Psychological Distress and its Risk Factors during COVID

ASSIGNMENT COVER SHEET Course name: Health Care Research Methods and Analysis Course number: PHC 215 CRN: Assignment 1 Literature Review Please search and find at least three journal articles on “Knowledge and attitude about COVID-19” Assignment title or task: (You can write a question) Write the literature review that should be of 2 pages with a text of no more than 600 words excluding references with a font of Times New Roman and size of 12. The line spacing should be 1.5. Though it is a mini-literature review it should include separate sections like introduction, methods, results, discussion, conclusion and references with APA style. Please kindly attach the screen shot of 3 journal articles on “Knowledge and attitude about COVID-19” at the end of your assignment as an appendix. Student name: Student ID # Submission date: Instructor name: Dr. Mohammed Alkharaiji Grade: …. Out of 5 Elhessewi et al. Middle East Current Psychiatry https://doi.org/10.1186/s43045-021-00089-6 (2021) 28:7 Middle East Current Psychiatry RESEARCH Open Access Psychological distress and its risk factors during COVID-19 pandemic in Saudi Arabia: a cross-sectional study Ghada Moh Samir Elhessewi1,2†, Fatmah Almoayad1*† , Samira Mahboub1†, Anwar Mohammed Alhashem1† and Lamiaa Fiala1,3† Abstract Background: The control measures during COVID-19 such as curfew, lockdown, and social distancing had observed differences in controlling the spread of the disease around the Kingdom of Saudi Arabia; however, they might contribute to psychological illnesses such as anxiety, depression, panic disorder, and distress. A cross-sectional descriptive study was conducted to assess psychological distress and the factors affecting it among general population in the Kingdom of Saudi Arabia during the COVID-19 pandemic. Results: Seven hundred and thirty-nine people completed an online questionnaire which included the Kessler Psychological Distress Scale (K10). Psychological distress was found among 35% of the study sample. Western and northern regions reported higher rates of distress. In addition, higher rates were found among younger and unmarried individuals. Distress was significantly positively correlated with perceptions of susceptibility and severity of COVID-19 infection, and the fear to lose a job as a result of the pandemic and the related precautions. Conclusion: Psychological support programs should be provided targeting high-risk groups of younger and unmarried population. Further research should be conducted to evaluate the effectiveness of psychological support interventions. Keywords: Psychological distress, COVID-19, Saudi Arabia, K10 Background The Saudi Ministry of Health announced the first case of COVID-19 on 2 March 2020 [24], after 12 weeks from the spread of the pandemic in sixty-six countries around the globe [5]. Up to 2 July 2020, the total number of cities reporting at least one case was 197 and a total number of deaths up to 1698 cases across the Kingdom. Makkah region has the most cases (57,548 cases) than the capital region Riyadh which had a total of 52,936 cases [23]. In only 1 month (March 2020), the Saudi * Correspondence: ftm.myd@gmail.com † Ghada Moh Samir Elhessewi, Fatmah Almoayad, Samira Mahboub, Anwar Mohammed Alhashem and Lamiaa Fiala contributed equally to this work. 1 Department of Health Sciences, College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Kingdom of Saudi Arabia Full list of author information is available at the end of the article authorities had restricted sports events; closed educational facilities, parks, and malls; and suspended domestic public transportation, and had started partial curfew [29, 32]. Psychological Distress and its Risk Factors during COVID

The control measures such as curfew, lockdown, and social distancing had observed differences in controlling the spread of the disease around the Kingdom [32]; however, they contribute to psychological illnesses such as anxiety, depression, panic disorder, and distress [1, 12, 26]. The prevalence of some mental conditions varies from one country to another. In China, in a study of 52, 730 participants, psychological distress affected almost 35% of their participants [26]. Similarly, a couple of reviews in Italy found an extremely high range level of depression among 15.4% of Italians, 11.5% extremely anxious, 12.6% extremely stressed [21], 57% with © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Elhessewi et al. Middle East Current Psychiatry (2021) 28:7 sleeping problems, and 41.8% suffers from high distress [10]. In previous studies, women, elderly, and young are more vulnerable to develop stress and suffer from posttraumatic syndrome after pandemics [21, 26, 28], and it is reported that excessive exposure to news, social media, and TV influences by exuberating stress [1, 26]. The psychological effect of COVID-19 has been also reported in Saudi Arabia. Different ranges of distress were reported among 40% of the general Saudi population as a result of COVID-19 as reported by Al-Hanawi et al. [2]. Moreover, Alkhamees et al. [3] reported moderate to severe psychological impact among 23.6% of the Saudi general public. Both previously mentioned studies found higher rates among females, young people, and health practitioners [2, 3]. While literature established the psychological impact of the pandemic on Saudi population, there was limited discussion of the factors influencing it. Yet, Alkhamees et al. [3] found that commitment to infection control preventive measures is negatively significantly associated with stress and anxiety levels. The psychological distress is a reaction to a stressor that can cause timely or permanent dysfunction [27]. Psychological Distress and its Risk Factors during COVID

