key: cord-0854099-6o7y8gbj authors: Jean-Baptiste, Cindy Ogolla; Herring, R. Patti; Beeson, W. Lawrence; Dos Santos, Hildemar; Banta, Jim E. title: Stressful Life Events and Social Capital During the Early Phase of COVID-19 in the U.S. date: 2020-08-28 journal: Social sciences & humanities open DOI: 10.1016/j.ssaho.2020.100057 sha: 14d394d28232f22201ed63b34c224be8f0b507b6 doc_id: 854099 cord_uid: 6o7y8gbj Background A novel coronavirus disease (COVID-19) was reported in Wuhan, China late December 2019. The disease has as of the end of March 2020, affected over 35 countries (with over 570,000 cases and 26,000 deaths) worldwide. This includes the U.S., where cases are increasing by the thousands every day (100,000 cases with 1,500 deaths as of April 2020). We set out to investigate new or increased stressful life events (SLEs) as a result of this pandemic in the U.S. Methods In this exploratory qualitative study, we examined new or heightened SLEs during an active phase of this outbreak. We used a list of SLEs acquired from the first phase of our study, whereby we conducted open-ended surveys and performed an in-depth focus group. We applied Lazarus and Folkman’s transactional model of stress and coping to understand diverse focus-group participants’ appraisal of events. We coded survey data and applied sentiment analysis. Results Participants varied in perceived threat and challenge appraisals of COVID-19, indicating both calm and fear. From 267 coded and sentiment analyzed events from survey text, 95% were predominantly negative; 112 (42%) very negative and 142 (53%) moderately negative. Social capital was unanimously emphasized upon as monumental for example: family, friends or technology mediated. We additionally identified seven major themes of SLEs due to the pandemic. Limitations Our sample profile is not inclusive of all subsets of the population. Conclusions Participants mostly shared similar frustrations and a variety of SLEs such as fear of the unknown and concern for loved ones as a result of COVID-19. The Corona Virus Disease of 2019 (COVID-19) was first reported in Wuhan China in December of 2019 [1] . Since then, the disease has ravaged through populations worldwide paralyzing public health efforts and health systems with the continued devastating death tolls projected by the time of this publication. On March 11 th 2020, the World Health Organization (WHO) declared the disease a global pandemic [2] and nations all over the world called for measures to combat the disease within their own countries. As of the writing of this article, March 28 th 2020, the global count includes 571,678 confirmed cases with 26,494 deaths [3] . In the U.S., there have been 101,242 confirmed cases and 1588 deaths [4] . Stressful life events (SLE) have been studied over tens of decades and are postulated precursors of health behaviors, outcomes and quality of life [5] [6] [7] [8] [9] [10] . In health psychology, the overall physical and environmental effects of stress are often studied along with mediating and moderating factors, such as coping and social support [11, 12] . Social capital is the collective term for various support initiatives available to members of social groups which have been shown to provide individuals and communities resources to deal with adversities [13, 14] . Studies have long demonstrated that variations of stress-related depressive moods depend on individual satisfaction with social capital from available social support systems [13] [14] [15] . In early 2020, while the COVID-19 crisis was still in a semi-latency period, at least for the U.S., we began our initial study on stressful life events (SLEs). We aimed to investigate SLEs for different demographic groups and assess differences, if any, in how the different demographic groups experience and appraise SLEs. We were also interested in whether there were differences in social capital for different demographic groups, particularly of varying J o u r n a l P r e -p r o o f nativity and whether appraisals of SLEs would vary due to perceived social capital. To help answer this question and others we embarked on a mixed methods study that assessed the variety of stressors largely faced by people in different demographic groups in the U.S. Through this phase of our study, we hoped to create, pilot test and validate a stress rating scale that can be used to assess the onset of disease as an enhancement to what has been previously presented by Holmes and Rahe [5] with their Social Readjustment Rating Scale (SRRS). Our intention was to develop a toolkit informed and appraised by individuals from diverse backgrounds and inclusive of modern-day stressors beyond the SRRS and its variants. By the time we were done conducting the interviews and first surveys, the COVID-19 U.S. numbers had more than tripled with cases hitting over a hundred thousand. As we analyzed results for our ongoing study, it became clear that the pandemic, as a stressful life event, was becoming dominant. Researchers acknowledge the complexities in studying perceptions and reactions to unexpected and potentially stressful events especially where events unfolding could reveal changes in affect, cognitions and even behavior patterns [16] . Our initial study participants