|Year : 2021 | Volume
| Issue : 1 | Page : 57-63
Stress, sources of stress and coping during the Covid-19 lockdown: A population study from India
Jessy Fenn, Noble Chacko, Tony Thomas, Varghese K Varghese, Sanju George
Department of Psychology, Rajagiri College of Social Sciences (Autonomous), Kochi, Kerala, India
|Date of Submission||08-Jun-2020|
|Date of Decision||09-Jul-2020|
|Date of Acceptance||03-Oct-2020|
|Date of Web Publication||31-Mar-2021|
Dr. Jessy Fenn
Department of Psychology, Rajagiri College of Social Sciences (Autonomous), Rajagiri P. O., Kalamassery, Kochi - 683 104, Kerala
Source of Support: None, Conflict of Interest: None
Background: Pandemics such as COVID-19 (with or without lockdown) can cause considerable stress to individuals, testing their coping resources. To contain the pandemic, there was a nationwide lockdown in India from March 25, 2020, severely limiting movement of the 1.3 billion population till the first relaxation came on April 21. This study was done in the 3rd week of April, just before relaxations were announced, to study the perceived stress, sources of stress, and coping strategies of adults during this core lockdown period in Kerala, India. Materials and Methods: We gathered data from 1073 adults using sociodemographic information, perceived stress scale, sources of stress checklist, and COVID-19 coping strategies scale. Correlation analyses, t-test, and one-way analysis of variance were employed for data analyses. Results: 65.7% of respondents scored high on the stress scale with 8.3% experiencing severe stress and 57.4% reporting moderate stress. Stress was negatively correlated with age, education level and income. Anxiety about the impact of the pandemic on the world and their own personal future were the main sources of stress. This was followed by financial worries, stress due to frustration of limited movement, and fear about contracting COVID. The five most common coping strategies used were increased hygiene, social distancing, increasing awareness about the disease, increased communication with family, and distraction through movies and books. Conclusion: During the core lock down period in April 2020 in India, there was high levels of stress among the people primarily due to the worry about the future impact of the pandemic as well due to the restrictions imposed.
Keywords: COVID-19, India, mental health, perceived stress, sources of stress coping strategies
|How to cite this article:|
Fenn J, Chacko N, Thomas T, Varghese VK, George S. Stress, sources of stress and coping during the Covid-19 lockdown: A population study from India. Indian J Soc Psychiatry 2021;37:57-63
|How to cite this URL:|
Fenn J, Chacko N, Thomas T, Varghese VK, George S. Stress, sources of stress and coping during the Covid-19 lockdown: A population study from India. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Oct 28];37:57-63. Available from: https://www.indjsp.org/text.asp?2021/37/1/57/312858
| Introduction|| |
COVID-19 or 2019-novel coronavirus or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a virus of the family Coronaviridae. Although global pandemics are not new to man (plague, cholera, flu, Spanish flu, SARS, MERS, Ebola, etc., have been major pandemics in the past), the scale and impact of COVID-19 has been like no other in history. Further, experts believe that perhaps the worst is yet to come. To date (as of June 5, 2020), globally, COVID-19 has spread to 213 countries or territories, has infected nearly 6.84 million people, and has resulted in the loss of 400,989 lives.
