key: cord-0964957-2qdv42rw
authors: Abu Kamel, Andaleeb K.; Alnazly, Eman K.
title: The impact of confinement on older Jordanian adults' mental distress during the COVID‐19 pandemic: A web‐based cross‐sectional study
date: 2021-04-08
journal: Perspect Psychiatr Care
DOI: 10.1111/ppc.12798
sha: 08fa3459391685a51d0c0dcf42c1ba43aef502e5
doc_id: 964957
cord_uid: 2qdv42rw

PURPOSE: This study aimed to determine the impact of Coronavirus disease, 2019 (COVID‐19) confinement on older Jordanian adults' mental distress and to assess which study variables that predict Posttraumatic Stress disorder. DESIGN AND METHODS: This cross‐sectional study was conducted on 315 older Jordanian adults using an online survey in Amman, Jordan between May 28 and June 12. FINDINGS: The assessment revealed a moderate level of avoidance (M = 1.97, SD = 0.7), a higher effect of intrusion (M = 2.08, SD = 0.9), an above midpoint level of fear 18.50 ± 8.6, and mild depression (M = 6.96, SD = 7.3). Hierarchical Multiple Regression model revealed that 77.8% of the Impact of Event Scale‐Revised was explained by both Fear of COVID‐19 Scale and Patient Health Questionnaire‐9 (R change = 0.66, SE = 8.4, p < 0.001). PRACTICE IMPLICATION: This suggests that confinement affects different aspects of the psychological well‐being of older Jordanian adults. An early assessment and intervention can make confinement as tolerable as possible.

The Coronavirus disease, 2019 (COVID- 19) was declared a global pandemic in March 2020. Following the declaration, COVID-19 has had devastating effects on not only the world's health and social well-being, but has also had economic, political, and religious implications. 1 The predominant recommended measure to prevent the infection's spread was confinement. 2 The state of confinement has led other researchers to study its effects on the general population. A study among the uninfected adult Indian population was conducted to assess the anxiety level and perceived mental health needs. The authors distributed online semistructured questionnaires. More than of respondents reported that they followed the government's recommendations of social distancing, avoiding travel, self-quarantine, and adequate personal hygiene measures. Respondents exhibited a high level of anxiety, of the participants were worried about COVID-19, experienced sleep difficulties, and paranoia over acquiring COVID-19, had reduced social contact, and more than of participants perceived the need for mental health care. 3 Another recent study evaluating the effects of the stay-at-homeorder and social distancing showed that there was an increased rate of depression, stress, and suicidal ideation among older adults. In addition, a decreased antiviral immune response was also noted. 4 An international online survey launched during the early days of the COVID-19 pandemic investigated the negative effect of confinement on mental health and emotional well-being. Due to homeconfinement, there was an increased negative effect on the mental and emotional well-being of individuals with more people developing depressive symptoms during the pandemic as compared to the period before the pandemic and confinement period. The survey analysis showed stress, depression, fear, anger, frustration, boredom, and stigma during confinement. 9.8% of participants were 55 years and older, all other participants were younger than 55. Consideration should be given to cultural differences regarding mood and psychological well-being as these studies were conducted in different countries. 5 Per Santini et al., social confinement during the pandemic heightens the sense of disconnectedness from society among older adults aged 57-85, leading to an increased risk of depression, anxiety, and stress. 6 The effect on the psychological health of the general population of India proved that the decline of psychological health variables increased with the length of confinement. Pandey et al. 7 reported an increased level of psychological distress measures (depression, anxiety, and stress) in the third week of confinement compared to the first week. Other factors affecting psychological health included age, gender, education, and marital status. The age group most affected were younger individuals who were still pursuing their educational goals. They experienced mild to severe levels of depression. Women experienced higher psychological distress (anxiety, stress, and depression) than men, and unmarried women suffered higher distress compared to divorced and married women. 7 A similar survey was conducted in China and found that there were no differences between males and females. At the same time, people over 50, people with undergraduate-level education or lower, those who were widowed/widowered or divorced, and agricultural workers showed significantly higher stress symptoms. 8 One month after the COVID-19 outbreak commenced in China, Liu et al. 9 conducted a survey of the prevalence of Posttraumatic Stress Disorder (PTSD) among; of Wuhan and surrounding cities. They consequently found that women showed a significantly higher prevalence of PTSD in terms of re-experiencing symptoms, negative alterations in cognition and mood, and hyperarousal when compared to men. 9 The COVID-19 pandemic is a potential source of trauma, such as experiencing the death of close relatives or friends. PTSD as de- Considering this, the current study aimed to determine the impact of COVID-19 confinement on the mental distress of older Jordanian adults, and to examine the mental distress measures IES-R, FCV-19S, and PHQ-9 variation across sociodemographic characteristics. More specifically, the study assessed the study variables that predict PTSD.