Its combined symptoms such as depression, anxiety, difficulty to sleep, and lethargy, and all may vary from person to person [17]. The person may experience coping difficulty, fluctuations of emotions, and feeling irritable, mostly [27]. The Saudi authorities noted the rise of psychological disorder and several health messages and guidelines distributed to the public. For example, Saudi CDC [11] provided a preventive guide for mental and social health focused on prevention and stress and fear management during the pandemic. They targeted the general population and how to take care of children and the elderly as well as tips for healthcare providers and managers of health facilities. The National Centre for Mental Health Promotion [25] promoted free call counseling center with mental health specialist for help during the pandemic as well as provided some health messages on psychological tips during lockdown such as how to increase resilience and to deal with loneliness and isolation especially with elderly and with special need family members. Some hospitals act by educating the public about mental health, such as King Faisal Specialist Hospital and Research Center had provided social media messages on how to manage stress and anxiety during the pandemic [16]. The aim of this study was to explore the psychological distress and the factors affecting it among residents of Saudi Arabia during the pandemic COVID-19. By understanding the current situation of psychological distress in Saudi Arabia, the health practitioner can develop rapid protection and intervention programs that enhance mental health, especially among the distressed population. Page 2 of 7 Methods Design of the study This is a cross-sectional descriptive study to assess psychological distress and the factors affecting it among general population in the Kingdom of Saudi Arabia (KSA) during the COVID-19 pandemic. Data was compiled during June 2020. Participants of the study The study population included those of 18 years and older, of any nationality, and are present inside KSA during the pandemic. Non-probability, convenient sampling technique was used to recruit the participants. The research questionnaire was available through Microsoft forms and distributed via social media in both Arabic and English languages. With a confidence level of 99% and total population in KSA of 25.8 million [13], the sample size was 666 participants, calculated using the sample size calculator the Survey System [30]. The questionnaire was completed by 760 participants of which 739 met the inclusion criteria. Research instrument The research tool used for this research consisted of 37 questions distributed into 3 sections as follows: Section 1: consisted of 8 questions which covered the sociodemographic characteristics of the participants including age, gender, income, education, marital status, employment status, region of residence, and housing condition. Section 2: Kessler Psychological Distress Scale (K10) was used to assess the psychological distress among the participants [14]. The K10 scale included 10 questions which measure emotional distress by assessing anxiety and depressive symptoms and has been recommended for use among the general population. It uses a 5-point scale ranging from “None of the time” which is assigned a score of 1 to “All of the time” which is assigned a score of 5. The maximum total score is 50, and the minimum is 10, and the results indicate the likelihood of the mental health as follows: well < 20, have a mild mental disorder 20–24, have moderate mental disorder 25–29, and have a severe mental disorder ≥ 30 [4]. Section 3: targeted factors related to COVID-19 pandemic that may influence the psychological status. It included four questions to assess perceived threat of COVID-19, five questions for the perceived seriousness of the COVID-19 infection, four questions for the commitment to precautionary measures, and four questions assessing the perception of effectiveness of those precautionary measures. Psychological Distress and its Risk Factors during COVID