Since its first case on January 30, 2020, India has had 263,722 confirmed cases of COVID-19 and 7341 deaths (as of June 5, 2020) from its 29 states and 7 union territories (UTs). Importantly and worryingly, cases and deaths in India are on the rise. India, home to 1.3 billion people, has 29 States and 7 UTs in its catchment, all with vastly varied and diverse cultures, practices, and health-care systems. This has meant that individual states and UTs have varied in their public health responses and health-care strategies to counter the COVID-19 pandemic. India's southernmost state is Kerala, with a population of approximately 35 million people and Human Development Index of 0.78, which is the highest in India. At the time of the survey in the 3rd week of April 2020, there were about 486 confirmed cases in Kerala and 4 COVID-19-related deaths. The first case of COVID-19 in India was reported in Kerala on the January 30, 2020, in a medical student who returned from the city of Wuhan in China. The spread was then contained very successfully, even though Kerala is three times more populated than the rest of India. However, Kerala has a very large expatriate population (3.4 million) and an average inflow of about 16.7 million tourists annually. Therefore, the state had its major wave of COVID-19 spread in March 2020 through the primary and secondary contacts of the tourists and the expatriate population who arrived from COVID-infected countries. At this stage, Kerala's experience in handling past disasters and epidemics helped in handling COVID-19 in this early stage, keeping the mortality rate low at 0.53% and getting publicity for its well-handled fight against the spread of the COVID-19 in terms of its public health policies, its implementation, and health-care provision,
To curb the spread of COVID-19, the Government of India announced a countrywide lockdown on March 24, 2020, for 40 days to reduce transmission of the virus through contact by restricting people getting out of their homes; shutting shops, workplaces, and places of worship; and restricting access to public transport and ending social gatherings. As the lockdown and these public health measures had to be hastily implemented, there were several (mostly unavoidable) deficiencies in its imposition and management including its consequences on the psychological well-being of individuals. Most common psychological reactions to such situations include stress, anxiety, depression, substance use, and exacerbation in preexisting mental health difficulties. Exposure to stressful situations draws on the individual's resilience and coping resources/strategies. All in all, “the mental health and psychosocial impact of COVID-19 is far-reaching.” Stress can be viewed as a psychological and physical reaction to the ever-increasing demands of life. During pandemics, the source of stress can be multiple: the WHO stated that it is “absolutely natural for each of us to feel stress, anxiety, fear, and loneliness during this COVID-19 pandemic” due to the disease, as well as social distancing, and loss of activities we used to love to do. Studies during previous pandemic instances such as SARS, Ebola, and HIV/AIDS have indicated psychological distress symptoms such as depression, anxiety, fatigue, and adverse health outcomes that affected the individual's functioning and physical, social, and emotional well-being.
Given that pandemics (with or without lockdowns) can cause considerable stress to individuals drawing on their coping resources, we decided to explore the mental health responses (focusing on perceived stress, sources of stress, and coping strategies) of people during the lockdown in Kerala, India.
| Materials and Methods|| |
This cross-sectional, descriptive study was conducted in Kerala. The sample size was calculated taking standard confidence level of 95%, a margin of error of 3%, prevalence value of 50% and the minimum required sample size was 1067.Therefore the study targeted a sample size of over 1000 Keralites.
Standardized instruments were administered to assess perceived stress, sources of stress, and coping strategies. They were all self-completion questionnaires, details of which are given below. Basic sociodemographic information was also collected using a form devised by the research team (all questionnaires are available from the corresponding author, on request). All questionnaires were in both English and Malayalam (the vernacular language).
Perceived stress scale
Stress experienced by the respondents was measured using the perceived stress scale 4 (PSS-4). PSS-4 scale has ease of use and high reliability and validity.
Sources of stress were captured by listing 15 potential sources during this COVID-19-lockdown period created by the researchers and asking the respondents to list the top four sources of stress. The sources of stress included pandemic related fears such as worries about job, business, studies, finances, unknown future, and pandemic impacts on countries as well as stress due to home confinement situation such as loneliness, boredom, increased workload, relationship problems, management of children and older relatives, and managing addictions. The respondents also had the option to add any other sources of stress which were relevant to them but not included in the list.
The 15 items of the COPE inventory were the base for creating 25 coping strategies that were relevant during the COVID-19 lockdown time. Approximately two activities each were created for the various strategies. Respondents were asked to rate how much these listed coping strategies were being engaged in as compared to before lockdown on a 5-point scale with the midpoint 0 being “same as before” and 1 and 2 indicating more than before and −1 and −2 as lesser than before.
Procedure and participants
This survey was created in two languages – Malayalam, the local language, and English. The original English items were translated into Malayalam by two translators who were experts in the subject as well as the languages. Forward and backward translation was done to ensure the accuracy of the translated version. The survey tool was created in Google Forms and distributed through social media such as WhatsApp and Facebook to several people across Kerala. The local language form was circulated through WhatsApp to village-level self-help groups and other government bodies to have access to all strata of the population. The first page of the survey detailed the study intent, informed the participants of confidentiality, option to opt out anytime, and requested their consent to participate. If they consented with a “yes,” they were led to the survey form. The survey was released on April 15, 2020, 21 days after the lockdown started and wound up on April 20, 2020, since lockdown restrictions were being eased in a few districts of Kerala from the April 21. One thousand seventy-three responses were collected and included in the analyses.