A cross sectional, and correlational survey design was utilized to assess psychological well-being of older adults during confinement.

The inclusion criteria were Jordanian women and men who were aged 60 years and above that had access to cell phones or computers or had family members that were able to read and mark survey question answers. All participants were living in Amman/Jordan during the COVID-19 Pandemic. The exclusion criteria were individuals who had mental-health problems, those who were in quarantine due to the COVID-19 infection and were living in resident (nursing) homes. Participants completed online surveys through google survey 14 from May 28 to June 12. The study was announced via email, messenger, and text messaging. It was conducted during the period that the Jordanian government issued a stay-at-home order for older adults, where only a limited number of essential services were allowed to stay open.

Participants were recruited through convenience sampling which then expanded to utilizing a snowball sampling technique. A snowball sampling technique is defined as existing study participants being asked by researchers to identify other study participants. 15 The study's announcement included information related to the survey (title of the study, the purpose and significance of the study, privacy information, researchers' contact email, and phone numbers to contact the researchers if they agreed to participate. Researchers contacted a total of 17 older individuals known to the research team.

The study announcements were sent via email and text message to the group of 17 individuals and this group agreed to forward the announcement to other friends, relatives and neighbors who met the inclusion criteria.

People who agreed to participate were contacted by a member of the research team through email or text message. All participant's questions regarding participation in the study were answered and a URL linking to the consent form and google survey were sent to each participant who agreed to participate. A signed consent to participate was confirmed through electronic signature (i.e., participants initial on the form).

The researchers emailed the URL to a total of 498 participants with a total of 315 (63%) responses returned. The sample size was determined by using Power and Sample Size, 16 using a population SD of 0.4, the margin of error 0.05, and a 95% confidence interval. This returned an estimated sample size of 245 respondents; ultimately, 315 participants were recruited for the survey.

Participants were asked to electronically enter their age, gender, education level, marital status, employment, living arrangement (e.g., with family, son's/daughter's family, and relative's family), monthly income, history of chronic diseases, and dependency level.

The visual analogue scale (VAS) is a psychometric response scale, 17 was used to determine participants' level of compliance with the confinement orders. The participants were asked to respond to the following VAS item: "To what extent are you complying with the COVID-19 confinement order? Rank your answer from 'not complying at all' (0) to 'fully complying' (10) ."

A single item question which measures participants perceived their own general health status during the preceding month using a 12-Item Short-Form Health Survey. 18 Researchers asked the following question: In general, how would you describe your general health 5 excellent, 4 = very good, 3 = good, 2 = fair, and 1 = poor. A higher score indicates a higher general health status. This assessment has been shown to be consistent with previously validated single-item general measurements of subjective wellbeing, which demonstrate good reliability and validity. 19 

