendations, compatible with other papers. In China, Qiu et al. ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213. reported that measures adopted by health authorities to control the epidemic were associated with perceived distress. The data suggest that reliance in national health authorities outlines emotional responses during epidemic situations ¹¹11. Kunitz SJ. Social capital and health. Br Med Bull 2004; 69:61-73..

Other studies noticed that high psychosocial stress was more common among young people ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213.^,1010. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002; 32:959-76.. Although our study expected a higher prevalence of perceived stress among younger people, due to their information overload by social networks ⁸8. Reinecke L, Aufenanger S, Beutel ME, Dreier M, Quiring O, Stark B, et al. Digital stress over the life span: the effects of communication load and internet multitasking on perceived stress and psychological health impairments in a German probability sample. Media Psychol 2017; 20:90-115., it was similar among the three age groups.

Findings regarding education are inconsistent: in Australia, distress was higher among less educated people ⁶6. Taylor MR, Agho KE, Stevens GJ, Raphael B. Factors influencing psychological distress during a disease epidemic: data from Australia's first outbreak of equine influenza. BMC Public Health 2008; 8:347.; whereas in China, stress was higher among more educated participants ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213.. Studies currently under developments aim to clarify the role of education in the emotional response to crises such as COVID-19 epidemic.

Other variables may mediate emotional responses to epidemics. In this investigation, the perceived stress did not depend on gender, contrarily to a previous study performed in China, which found that women reported greater psychosocial distress than men ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213., suggesting that biological and sociocultural factors associated with gender may mediate the association ¹⁸18. Younas S, Tahir F, Sabih F, Hussain R, Hassan A, Sohail M, et al. Psychological capital and mental health: empirical exploration in perspective of gender. Int J Sci Res 2020; 76:1.11..

Our study omitted proximity to most affected areas by the epidemic and access to medical services as modifiers to emotional responses ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213.^,1717. Cooch EG, Conn PB, Ellner SP, Dobson AP, Pollock KH. Disease dynamics in wild populations: modeling and estimation: a review. J Ornithol 2012; 152:485-509.. We found health professionals to equally report perceived stress when compared to other jobs ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213.^,1010. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 2002; 32:959-76., contrarily to the equine epidemic in Australia, in which healthcare professionals showed a significantly higher psychological distress ⁹9. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33:e100213.. This disparity may be explained by biosecurity measures followed by health personnel in hospitals ¹⁹19. Aparicio-Martínez P, Martínez-Jiménez MP, Perea-Moreno AJ, Vaquero-Álvarez E, Redel-Macías MD, Vaquero-Abellán M. Is possible to train health professionals in prevention of high-risk pathogens like the Ebola by using the mobile phone? Telemat Inform 2020; 38:74-86..

The emotional response to epidemics and their control measures relate to several variables, many of which have been little investigated. Our results suggest that a distal variable, as conceived in the model of social determinants of health, such as mistrusting government institutions, may portray a stress factor for citizens ¹¹11. Kunitz SJ. Social capital and health. Br Med Bull 2004; 69:61-73.^,1919. Aparicio-Martínez P, Martínez-Jiménez MP, Perea-Moreno AJ, Vaquero-Álvarez E, Redel-Macías MD, Vaquero-Abellán M. Is possible to train health professionals in prevention of high-risk pathogens like the Ebola by using the mobile phone? Telemat Inform 2020; 38:74-86..

This research provides new information on acute emotional responses to quarantine, which must be considered by health authorities alongside the epidemiological aspects of the infection. Emotional aspects are essential for infected people, their family members, and healthy citizens who must remain quarantined ⁵5. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395:912-20.. Yet, this study present some limitations and potential biases: snowball sampling is nonrandom, so results should be interpreted with caution; the chosen method is undershoot, so that it did not reach the general population; and the authors adapted an existing scale to measure perceived stress associated with COVID-19 ²⁰20. Wright KB. Researching Internet-based populations: advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services. J Comput Mediat Commun 2005; 10:1034..

In conclusion, 15% of the participants reported high perceived stress associated with COVID-19. High levels of stress were related to perceived inconsistent strategies adopted by health authorities in view of scientifically-verifired recommendations. Further researches must address the psychosocial aspects of epidemics.

Acknowledgments

The authors thank the University of Magdalena, Santa Marta, Colombia, for supporting the project.

References

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