underscored heightened stressful life events associated or as a result of the pandemic. We subsequently incorporated a COVID-19 based study and initiated a second guided-survey where we collected open-ended responses on COVID-19 associated or exacerbated stressors. We also conducted an in-depth focus group with a group of 15 diverse individuals from assorted professions. We incorporated triangulation to investigate the element of stress from a variety of cultural groups. Triangulation involves more than one method of data collection and can help determine completeness of data and transcend limitations of individual methods [17] . We (N=85 and 205 respectively) and two focus groups (N=10 and 15 respectively). We restricted participation to only eligible U.S. adult residents who were 18 years and older and were able to communicate in and read English. Interview and focus group scheduling were all done via online schedulers (www.calendly.com and www.doodle.com ). Adult individuals from all races/ethnicities could participate, including undocumented U.S. residents as long as temporary status from a visa or other instrument was not an issue. We did not ask for verification or description of eligibility. Our interviews and first survey occurred concurrently. The survey was hosted on Qualtrics (Qualtrics, Provo, UT) and used the same questions as the interviews. We used the research crowdsourcing website, Amazon's Mechanical Turk (MTurk https://www.mturk.com), which offers research tools including an Amazon verified diverse, heterogeneous population and verifying participants using active Amazon account information. MTurk's Human Intelligence Tasks (HITs) allow for a researcher to set requirements for subjects including demographics, country of residence and prior approval rate based on the worker's other MTurk work. Qualified MTurk participants received information about the survey and were routed to our online survey on Qualtrics where their informed consent was requested. A total of 120 participants responded. A focus group was scheduled after the interview and survey data were completed to dig deeper into the stressful life events by select demographics and narrow down data into themes. This first two-hour focus group with ten participants entailed an in-depth discussion about social capital and a guided session on the second half. Poll-everywhere (www.polleverywhere.com), a website that allows for live participant interaction, was used to refine our coded stressful life events towards a scale creation in our ongoing study. J o u r n a l P r e -p r o o f Dominant themes associated with the Coronavirus pandemic were investigated further using additional open-ended Qualtrics surveys via MTurk and a second two-hour in-depth focus group. We obtained data from 220 survey respondents and 15 focus groups participants. We used NVivo professional plus software (QSR International Pty Ltd. Version 12, 2018) to code all research data. The unit of analysis was the life events and stressful experiences described by participants and the social capital from person-centered coping mechanisms identified. Stressful life events (SLE) themes were coded and grouped for each demographic category. Sentiments were auto-coded for survey data and manually verified and refined on NVivo. We reported data from a diverse group of individuals of varying races, ethnicity and nativity status. Table 1 illustrates the demographic breakdown of all study participants. We informally defined stressful life events as distinct non-episodic events that would cause a significant change in mood or strain routine functioning and gave two specific examples (i.e. death of a loved one and loss of employment). We asked participants to identify at least five of these events that would be significantly stressful for them if they happened and any additional ones that others who shared the same demographics (specifically race, ethnicity and nativity) would experience. We coded data from 34 interviews and 120 surveys highlighting the most dominant (top 15) stressful life events by race, ethnicity and nativity status in Table 2. The table indicates how many code frequencies of the SLEs were recorded by participants from each demographic group. By the time we were gathering these data, the U.S. had not yet reported any cases of COVID19 so any stressors related to disease outbreaks or global pandemics ranked low, J o u r n a l P r e -p r o o f at position 28. A complete list of identified SLEs from preliminary qualitative results from our ongoing study is shared in Appendix 1. We asked participants to highlight any new stressors or exacerbated existing stressful life events due to the current pandemic and describe them in detail. Qualtrics validation was applied so that this was a required question on the survey. Out of 299 responses, 205 were deemed usable and were coded in NVivo. The software identified positive and negative sentiments in a high (very) and moderate extreme. Text analysis on software like NVivo is limited and does not fully analyze sentiment or recognize contextual phrases associated with some sentiment like sarcasm, slang or ambiguity. We thus manually refined these and coded overarching SLE themes. Ninety five percent of the 267 unique coded sentiments were predominantly negative for SLEs, with 112 (42%) 'very negative' and 142 (53%) 'moderately negative'. We classified 'very negative' stressors as those actually experienced by participants, for instance loss of a job or lack of amenities. 