Finally, participants were asked about their fear of losing their jobs as a result of the pandemic lockdown, the feasibility of staying home and Elhessewi et al. Middle East Current Psychiatry (2021) 28:7 not going out unless necessary, and the feasibility of avoiding social gatherings with family and friends. This section was assessed using a 5-point Likert scale ranging from “strongly agree” which was assigned a score of five to “strongly disagree” which was assigned a score of one. Validity and reliability The tool used for this research was developed after extensive review of the literature. K10 tool which was used to assess psychological distress is a valid and reliable tool that has been used in different contexts [8, 31]. The tool was translated to Arabic using forward-backward technique and displayed to participants in both Arabic and English. Reliability test was done using Cronbach’s α test which resulted in α =0.89 for the Arabic translation of K10. Validity was tested for all questions and was all significantly correlated with the overall score r > 0.5. Reliability test for the influencing factors scored as follows: perceived threat α = 0.7, for perceived seriousness α = 0.8, for precautionary measures α = 0.7, and for the perception of effectiveness of preventive measures α = 0.7. Data analysis Data was analyzed using the statistical software (JMP version 14.2). Frequency tables were used for descriptive data. Associations between categorical variables were done using the Chi-square test. Correlation between scale variables was assessed using Pearson correlation coefficient test. Multiple linear regression was performed to predict K10 score among the studied sample. Statistical significance was set at p ≤ 0.05 and high significance at p < 0.01. Page 3 of 7 Table 1 Sociodemographic characteristics of the study sample (n = 739) N % Female 507 68.8 Male 230 31.2 19 to 35 years 211 28.7 36 to 50 years 307 41.8 More than 50 years 217 29.5 Married 563 76.2 Not married 176 23.8 Less than college degree 129 17.5 College degree or postgraduate 610 82.5 Working 435 58.9 Not working 186 25.2 Retired 118 15.9 East 51 6.9 Central 463 62.7 Sociodemographic characteristics Sex Age (years) Marital status Education Working status Residence in KSA North 20 2.7 South 32 4.3 West 173 23.4 Saudi 649 87.2 Non-Saudi 90 12.8 Less than 8000 232 31.4 8000–16,000 251 33.9 More than 16,000 256 34.7 Nationality a Results The sociodemographic characteristics of the study population are presented in Table 1. More than half of the sample were females (68%), and nearly one fourth were young adults aged less than 35 years old. The participants in this study had a good educational level as 82% had at least a college degree, and most of them were married (76%). Regarding working status, 58% were working, and 15% were retired. More than half of the participants were from the Central Region of KSA (62%), one fourth from the Western Region, and those from other regions were about 14% of the whole sample. The overall prevalence of psychological distress of different degrees was 35% (n = 260), and only about 65% (n = 479) were likely to be well. The highest prevalence of those who were likely to be well were living in the Eastern Region (66.6%, n = 34) and the Central Region (67.39%, n = 312), while the lowest prevalence was in the Northern region (only 45%, n = 9). Regarding prevalence of different degrees of psychological disorders, Income (SR per month) a Saudi riyal Northern Region demonstrated the highest prevalence of mild disorder (30%, n = 6), and one fifth (n = 7) of those living in the Southern Region suffered from moderate disorder. The overall prevalence of severe disorder was 8% (n = 60) where the Western and the Northern Regions had the highest prevalence of 10% each (n = 18, 2 respectively). During the past month, nearly 40% of the participants felt nervous (n = 298) and restless (n = 288) and about 30% felt that everything was an effort (n = 230). About one fifth of the studied population felt depressed and so sad that nothing could cheer them up at least sometimes in the past month (n = 177). Elhessewi et al. Middle East Current Psychiatry (2021) 28:7 Page 4 of 7 Table 2 illustrates the association between psychological distress and social factors among the population living in KSA. Older age groups demonstrated better psychological status. Psychological Distress and its Risk Factors during COVID

