key: cord-0980167-eqpaaz5a
authors: Zubayer, Abdullah Al; Rahman, Md. Estiar; Islam, Md. Bulbul; Babu, Sritha Zith Dey; Rahman, Quazi Maksudur; Bhuiyan, Md. Rifat Al Mazid; Khan, Md. Kamrul Ahsan; Chowdhury, Md Ashraf Uddin; Hossain, Liakat; Habib, Rahat Bin
title: Psychological states of Bangladeshi people four months after the COVID-19 pandemic: An online survey
date: 2020-09-28
journal: Heliyon
DOI: 10.1016/j.heliyon.2020.e05057
sha: e8f2d16c81f7ed0d49c6dbd29c4fe0813c0e4b26
doc_id: 980167
cord_uid: eqpaaz5a

BACKGROUND: The COVID-19 pandemic essentially imposes psychological effects on people. As the pandemic progresses, people experience psychological trauma gradually, which can change over time. The present study aimed to assess the prevalence of depression, anxiety, and stress among Bangladeshi people four months after the COVID-19 outbreak. METHODS: An online cross-sectional survey was conducted among Bangladeshi citizens aged ≥18 years from June 1 to June 10, 2020. The participants completed an online questionnaire examining socio-demographic variables and COVID-19 related factors, along with the Depression Anxiety and Stress Scale 21. A total of 1146 respondents have been included in the study. Data were analyzed using the Statistical Package for Social Sciences, IBM Statistics version 22.0. RESULTS: The prevalence of moderate to the extremely severe levels of depression, anxiety, and stress was 47.2%, 46.0%, and 32.5%, respectively, with no significant gender differences. The prevalence of anxiety and stress was significantly higher in participants aged >30 than in participants aged 18–30 years. Daily follow up COVID-19 related news, having COVID-19 symptoms so far, having contact (direct or indirect) with COVID-19 infected person, and fear of infection were significantly associated with depression, anxiety, and stress. CONCLUSIONS: Sizable proportions of participants had depression, anxiety and stress four months after the COVID-19 outbreak in Bangladesh. The findings of this study underscores the need for strategies aimed at reducing these psychological sufferings in Bangladeshi people in the context of COVID-19.

An epidemic, triggered by the new coronavirus strain SARS-CoV-2, has become a public health threat worldwide (Pal et al., 2020) . To date, there is no approved vaccine to prevent COVID-19, or therapy to treat it (CDC, 2020) . COVID-19 infection in human causes a range of clinical presentations, from asymptomatic infection to acute respiratory infection and even death (Wang et al., 2020b) . On March 11, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic (Cucinotta and Vanelli, 2020) . As of August 18, 2020, this pandemic has affected 216 countries, areas, and territories with 21, 756,357 confirmed cases and 771,635 deaths recorded globally (WHO, 2020) . Bangladesh confirmed its first three case of COVID-19 on 8 March, 2020 (The Daily Star, 2020a). According to the Institute of Epidemiology Disease Control and Research, the number of COVID-19 confirmed cases was 282,344 and 3,740 people had died from COVID-19 in Bangladesh through August 18, 2020 (IEDCR, 2020 .

The Bangladesh government has introduced various measures to combat the spread of COVID-19, including lock-down, social distancing, self-isolation or quarantine (Anwar et al., 2020) . From 26 March to 30 May 2020, the Government announced a nationwide lockdown extending it seven times (The Daily Star, 2020a . In addition, as part of restricting the spread of COVID-19, the government has placed restrictions on public activities and movement across the country until 31 August (Tribune, 2020) . Because of the continuing spread of the virus and pandemic-related restrictions, the general population is increasingly experiencing various levels of psychological distress such as anxiety, tension, fear, panic, frustration and depression.

There is much evidence that many individuals during the COVID-19 pandemic developed psychiatric symptoms, such as anxiety, stress, panic attacks, sleep problems, depression, and even self-harm (Xiong et al., 2020; Shammi et al., 2020; Islam et al., 2020a) . A study conducted among the general population in China reported that 16.5% of participants had depression, 28.8% had anxiety, and 8.1% had stress during the initial stage of the COVID-19 outbreak (Wang et al., 2020a) . In a study conducted among Bangladeshi people at the initial stage of the pandemic, it had been revealed that 37.3% of participants had generalized anxiety disorder (Islam et al., 2020a) . Furthermore, a study conducted among Bangladeshi home-quarantined students showed that 46.92% had depression, 33.28% had anxiety, and 28.5% had stress (Khan et al., 2020) .