'Moderately negative' stressors had mostly to do with fears and worry, for example the indication of uncertainty. Positive themes included entries of readjustments of life that didn't show indication of stress or strain, for example, "I work from home now". A few entries explicitly stated they had no COVID-19 related stressors and were thus coded into 'very positive'. Table 3 highlights a few examples of survey entries coded at each sentiment. Stress viewed within a transactional model was introduced in 1984 by Lazarus and Folkman [18] where an individual's level of stress at a given time depends on the dynamic transaction between the individual and his/her environment. Stress levels were determined from the net transactional effect between personal and environmental SLEs and available resources J o u r n a l P r e -p r o o f such as coping mechanism. Lazarus and Folkman [18] described cognitive appraisal as an evaluation of the stress effect to an individual. As a result of the appraisal, an event was categorized as irrelevant, benign, or a threat currently or potentially harmful. Cognitive appraisal was further subdivided into primary and secondary appraisal where primary appraisal considers encounters with the SLE while secondary appraisal evaluates available mediators and their efficacy in reducing the harm. Coping was either problem focused, actively tackling the SLE, or emotional passively addressing the stressor by focusing on reducing effects of the SLE. About half of focus group participants indicated an ability to cope or just experience calmness from a cognitive appraisal of their threat and challenges supporting the theory that threat and challenge are not mutually exclusive [18] . Responses highlighted support of the theory that coping serves either to regulate the emotions and distresses from the SLE (emotion-focused coping) or to manage the problem by directly tackling the element influencing the SLE (problem-focused coping). Participants appraise their new or heightened COVID-19 based SLE challenges as either threatening or non-threatening, and secondarily in terms of whether they had the resources to respond to or cope effectively. Participants reported making significant physical and psychological alterations in order to cope with the imminent threat, such as shutting off all J o u r n a l P r e -p r o o f news, incorporating new hobbies or adopting faith and spirituality. This was consistent with the "threat or harm" approach [6] that significantly alters routine activities or status and poses a threat to available resources [19] . If the perception is that there is a lacking capacity to respond to the challenge, the individual would most likely to lean on emotion-focused coping responses such as wishful thinking [18] . Table 4 . From survey data and focus group sentiments, we identified five major themes from the current pandemic: (a) financial constraints, (b) isolation from family, (c) dwindling mental health, uncertainty, (4) worry about the future and (5) work-related challenges. Demographic differences from the survey are shared where applicable. Select excerpts are shared as spoken by focus group participants (FGP) with code names used. We omitted any reference to people such as celebrities or politicians and political parties. An assortment of financial challenges was identified as the dominant stressor during the pandemic. Survey participants indicated job loss, lost hours and other pressures from bills. We J o u r n a l P r e -p r o o f did not notice any demographic specific differences other than by educational attainment and socioeconomic status. Participants who particularly relied on or were qualified for government assistance indicated financial struggles and fears such as how they would pay for essentials and medical care. Slightly more participants below a bachelor's degree attainment (36%) indicated new or increased financial stressors compared to 20% of those with bachelor's degrees and higher. Participants from higher-ranking socioeconomic categories (can make do without government assistance or can make do with plenty to spare) largely described financial uncertainty for the future including downturns in their retirement, stock and savings accounts as a result of the pandemic. No personal financial concerns were discussed by the focus group, but participants did share professional experiences and concerns particularly those in communitybased professions including public health working with disadvantaged communities. Poor mental health was noted across demographics with a few noticeable intensities. More males than females indicated mental illness, albeit without further description as a stressor, caused by the pandemic. Increased substance use, (e.g. alcohol and tobacco), also accompanied entries of reduced mental health for males. Females, however, elaborated on stressful life events they were experiencing, such as job loss due to being in the hospitality or food industry, highlighting potential underlying