Data analyses were performed using SPSS version 20.0 (IBM, Armonk, NY, USA). The data were seen to be normally distributed based on the Kolmogorov–Smirnov test for normality, so parametric test of Pearson's correlation was used to find the association between perceived stress and the other variables, and t-test as well as one-way analysis of variance (ANOVA) was used to compare the mean values of stress with the various demographic variables such as gender, religion, age, monthly income, job, and marital status.
| Results|| |
A total of 1073 respondents, 59% women and 41% men, completed the survey during the 6-day study period from April 15, 2020, to April 20, 2020. With an average age of 31.2 years, the age groups were as follows – 32.8% of the samples were below 21 years, 32.7% between 22 and 29, and around 10% in the 30 s, 40 s, and 50 s [Table 1]. In addition to the variables given in Table 1, other information gathered included educational status and occupation (information available). The monthly income of respondents ranged from below Rs. 20,000/$265 (16% of the samples), to above Rs. 80,000/$1065 (30%).
Stress experienced by the respondents was measured using the 4-item PSS-4 and scores of the PSS-4 between 0 and 5 were coded as mild, 6–10 as moderate, and 11–16 as high as instructed in the scale manual. Of the respondents, 8.3% experienced high stress, 57.4% experienced moderate stress, and 34.3% experienced mild or no stress.
There was no statistically significant difference in the stress level experienced between males (mean = 6.39, standard deviation [SD] = 3.20) and females (mean = 6.67, SD = 2.91), as seen from an independent sample t-test (t = −1.4, P = 0.16). Stress was significantly negatively related to age as seen from Pearson's correlation coefficient of − 0.18 and significant at 0.01 level; the more the age, the less the stress. The mean stress value for each age range is given in [Table 2].
One-way ANOVA also showed a statistically significant difference in stress based on education (F = 4.36, Sig. = 0.001). The mean stress value was higher for lower education levels. Post hoc test revealed that the group with education of up to precollege (plus two level) education had significantly higher stress (mean = 7.61) than bachelor's (mean = 6.51) and master's degree holders (mean = 5.9).
Stress was also significantly negatively correlated with income levels (Pearson's correlation coefficient = −0.02), significant at 0.01 level, and one-way ANOVA showed a statistically significant difference between income groups (F = 2.79, Sig. −0.025).
There was no statistically significant difference in stress among participants based on their religious affiliation.
Sources of stress
Respondents were asked to list the top four sources of stress and [Table 3] shows the various sources of stress arranged based on their frequency of mention in the top four sources of stress by the 1073 respondents.
|Table 3: Sources of stress and respondents who ranked it as the top four sources of stress|
Click here to view
The top sources of stress were the anxieties regarding the future. This was followed by worries about family financial condition and future of one's job/business. Worry regarding contracting COVID-19 came in the 6th place.
Faced with uncertainties and its concomitant anxieties, it is the natural tendency of humans to find methods to reduce, minimize, master or tolerate it, or in other words, cope with it. There were 25 coping strategies listed and respondents indicated if they were engaging in the same level or increasing or decreasing levels of the coping strategies on a 5-point scale, with a midpoint of 0. They were also given the option of entering any other nonlisted strategies used. [Table 4] shows the various coping strategies used by the sample of 1073, during the COVID-19 lockdown period, arranged in decreasing magnitude of the mean, which was computed based on the rating of all the respondents on that item.
|Table 4: Frequency pattern of coping strategies used by the sample during COVID-19 lockdown in Kerala, India (n=1073)|
Click here to view
Problem-focused strategies such as active coping, planning, as well as emotional support were most used, while substance abuse, avoidance, and venting were less used. Although the top 5 strategies adopted by men and women were the same [as in Table 4], t-test revealed that they differed significantly (P < 0.05) in the level of usage of 13 of the strategies, which in the order of reducing the magnitude of difference were praying, stocking food, increased sleep, watching movies, listening to religious talks, hygiene practices, exercises/walks, indulging in hobbies, self-discovery exercises, reading about COVID-19 prevention, and communicating with family. Women used these strategies significantly more than men did.