Evidence suggests that the psychological problems that may arise following large-scale disasters like the COVID-19 pandemic, can vary over time. Some research indicates that psychological issues rise within the first few months or years following the disaster (Goldmann and Galea, 2014; McFarlane and Williams, 2012) , other studies suggest a reduction in psychological problems after such events (Morganstein and Ursano, 2020; Gerstner et al., 2020) . In the present study, we aimed to assess the prevalence of depression, anxiety, and stress among Bangladeshi people four months after the COVID-19 outbreak.

An online cross-sectional survey was carried out among Bangladeshi people from June 1 to June 10, 2020. The inclusion criteria for taking part in the study were being a citizen of Bangladesh, at least 18 years of age, getting internet access, and responding with voluntarism. The online survey was shared with social media including LinkedIn, Facebook, Instagram and others. Moreover, the survey was circulated to research group members ' personal contacts through WhatsApp and e-mails. The study was performed in compliance with the Helsinki Declaration on Institutional Research Ethics, or its equivalent ethical principles. Ethical approval was waived by Sheikh Sayera Khatun Medical College, Gopalganj, Bangladesh. Participants were well briefed on the process, study intent and said their details would remain confidential. Data were collected anonymously, with informed consent from all participants. Participants were not offered any incentives to participate in the research, and could withdraw at any time without having to provide evidence. A total of 1175 participants completed the online survey. Among them, 29 participants were excluded, as they did not meet the requirements for inclusion (i.e. below 18 years). Therefore, data from 1146 participants had been held for final analysis.

In the present study, a semi-structured questionnaire containing informed consent, questions regarding socio-demographics, COVID-19related factors, and Depression Anxiety Stress Scale 21 (DASS 21) to assess depression, anxiety, and stress, were used to collect data.

Socio-demographic variables included age, gender, marital status, education level, occupation, number of family members, and residence.

COVID-19-related factors investigated in the present study were: (1) relatives or acquaintances infected with COVID-19 (yes vs. no), (2) relatives or acquaintances died from COVID-19 (yes vs. no), (3) daily follow up COVID-19-related news (yes vs. no), (4) COVID-19 symptoms so far (yes vs. no), (5) direct contact with COVID-19 infected person (yes vs. no), (6) indirect contact with COVID-19 infected person (yes vs. no), and (7) fear of COVID-19 infection (yes vs. no).

The DASS 21 (Lovibond and Lovibond, 1995) is a widely used self-report instrument for screening depression, anxiety, and stress. The scale was also used to measure psychiatric comorbidity of psychiatric patients , general workers and healthcare workers (Chew et al., 2020) during COVID-19. The scale includes 21 items divided evenly into 3 sub-scales of stress, anxiety and depression with 7 items, and scored on a four-point Likert scale ranging from 0 ("never") to 3 ("always"). The sub-scale of stress consists of questions 1, 6, 8, 11, 12, 14 and 18, and the cut-off scores were: normal (0-14), mild stress (15-18), moderate stress (19-25), severe stress (26-33), and extremely severe stress (34 and above). The sub-scale of anxiety consists of questions 2, 4, 7, 9, 15, 19, and 20 , and the cut off scores were: normal (0-7), mild anxiety (8-9), moderate anxiety (10-14), severe anxiety (15-19), and extremely severe anxiety (20 and above). The sub-scale of depression consisits of questions 3, 5, 10, 13, 16, 17 and 21, and the cut off scores were: normal (0-9), mild depression (10-13), moderate depression (14-20), severe depression (21-27), and extremely severe depression (28 and above). In the present study, we used the validated Bangla version of the DASS 21 (Alim et al., 2017) . The present study used moderate to serious or extremely severe scores to categorize depression, anxiety and stress levels, using the following cut-offs: depression!14, anxiety!10, and stress!19 (Lovibond and Lovibond, 1995) . In this study, the Cronbach's alpha for the depression, anxiety, and stress subscales were 0.89, 0.85, and 0.86, respectively, and the overall DASS-21 scale was found to have excellent reliability (Cronbach's alpha ¼ 0.87).

Data were analyzed using the Statistical Package for Social Sciences (SPSS), IBM Statistics version 22.0. Descriptive analyses to describe the socio-demographic characteristics and factors related to COVID-19 were performed. The prevalence of depression, anxiety, and stress stratified by age and gender were reported, and Chi-square test (χ 2 ) was used to compare the differences between groups. Logistic regression analysis was performed to investigate potential influencing factors for depression, anxiety, and stress. The results of regression analyses were reported by the odds ratio (OR) with a 95% confidence interval (CI). The association of variables was deemed statistically significant if the p-value was below or equal to 0.05.