Those who were more than 50 years old had a significant higher prevalence of normal psychological status compared to younger age groups of 36 to 50 years and those of less than 36 years (76%, 63%, and 55% respectively, p < 0.01). Those who were 19 to 35 years old had a significantly higher prevalence of severe psychological disorder than older groups (12% vs 8% and 2% respectively). There was also a significant association between being unmarried and having psychological distress. Those who were unmarried had a significantly higher prevalence of severe psychological disorder than married (13% vs 6%, p<0.01). No significant association was found between psychological status and all of the following social factors: nationality, gender, income, working status, and being a health care worker (p > 0.05). Table 3 demonstrates the correlation between K10 score of the psychological distress and factors related to the COVID-19 pandemic among the population living in KSA. It was found that there was a positive significant correlation between the K10 score of psychological distress and the scores of perceived seriousness of the disease, perceived threat of the COVID-19 infection, fear of losing job because of reasons related to the pandemic, and difficulty of staying home and not going out unless necessary. (p < 0.01 for all of them except difficulty of staying home that had p < 0.05.) There was also a highly significant negative correlation between K10 score of psychological distress and the scores of feasibility of avoiding social gathering, commitment to all preventive measures, and the perception of effectiveness of theses preventive measures (p < 0.01). All the nine factors that showed significant association with psychological distress were entered a regression model to predict psychological distress among Table 2 Association between psychological distress and social factors among the population living in KSA Social factors Psychological status Likely to be well Mild disorder Psychological Distress and its Risk Factors during COVID

Moderate disorder Severe disorder 19–35 years 117 (55.45%) 40 (18.96%) 27 (12.80%) 27 (12.80%) 36–50 years 196 (63.84%) 49 (15.96%) 35 (11.40%) 27 (8.79%) More than 50 years 165 (76.04%) 33 (15.21%) 13 (5.99%) 6 (2.76%) p value Age 0.0001† Nationality Saudi 421 (64.87%) 105 (16.18%) 70 (10.79%) 53 (8.17%) Non-Saudi, Arabic speakers 49 (62.03%) 17 (21.52%) 6 (7.59%) 7 (8.86%) Non-Saudi, non-Arabic speakers 9 (81.82%) 2 (18.18%) 0 (0%) 0 (0%) Unmarried 97 (55.11%) 34 (19.32%) 21 (11.93%) 24 (13.64%) Married 382 (67.85%) 90 (15.99%) 55 (9.77%) 36 (6.39%) Female 319 (62.92%) 86 (16.96%) 62 (12.23%) 40 (7.89%) Male 158 (68.70%) 38 (16.52%) 14 (6.09%) 20 (8.70%) Less than 8000 147 (63.36%) 37 (15.95%) 27 (11.64%) 21 (9.05%) 8000–16,000 153 (60.96%) 49 (19.52%) 27 (10.76%) 22 (8.76%) More than 16,000 179 (69.92%) 38 (14.84%) 22 (8.59%) 17 (6.64%) 0.3 Marital status 0.003† Gender 0.08 Income (SRa [per month) 0.4 Working status Not working or retired 199 (65.46%) 49 (16.12%) 33 (10.86%) 23 (7.57%) Working 280 (64.37%) 75 (17.24%) 43 (9.89%) 37 (8.51%) No 412 (66.03%) 102 (16.35%) 63 (10.10%) 47 (7.53%) Yes 67 (58.26%) 22 (19.13%) 13 (11.30%) 13 (11.30%) 0.9 Being a health care worker *p < 0.05 † p < 0.01 a Saudi riyal 0.3 Elhessewi et al. Middle East Current Psychiatry (2021) 28:7 Table 3 Correlation between K10 score of psychological distress and factors related to COVID-19 pandemic among the population living in KSA Factors K10 score Perceived seriousness of the disease r = 0.14† Perceived threat of infection r = 0.13† Fear of losing job because of reasons related to the pandemic r = 0.18† Difficulty of staying home and not going out unless necessary r = 0.10* Feasibility of avoiding social gatherings with family and friends r = − 0.11† Commitment to all preventive measures r = − 0.14† Perception of effectiveness of preventive measures r = − 0.17† *p < 0.05 † p < 0.01 population in KSA (Table 4). Psychological Distress and its Risk Factors during COVID

It was found that five factors can successfully predict the psychological disorder. These factors are age, perceived seriousness of the disease, perception of effectiveness of precautionary measures, fear of losing job because of reasons related to the pandemic, and difficulty of staying home and not going out unless necessary (P < 0.001 for all of them and for the whole model). Discussion The results have revealed that more than one third the study population suffer different degrees of psychological distress, and around two thirds were likely to be well. Psychological distress was significantly higher among younger age groups and unmarried individuals. There was also a significant positive correlation between psycholo … Psychological Distress and its Risk Factors during COVID