| Discussion|| |
We studied 1073 adults from Kerala, India, to assess their stress levels, sources of stress, and coping resources during the COVID-19 pandemic and its consequent lockdown. The study was carried out during a 6-day period of full-scale lockdown from April 15, 2020, to April 20, 2020, 3 weeks after the lockdown was imposed. Our sample consisted of participants from across a wide spectrum of age, gender, religion, occupation, and other sociodemographic factors. The key findings of our study were that there was a relatively high level of stress (mean: 7.7 on PSS-4) among the people, with 8.3% experiencing severe stress and 57.4% reporting moderate stress during this lockdown. Although the PSS-4 scale does not provide norms, previous studies from several countries have shown average mean values of populations to be between 5 and 6.5 (Vallejo et al., 2018), thereby confirming the increased stress level. About 66% of respondents reported that stress during the lockdown period is understandable given the scale (severity of restrictions) and duration of the lockdown and its impact on several aspects of one's life. Most people had not experienced anything like this before and the news on print and TV was constantly broadcasting the dismal situations in other developed countries. Other studies in India support this result. A study by Varshney et al. in the 1st week of lockdown in late March showed that it had a significant psychological impact on 33% of the population, while a study by Verma and Mishra found about 11% of the population was severely stressed 2 weeks after lockdown in April, and Grover et al. found about 74% of the population had a moderate level of stress by the 3rd week of April, matching the results of our study which was also conducted in the 3rd week of April.
On comparing the relation of stress to the demographic variables, it was seen that though women experienced higher stress (M = 6.7) than men (M = 6.4), the difference was not significant. Perceived stress was significantly negatively correlated to age, showing that younger people had more stress; those between 17 and 21 had higher levels of stress (M = 7.03) compared to those in their 60s (M = 4.5). The level of education and income were also found to be negatively related to stress; the younger, less educated, and those with lesser income felt higher levels of stress. This matched data from other research on stress that were conducted during the COVID-19 period by Park et al. On analyzing the reason for the higher stress among the younger participants, which could also account for the negative correlation between stress and education, it was seen that the top source of stress was the generalized anxiety about what was happening around the world, with even developed countries being severely affected by the pandemic. It was followed by the worry about what would happen in the personal future due to lockdown effects. The younger group were college students who were at the end of the academic year and the lockdown was enforced before their year-end examinations were completed. One of the reasons for the high stress could be the uncertainty regarding the future of their studies or career, especially for those in their final year of the graduate or undergraduate level. The stress in this younger group due to being confined in the house with restricted access to friends and loss of earlier lifestyle was also seen as among the top five sources of stress. Financial worries about job and business came after these future anxieties, matching the results of a similar study in the USA by Park et al. conducted around the same time.
The five most common coping strategies used among the participants include three problem focused ones such as active coping and planning through increased hygiene, social distancing, and cultivating awareness about the disease. Two emotion-focused coping methods such as increased communication with family and mental disengagement methods of reading and watching movies were among the top five methods of coping with the lockdown. Other methods included engaging in social media, getting updates about COVID-19 news around the world, stocking food, increasing immunity, and sleeping more, as seen in Table 4.
This study has a couple of unique points; it is one of the early COVID-19 studies in Kerala, India, to look at stress, coping, and coping strategies among the general population, as it was conducted within the core lockdown period (March 24–May 3) following which there was a slow easing of lockdown restriction in Kerala. Second, a sample size of over 1000 gives fairly valid and generalizable findings in community studies, as the sample covers those of lower socioeconomic status too. The above said, our study is not without its pitfalls. First, this was limited to one state (Kerala) in India and it could be argued that our findings may not be relevant to the rest of India. Second, ours was an e-survey (without face to face contact due to lockdown regulations), so only those with access to social media such as WhatsApp and Facebook were the respondents. Third, it is difficult from this study to delineate whether the psychological impact was solely due to the pandemic or if it was a result of the consequent lockdown or both. Nevertheless, having seen the sociodemographic spread of our sample, we make the case that these findings are representative of the wider population of India and will offer useful pointers to present and future public health and mental health prevention measures.