The IES-R measures PTSD symptoms in survivors after a stressful event. In this study, people experienced social isolation, anxiety, panic, trauma-related memories, and fear for survival because of COVID-19. 20 It is short and can be used for recent and specific traumatic event. 20 In this study IES-R was used to measure the psychological impact of the COVID-19 Pandemic. The scale comprises 22 items regarding difficulties people have experienced in the past 7 days as a result of stressful events. Items are rated using a five-point Likert-scale ranging from zero to four (0 = "not at all," 1 = "slightly," 2 = "moderately," 3 = "quite a bit," and 4 = "extremely"). The scale features three subscales: intrusion (eight items), avoidance (eight items), and hyperarousal (six items). Total scores range between 0 and 88. The maximum mean score for each subscale is four, and the maximum "total mean" score is 12. Lower scores indicate less stress. A score of 33 or above indicates that PTSD may be present. According to previous literature, 20 to five ("strongly agree"). Total scores range from 7 to 35. The Cronbach's α for FCV-19S scale in this study was 0.934.

PHQ-9 23 is a nine-item self-administered instrument that is used to detect depression in the past 2 weeks in older adults under confinement. Responses are scored between 0 and 3 with (0 not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). The total score is ranging between 0 and 27. The severity of the respondent's depression symptoms will be calculated by summing the scores of nine items. The severity index score is classified depression as follow: Minimal (0-4), mild (5-9), moderate (10) (11) (12) (13) (14) , moderately to severe (15) (16) (17) (18) (19) , and severe (20) (21) (22) (23) (24) (25) (26) (27) . The Cronbach's α for original scale was 0.88 and test-retest reliability was 0.84. The

Cronbach's α for PHQ-9 scale: 0.945.

All scales were translated from English into Arabic by following the five steps recommended by Guillemin, Bombardier, and Beaton 24 :

translation, back-translation, committee review, pretesting, and weighing of scores.

The validity of these questionnaires was established using a panel of eight experts who utilized face, construct, and criterion validity methods. 25 

Data were analyzed using SPSS (IBM, SPSS Statistics, Version 24).

Any missing data and outliers were addressed by double-checking the original data sources. For descriptive statistics, the frequency, percentage, mean, and SD were used. Variations in subcategories of demographic variables were checked using χ 2 tests, while independent samples t-tests and correlation coefficients were used to identify the relationship and differences between the means of the study variables. The effect size for independent t-test was calculated based on Cohen 26 and partial η 2 for one-way analysis of variance (ANOVA). Hierarchical multiple regression was conducted to examine the influence of covariates on the total IES-R score. The internal consistency of all scales and subscales was examined using Cronbach's α. Assumptions regarding multivariate statistics, including normality and multicollinearity, were assessed before analysis.

This study was conducted in compliance with the Declaration of Helsinki and with the approval of the human subjects review board of Al-Zaytoonah University of Jordan. Consent forms were obtained from the participants before data collection. The anonymity of the participants was maintained throughout the study, with initials assigned to transcripts rather than the participants' names. Furthermore, the transcripts were only handled by the two researchers.

The analyzed data indicated that the mean age of the sample was 67.6 years with a SD of 7.1. The sample had 185 (58.7%) males and 130 (41.3%) females' respondents. Among them, 219 (69.5%) were married, 10 (3.2%) were divorced, 25 (7.9%) were single, and 61 (19.4%) were either a widow or a widower (See Table 1 (11.7%) claimed they were partially dependent on others, and 15 (4.8%) recorded being entirely dependent on others. The mean score for the participants' self-rated adherence to confinement (VAS) orders was 8.71 (SD = 1.91) ( Table 1) . Over 80% perceived their health as "good-excellent" (Figure 1 ). ▪ Table 3 The effect size with partial eta square η p 2 is 0.255, a large effect size.

The Pearson correlation revealed a statistically significant positive correlation was found between IES-R with fear (FCV-19S) and depression (PHQ-9) (r = 0.85 and 0.82) p ≤ 0.001 respectively. (Table 5 ).

In conclusion, correlation analysis revealed five variables that made potential contributions to the impact of the event of COVID-19related confinement on older adults: depression, fear of COVID-19, age, monthly income, and compliance with confinement orders.