The mean age of the participants was 26.38 years (AE8.87), ranging from 18 to 61 years. 83.4% were aged 18-30 years old and 16.6% were above 30 years old. About 59.2% were males and most of the participants (74.2%) were unmarried. Education level was as follows: 6.2% with a secondary degree or below, 15.3% with a higher secondary degree or Diploma, and 78.5% with a graduation or higher degree. Occupation was as follows: student (58.6%), housewife (3.9%), govt./private employee (16.6%), doctor/health worker (12.7%), and unemployed (8.2%). About 52.4% had 1-4 family members and 70.8% resided in urban areas (Table 1) . Due to frequent access and use habit of internet existing in A.A. Zubayer et al. Heliyon 6 (2020) e05057

Bangladesh (Islam et al., 2020b) , participants were predominantly 18-30 years of ages (83.4%), and urban residents (70.8%) in the present study.

Of the 1146 participants, 52.8% were non-depressed, 16.2% were mildly depressed, 20.4% were moderately depressed, 6.5% were severely depressed, and 4.1% were extremely severely depressed. The study further shows that 54.0% were non-anxious, 13.2% were mildly anxious, 15.4% were moderately anxious, 10.1% were severely anxious, and 7.3% were extremely severely anxious. It was also found in the present study that 67.5% were non-stressed, 9.2% were mildly stressed, 13.4% were moderately stressed, 7.4% were severely stressed, and 2.5% were extremely severely stressed (Figure 1 ).

The prevalence of depression, anxiety, and stress were shown in Figure 2 . Considering the cut-off score as 14 for the DASS depression subscale, we found that 47.2% of participants had depression four months after the COVID-19 outbreak. Similarly, considering a cut-off score of 10 for the DASS anxiety subscale, we found that 46.0% of participants had anxiety; 32.5% of participants had stress, considering a cutoff score of 19 for the DASS stress subscale (Figure 2 ).

The prevalence of depression, anxiety, and stress, stratified by age and gender were shown in Table 2 and Table 3 , respectively. The findings of the present study indicate that the prevalence of anxiety (χ 2 ¼ 13.004 (1); p < 0.001) and stress (χ 2 ¼ 7.669 (1); p < 0.006) was significantly higher in participants aged >30 years than in participants aged 18-30 years ( Table 2 ). In this study, we found no statistically significant difference in the prevalence of depression, anxiety, and stress by gender (Table 3) . 

The current COVID-19 pandemic takes a toll on mental health worldwide (Xiong et al., 2020) . In the present study, we investigated the prevalence of depression, anxiety, and stress among Bangladeshi people four months after the COVID-19 outbreak. The findings of this study indicate that 47.2% of participants had depression, 46.0% had anxiety and 32.5% had stress. Compared to a previous Bangladeshi study (assessing anxiety and panic disorder) conducted at the initial stage (March 29 to April 06, 2020) of the pandemic, the prevalence of anxiety was higher in the present study (46.0% vs. 37.3%) (Islam et al., 2020a) . Another study conducted among Bangladeshi students during the COVID-19 pandemic reported the prevalence rates of depression to be 46.9%, anxiety to be 33.3%, and stress to be 28.5% (Khan et al., 2020) . The prevalence of depression, anxiety, and stress was also higher in the present study than that reported in Chinese people during the initial stage of the COVID-19 outbreak (Wang et al., 2020a) . This higher prevalence of overall mental health issues (i.e. depression, anxiety and stress) may be attributed to the continued spread of the virus, growing number of new cases, death of a beloved and fear of infection (Lahav, 2020) . The present study, therefore, underscores the need for strategies aimed at reducing these psychological sufferings in Bangladeshi people in the context of COVID-19 by online psychological intervention such as cognitive behavior therapy .

The present study showed that the prevalence rates of anxiety and stress were significantly higher in participants aged >30 years than in participants aged 18-30 years. It is due to the fact that old age increases the risk of COVID-19-related infection and mortality. Although gender was reported to be associated with mental health problems (i.e., females were more likely to have depression, anxiety, and stress) (Moghanibashi-Mansourieh, 2020; Xiong et al., 2020) , in the present study, no significant gender differences were found in relation to depression, anxiety, or stress. The gender differences may be neutralized in the present study due to the COVID-19 situation.