mental dysregulations. Females in the study also reported multiple stressors as a result of the pandemic compared to fewer responses from males. FGP: Echo: Yes, I am stressed out actually last week. I was having panic attacks. J o u r n a l P r e -p r o o f Isolation was an overarching theme with most demographic groups sharing the same sentiment. Immigrants particularly had a lot to share as their isolation included sentiments of being away from their families in their home countries. Focus group participants represented diverse industries (Appendix 2) including education, health and healthcare. None of them indicated loss of employment except for the substitute teacher who was also a graduate student. Frustrations shared were based on professional experiences and readjustment. For instance, professors having to transition to an online format, or public health practitioners sharing frustrations and challenges experienced or on behalf of those they serve. Examples shared include lack of COVID-19 tests and personal protective equipment, economic effects of the pandemic on disparate communities and increased workloads. With news and current events dominated by COVID-19 related stories, we had limited challenges meeting our sample quotas. Open-ended online surveys were adequately responded to. Demographic-specific disparities were seldom reported except on xenophobic and racist events surrounding Asian individuals as described by both survey and focus group participants. Our observation matches recent reports highlighting a backlash of discrimination and xenophobia against Asian Americans [21] . The backlash is comparable to those during the SARS outbreak in 2003 [22] , H1N1 in 2009 [23] , and Ebola in 2014-2016 [24] where communities are vilified leading to racialized behavior such as avoidance and bullying [21] . The use of technology has reportedly skyrocketed with cell phones, messaging apps, web conferencing J o u r n a l P r e -p r o o f technologies (e.g. Zoom and Skype), email and social media being the main avenue that the majority of the population can keep in touch with their friends, families, and loved ones or keep up with the news. Furthermore, because of advances in technology, participants described fewer disruptions to their daily routine due to ability to work from home or attend classes online. It was additionally clear that everyone felt it necessary to be informed yet struggled with the changing and overload of COVID-19 related news and guidelines. To our knowledge, previous studies have not examined the association of social capital and stressful life events during a global scale pandemic. Results from our study highlight that greater social support is indeed associated with lower perceived stress during the early phase of the COVID19 pandemic. Our study participants who were parents of young kids emphasized challenges of homeschooling their children but reiterated during focus groups that it was more important to create a calm environment with a redefined normalcy for growing children whose future could very well be shaped by this crisis. One focus group participant highlighted that her child's school organized a weekly online class session via Zoom for students during the school closure and even had loaner electronic devices for children in need. Additionally, focus group participants appreciated the opportunity to vent and share some fears and frustrations in a group setting, some reiterating that the session has been the most human communication they have had outside their work and family in while. On coping, participants differed in their emotion vs. problem focused coping based on their appraisal of the COVID-19 threat and its current or potential challenges. Social capital, operationalized as social support is positively associated with health outcomes in the population and can provide resources to deal with adversities [13] such as those related to COVID-19. Due to the unprecedented nature of the current pandemic, research is lacking that would highlight the J o u r n a l P r e -p r o o f benefits of social capital in an era where distancing is encouraged to save lives. Nonetheless, previous studies have highlighted improved health outcomes from impacted health behaviors and influenced psychosocial processes due to connectedness [25, 26] . Kawachi specifically highlights lower levels of social trust associated with major causes of death particularly from chronic diseases such as heart diseases and cancer. The widespread disparities in health among racial, ethnic and socioeconomic groups particularly during emerging epidemics have been described in the literature [27] . Additionally, highlighted in the literature is the stress of contracting a disease due to worry and lack of information [26] , a concept we also observed in the early phase of the pandemic. Our focus group purposely deviated from a discussion of a political nature. Nonetheless, the rhetoric of uncertainty in communication especially from political leaders was not absent. Historical evidence regarding epidemics suggests that it is impossible to disentangle such events from the politics [28]. Social capital can improve health outcomes by influencing access to health services and amenities, impacting