The evaluation of the distribution of the dependent variable (IES-R) was assessed, and it was determined to have an acceptable normal distribution, evidenced by a skewness of 0.20 and a kurtosis of 0.61; this finding was complemented by a visual assessment of the curve shape (Figure 2 ).

The hierarchical multiple regression was utilized to assess the effect of the age, monthly income, compliance with confinement orders, fear, and depression variables on the IES-R scores. The first three the ability of both FCV-19S and PHQ-9 to predict the impact of distress event of older people after controlling the effect of other covariates (age, monthly income, and compliance with confinement).

The findings suggested that age, monthly income, and compliance with confinement orders could only account for 11.6% of the IES-R variance. However, the results were not statistically significant at 0.05 level of significance. Whereas the FCV-19S (fear) and PHQ-9

(depression) scores explained 77.8% of the observed variance in IES-R ( Table 6 ). The calculated p-values in Model 2 showed that results for both the fear and depression variables were statistically significant (p < 0.001). Abbreviations: CI, confidence interval, FCV-19S: Fear from COVID-19 Scale, PHQ-9: The Patient Health Questionnaire for Depression. a Significant value was drawn from the coefficients table indicating that the two models were statistically significant (Sig < 0.05).

In the face of the COVID-19 pandemic, and due to the nature of this infectious disease that has been associated with mental health distress, there is an unprecedented demand on mental health nurses to provide psychological support for older adults. However, as a result of the enforcement of lockdown and confinement during the pandemic, the findings of this study indicated, compliance with confinement orders positively correlated with the mental health distress of older adults. Older adults in confinement should be assessed for early detection of fear, depression, and distress symptoms while considering age, monthly income level, and compliance with the confinement orders. Early psychological support should be provided to minimize the impact of COVID-19 confinement on psychological well-being. Mental health experts should be prepared for the impact of COVID-19 on emerging psychiatric problems at the end of pandemic.

Hence, mental health nurses may assess and provide support to older adults in the community through computer-generated services at times when confinement and social isolation have been implemented and are in a position to preserve and ensure the psychological wellbeing of older adults. This is achieved by setting realistic goals for preserving and maintaining older adults' mental health wellbeing through the confinement period as well as preparing flexible strategies and action plans to support affected individuals by identifying other available resources that aid the implementation of the action plans.

This study has several strengths. This study represents a unique investigation of the mental health of older adults (a high-risk group for COVID-19) during the COVID-19 pandemic and helps to identify the psychological issues that such individuals may experience during confinement. The respondents showed high adherence to confinement, meaning our data adequately reflect the psychological impact of confinement. However, our study also has limitations. First, this study had a small sample size, which limits the generalizability of our findings. Second, participants' mental health was not determined before the pandemic.

Consequently, we did not have baseline data to assess the effect of the pandemic on mental health. Third, all participants used social media; thus, non-social-media users may have been excluded, causing selection bias that could lead to false or biased results. Fourth, cultural differences between different areas of Jordan, such as between urban and rural areas, should be taken into consideration. Fifth, most participants reported having good health. Thus, people with poor health and multiple chronic diseases or mental issues were not sufficiently represented in this sample.

The results of this study clarify the psychological impact of the COVID-19

pandemic. In Jordan, the pandemic has caused mild depression, moderate fear, and moderate distress among older adults. The correlation analysis revealed five variables that made potential contributions to the impact of the event of COVID-19-related confinement on older adults: depression, fear of COVID-19, age, monthly income, and compliance with confinement orders. Males indicated significantly higher levels of depression than females. We suggest that social support be provided during the pandemic to minimize mental-health distress among older adults.

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The authors would like to thank all the participants who kindly agreed to participate in the study.

The authors declare that there are no conflict of interests.

Andaleeb Abu Kamel and Eman Alnazly contributed 50% each to this study.

The data that support the findings of this study are available from the corresponding author upon request. And will be provided if the manuscript accepted for publication ORCID Andaleeb K. Abu Kamel https://orcid.org/0000-0001-6738-7594Eman K. Alnazly https://orcid.org/0000-0002-9327-6756