Although the above discussion has exclusively centered on theoretical aspects of stress and coping, we believe that our study findings have very important practical implications. Most importantly, health-care providers and public health policymakers need to acknowledge that pandemics cause considerable stress to people (and perhaps even more so when associated with lockdown) and its combined psychological impact is significant., Further, health-care professionals and policymakers need to understand and take note of what causes people stress and how they try to cope with the stress. Finally, remedial/prevention strategies need to be thought through and implemented as part of any pandemic-related lockdown measure: such preventive measures to safeguard the psychological well-being of individuals could include offering them timely and appropriate information, offering logistic, material, and emotional support, etc., and treating those psychologically affected, just to give a few examples.
| Conclusion|| |
Although limited to one Indian state (Kerala), this is one of the early large-scale studies of stress that offers considerable insights into what is perceived as stressful and what the coping strategies are used by the general adult population in times of a global pandemic. We believe that our findings will be of help to policymakers and health-care professionals in formulating policies and care pathways to offer appropriate and timely support, care, and treatment to those who experience psychological difficulties during this pandemic and in future.
We wish to thank all those who participated in the survey. We also express our sincere gratitude to the students of the department of psychology who helped in the data collection and other support during the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gorbalenya AE, Baker SC, Baric RS, de Groot RJ, Drosten C, Gulyaeva AA, et al
. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nature Microbiology 2020;5.
MyGov. (n.d) Government of India site Covid-19 Dashboard Information. Available from: https://www.mygov.in/covid-19
. [Last retrieved on 2020 Jun 05].
Irudaya RS, Zachariah KC. 'New Evidences from the Kerala Migration Survey 2018'. Economic and Political Weekly 2020;55:41-9.
Rahim AA, Chacko TV. Nipah outbreak in North Kerala – What worked? Insights for future response and recovery based on examination of various existing frameworks. Indian J Public Health 2019;63:261-4.
] [Full text]
Mental Health in the Times of COVID-19 Pandemic Guidance for General Medical and Specialised Mental Health Care Settings. Department of Psychiatry. National Institute of Mental Health and Neuro Sciences (NIMHANS); 2020.
Gardner PJ, Moallef P. Psychological impact on SARS survivors: Critical review of the English language literature. Canadian Psychol 2015;56:123.
Lötsch F, Schnyder J, Goorhuis A, Grobusch MP. Neuropsychological long-term sequelae of Ebola virus disease survivors-A systematic review. Travel Med Infect Dis 2017;18:18-23.
Tesfaye SH, Bune GT. Generalized psychological distress among HIV-infected patients enrolled in antiretroviral treatment in Dilla University Hospital, Gedeo zone, Ethiopia. Global Health Action 2014;7:23882.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
Vallejo MA, Vallejo-Slocker L, Fernández-Abascal EG, Mañanes G. Determining factors for stress perception assessed with the perceived stress scale (PSS-4) in Spanish and other European samples. Front Psychol 2018;9:37.
Carver CS, Scheier MF, Weintraub JK. Assessing coping strategies: A theoretically based approach. J Pers Soc Psychol 1989;56:267-83.
Varshney M, Parel JT, Raizada N, Sarin SK. Initial psychological impact of COVID-19 and its correlates in Indian Community: An online (FEEL-COVID) survey. PLoS One 2020;15:e0233874.
Verma S, Mishra A. Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19. Int J Soc Psychiatry 2020;66:756-62.
Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al
. Psychological impact of COVID-19 lockdown: An online survey from India. Indian J Psychiatry 2020;62:354-62. [Full text]
Park CL, Russell BS, Fendrich M, Finkelstein-Fox L, Hutchison M, Becker J. Americans' COVID-19 Stress, Coping, and Adherence to CDC Guidelines. J Gen Intern Med 2020;35:2296-303.
Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health 2020;2667:30061.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
Folkman S. Stress: Appraisal and coping. In: Encyclopedia of Behavioral Medicine. New York: Springer; 2013. p. 1913-5.
Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry 2020;7:300-2.
[Table 1], [Table 2], [Table 3], [Table 4]