health-related behaviors, and affecting individual psychosocial processes [29] . Participants particularly emphasized perceived dire effects if they were devoid of any form of social capital. Their family, friends, coworkers, religious and community associates or even social media comrades helped cope, share news and tips or just divert their attention from the current world-wide chaos. Despite the coping strategies discussed, the novelty of the pandemic and current events had participants leaning on multiple coping methods. The general scheme of social capital discussion was that both sets of participants either longed for interactions, held on to connections, or invented new ways to interact and maintain or enhance social capital. This concept is in accordance with Wind and Villalonga-Olives [13] who describe a manipulation that consists of activities that directly build or strengthen social capital when social capital is the intervention target. Snowden particularly discusses pandemic situations, and the effectiveness J o u r n a l P r e -p r o o f of quarantines [28] which would add value to future similar studies that investigate coping during social distancing and whether the enhanced survival is perceived as a worthy tradeoff from the lack of connectedness. A nascent concept towards the end of the group session touched on the aftermath of the pandemic; those who had lost loved ones, those who had been without or emerge from the pandemic without social capital and those with various forms of trauma due to the pandemic. In summary, the more pragmatic and objective problem based coping efforts (see Figure 1 ) was more pronounced in participants during this early pandemic phase. Participants efforts were more directed at defining the problem and finding solutions, which included enhancing their social capital. The protective effect of social capital on stress warrants further exploration. As the COVID-19 upheaval continues to unfold and the unknown evolves into fruition, it is clear that SLEs, having the potential to impact health and wellbeing, will continue to be experienced or exacerbated for most people. Due to the novel COVID-19 being a new pandemic currently ongoing as of the writing of this article, this study could present some gaps in stressful life events as the situation unfolds. Because of the caliber of its global effect, there seems to be a lot of uncertainty about the future which in itself is a huge stressor for most. People from different demographic groups could exhibit renewed or increased devastations as the ravaging effects of the disease continue. Only two out of 205 survey participants indicated educational levels lower than a high school diploma and all focus group participants were professionals with at least a bachelor's degree. Efforts to sample other minority groups proved futile with no American Indian and Pacific Islanders responding to the survey HITs. Additionally, those without computers or with lower literacy J o u r n a l P r e -p r o o f levels may not have been able to access the survey or focus group scheduling. As a result, experiences and perceptions of a subset of the population is lacking Our study highlights the broader effects of the pandemic. In the U.S. with exceptions by demographics, financial strains, racism and isolation increased due to reduced travel to home countries of immigrants. At the preparation of this manuscript, (April, 2020), the pandemic has not been controlled and various cities in the U.S. were on recommended or mandatory lockdown with all K-12 schools closed, most public universities transitioned to online and workers either temporarily displaced, telecommuting or deemed 'essential and are reporting to work'. To the best of our knowledge, this is the first study to explore stressful life events during the COVID-19 pandemic and associated social capital in terms of coping. Our findings suggest that as part of public health preparedness and health promotion, policies should be explored that fund increased social capital such as online religious events and district-wide K-12 class sessions via video hosting capabilities such as Zoom. Ultimately, social capital can effectively lower stress which can decrease the health and quality of life associated outcomes from unexpected or unavoidable stressful life events such as those from a global pandemic like COVID-19. Diseases has recently stated that the effects of the coronavirus pandemic would be imprinted on the personality of the country for years to come, stating "I think there's going to be some subliminal post-traumatic stress syndrome that we're all going to face" [30] . Future studies and health promotion efforts should address each stressor independently, particularly those who were already living on the edge before COVID-19 emotionally, socially or even financially. This study was approved by Loma Linda University Institutional Review Board. All study participants provided informed consent and had the option to decline or withdraw from participation at any time. No identifying information was requested. Anonymity was maintained through coded names for interview or focus group participation. Web-based survey did not query for any identifying information, and participants were reminded