The COVID-19 pandemic has forced us to change our everyday routines. Drastic changes in everyday life have caused habits and schedules to alter, contributing to mental health issues (Cao et al., 2020; Liu et al., 2020) . Since the first COVID-19 case confirmed in Bangladesh, the country continues to see a spike in the number of new cases. It was found in our study that nearly 59% of participants reported to have relatives or acquaintances infected with COVID-19, and it was found to be a protective factor against anxiety and stress. It may be because of their relatives or acquaintances who were infected with COVID-19 might have recovered or developed mild symptoms. The death of a beloved leads to psychological problems, such as anxiety (Moghanibashi-Mansourieh, 2020), is supported by the findings of the present study. The present study showed that daily exposure to COVID-19 related news was significantly associated with overall mental health problems. Previous studies showed that people who exposed COVID-19 related news were more likely to develop psychiatric symptoms (Islam et al., 2020c; Moghanibashi-Mansourieh, 2020) . It was also found in our study that people who had COVID-19 symptoms had significantly higher prevalence of mental health problems. People who reported having contact (direct or indirect) with infected person had higher prevalence of mental health problems. COVID-19 is highly contagious and it can be transmitted directly from human-to-human (Wang et al., 2020a,b) . Therefore, making contact with infected person imposes tremendous pressure on mental health which may lead to develop mental health problems. In line with previous studies (Xiong et al., 2020; Zolotov et al., 2020) , the present study also showed that fear of infection is directly associated with mental health problems. Individuals fear either of having COVID-19 themselves or of becoming asymptomatic carriers who spread the disease unknowingly to family and friends, contributing to psychiatric symptoms (Lu et al., 2020; Wang et al., 2020a) .

The present study had several limitations. This study relied on selfreport measures, which may have been vulnerable to certain possible prejudices, such as social desirability and memory recall. Moreover, this study was of a cross-sectional type and was unable to determine causality between any of the variables under investigation. One third of the participants in this study were urban residents due to online survey, indicating fair access to the internet in rural areas as well. Despite these limitations, this study provides novel information regarding the psychological states of Bangladeshi people in the context of COVID-19. The findings of this study might be helpful for concerned authorities to plan and adopt appropriate interventions for the current situation to ensure sound mental health in the context COVID-19.

The COVID-19 pandemic is generating an additional burden on people's mental health. The results of the present study indicate that four months after the COVID-19 outbreak in Bangladesh, substantial proportions of participants had depression, anxiety and stress. This study also indicates that the factors linked to COVID-19 had a substantial effect on mental health of individuals. Therefore, authorities should consider developing appropriate guidelines to address psychological distress during the COVID-19 pandemic and afterwards.

Author contribution statement 

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Translation of DASS 21 into Bangla and validation among medical students

COVID-19 and Bangladesh : challenges and how to address them

The psychological impact of the COVID-19 epidemic on college students in China

Centors for Dsease Prevention and Control (CDC), 2020. Information for Clinicians on Investigational Therapeutics for Patients with COVID-19. Retrieved

A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak

WHO declares COVID-19 a pandemic

Earthquake-related stressors associated with suicidality, depression, anxiety and posttraumatic stress in adolescents from Muisne after the earthquake 2016 in Ecuador

Mental health consequences of disasters

Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A Case-Control Study with Service and Research Implications for Immunopsychiatry

Bangladesh Covid-19 Update

Panic and generalized anxiety during the COVID-19 pandemic among Bangladeshi people: an online pilot survey early in the outbreak

Validation and evaluation of the psychometric properties of bangla nine-item internet disorder scale-short form

Exploring COVID-19 stress and its factors in Bangladesh: a perception-based study

The impact of COVID-19 pandemic on mental health & wellbeing among homequarantined Bangladeshi students: a cross-sectional pilot study

Psychological distress related to COVID-19 -the contribution of continuous traumatic stress

Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: gender differences matter

The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories

Psychological status of medical workforce during the COVID-19 pandemic: a cross-sectional study

Mental health services required after disasters: learning from the lasting effects of disasters

Assessing the anxiety level of Iranian general population during COVID-19 outbreak

Ecological disasters and mental health: causes, consequences, and interventions

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2): an update

COVID-19 pandemic, socioeconomic crisis and human stress in resource-limited settings

Is returning to work during the COVID-19 pandemic stressful? A study on immediate mental health status and psychoneuroimmunity prevention measures of Chinese workforce

Coronavirus Outbreak: Govt Orders Closure of Public, Private Offices from

Coronavirus Outbreak: Shutdown Won't Be Extended after

Restriction on Public Movement Extended till

Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China

World Health Organization (WHO), 2020. WHO Coronavirus Disease (COVID-19) Dashboard. Retrieved

Impact of the COVID-19 pandemic on mental health in the General Population: a Systematic Review

COVID-19 fear, mental health, and substance use among Israeli university students

Firstly, the authors would like to express the most profound gratitude to all of the respondents who participated in this study voluntarily and spontaneously. Secondly, the authors would like to thank Tanjila Marjahan (University of Dhaka), Sanjila Sharmin (University Of Chittagong), Taspia Islam (Jagannath University), Mehrab Hossain (East West University), Chaity Debnath Dipa (Comilla University), Tomalika Barua (University of Chittagong), Bineta Mondol (Jashore University of Science and Technology), Md.Shahrear Mostofa Romio (Daffodil International University) for their contribution in data collection.

The authors declare no conflict of interest.

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