to maintain their anonymity. Unexpected interview personal identifiers were anonymized in the analytical datafile to prevent participants from being identified from any sensitive information that may have been J o u r n a l P r e -p r o o f Having to stay inside a lot is causing lots of loneliness and mental health issues like anxiety, and dealing with a toddler all day is maddening. The other person in my home is not able to work as much so our finances are getting tighter and the stores are low on food that we need so it is making it stressful in that area as well. I'm unable to connect with friends in person and feel more isolated. Income reduced, no immediate family in this country fir support. Both work in medical field offering direct care to pt, daily potential exposure to covid victims. Anxiety due to daily challenges and changes with PPEs scare, lack of emotional support, psychological support. anxiety since all family live away from us, incase of anything we cannot even travel. Saving is currently a challenge since we have to support family back at home. Budget is tight. There is a huge spike of racism against my family and my people ever since the COVID-19 epidemic breaks out in the U.S. This makes me not only worry about my family's safety because of the possibility of contracting the virus, but also from the racists who are looking for an excuse to attack and terrorize Asian American families. Covid 19 has been me lonely because I have to stay at home.It has also made work very stressful and demanding I recently moved to a new town and was relying on my freelance work in the events industry to survive until I found a job in my new town, but the entire industry has been cancelled and I'm out of my usual way of making money. Jobs that are still available are hard to get because it's so competitive since a lot of people are unemployed. I don't have a home yet, it's hard to get one without a job so I am facing homelessness. I'm currently working and earning much less which makes me stress about meeting my family's financial obligations. I also don't know when I can travel overseas to see my parents or help them in any way. I have lost my job, filed for unemployment, have 0.00 and unemployment is backed up so no money has been sent. We are unsure when we will start receiving monies so likely will need to move since we cannot pay rent Having to stay inside a lot is causing lots of loneliness and mental health issues like anxiety, and dealing with a toddler all day is maddening. WHO statement regarding cluster of pneumonia cases in Wuhan Director-General's opening remarks at the media briefing on COVID-19) Situation Report -68. 2020 2020/03/28 US coronavirus cases reach more than 101,000 as reported deaths hit new daily high The Social Readjustment Rating Scale Ten Surprising Facts About Stressful Life Events and Disease Risk Stressful Life Events Moderate the Relationship Between Changes in Symptom Severity and Health-related Quality of Life in Patients With Irritable Bowel Syndrome Stressful life events, depression and demoralization as risk factors for acute coronary heart disease Stressful Life Events and Risk of Breast Cancer in 10,808 Women: A Cohort Study Stressful life events, chronic difficulties, and the symptoms of clinical depression. The Journal of nervous and mental disease Stress, culture, and community : the psychology and philosophy of stress. The Plenum series on stress and coping Stress, disease and 'joined-up' science Social capital interventions in public health: moving towards why social capital matters for health A four year (1996-2000) analysis of social capital and health status of Canadians: the difference that love makes Satisfaction with social support and depressive symptoms: a panel analysis Beyond positive or negative: Qualitative sentiment analysis of social media reactions to unexpected stressful events The use of triangulation in qualitative research Stress, appraisal, and coping Psychological stress and coping in adaptation and illness More than culture: structural racism, intersectionality theory, and immigrant health Xenophobia in the time of pandemic: othering, anti-Asian attitudes, and COVID-19. Politics, Groups, and Identities Fear and stigma: the epidemic within the SARS outbreak H1N1, globalization and the epidemiology of inequality. Health & Place Fear of Ebola: The Influence of Collectivism on Xenophobic Threat Responses Social capital and health Social capital, health behaviours and health: a population-based associational study Social factors associated with AIDS and SARS. Emerging infectious diseases Disease causing poverty: adapting the Onyx and Bullen social capital measurement tool for China Coronavirus will be 'imprinted on the personality of our nation for a very long time Environmental Educator, Community Organizer/Community Engagement Substitute Teacher and Graduate Student 10. Federal Regulation Writer 11. Prevention Health Specialist 12 Military Officer in the US Armed Forces Equal Opportunity, Diversity & Community Liaison Professional 14. Racial, Inclusion and Equality Professional 15 The authors would like to thank all participants who took part in the interviews, focus group and those from MTurk who responded to the open-ended survey.