Psychological Distress Related to COVID-19 Among Nepalese Professionals: An Online Cross-sectional Study

Background: COVID-19 is a highly infectious disease caused by SARS-CoV2 virus. It's psychological distress would be a major obstacle towards social normalcy to pre-COVID era. There were lacks of studies to assess these distresses. The aim of this study was to study psychological distress related to COVID-19 among Nepalese professionals. Methods: This online cross-sectional survey was conducted from 12th-20th, June-2020. Questionnaires were based on Corona-virus Anxiety Scale (CAS) and Obsession with COVID-19 scale (OCS). RESULTS Among 244 participants, majority were in the age group of 20-45 years with male female ratio of 2.1:1. About one third were health workers, 46% were teachers and service holders and remaining were from other professions. Majority of participants had subclinical obsessive (83.2%) and sub-clinical anxiety symptoms (69.3%). Law enforcement professionals (30.0%) and journalists 18.2% had highest prevalence of problematic obsessive symptoms. Law enforcement professionals (40%) had highest prevalence of problematic anxiety symptoms followed by health care workers (28.4%). About 35% of participants opted for multiple positive methods to cope with their obsessive and anxiety symptoms. Participants with higher obsession score had higher anxiety symptoms (r=0.592, p=<0.001). CONCLUSION Majority of participants only had sub-clinical obsession and anxiety related to COVID. But, health workers, law enforcement and journalism professionals were having problematic symptoms. Thus, efforts need MED PHOENIX: An Official Journal of NMC, Birgunj, Nepal Volume (5), Issue (1), July 2020, 10-18 10 Hussain Asraf , Sawant Sandesh, Mishra Jeetendra, Ram Ramji, Pandey Mahendra, Bista Sagun, Sarraf Pramod Kumar Department of Internal Medicine, National Medical College, Birgunj, Parsa, Nepal. Department of Psychiatry, National Medical College, Birgunj, Parsa, Nepal. National Medical College, Birgunj, Parsa, Nepal. Department of General Practices and Emergency, National Medical College, Birgunj, Parsa, Nepal. Psychological Distress Related to COVID-19 to be concentrated towards formulation of policies for safe and productive environment for these professionals.


COVID-19 is an abbreviation for Corona
Virus Disease 2019. It is caused by a severe acute respiratory syndrome corona virus 2 (SARS-CoV 2). SARS-CoV-2 belongs to family called corona virus which is responsible for the COVID-19 pandemic. 1,2 In the month of December 2019, there was an outbreak of pneumonia of unknown cause in Wuhan, Hubei province in China, with an epidemiological link to the Hunan Seafood Wholesale Market. World Health Organization (WHO) was notified about the disease on 31 Dec 2019 by the Chinese Health Authorities. On January 7, 2020, a novel Corona virus was identified by the Center for Disease Control and Prevention (CDC) from the throat swab sample of a patient, and was subsequently named 2019-nCOV by WHO. WHO declared it a public health emergency of international concern on January 30, despite these efforts, the virus continued to spread and WHO declared it as pandemic on 11 March 2020. 3 In Nepal, the first case of COVID-19 was tested positive by real-time RT-PCR assay on 23 January 2020. The case is reported to be a 31-year-old male who studies in Wuhan and traveled to Kathmandu from Wuhan. 4 The Government of Nepal issued a national lockdown on 23 March, 2020 and the lockdown continued till the date this article was being prepared (20 th June 20, 2020). As on 20 th June 2020 total number of cases of COVID-19 worldwide had been 87,86,592 with death toll reaching 4,63,156 whereas total number of cases in Nepal had been 8,274 with total number of death being 22. 5 Clinical features of COVID-19 can be mild like fatigue, myalgia, fever, dry cough, and dyspnea. It can also have severe manifestations like Acute Respiratory Distress Syndrome (ARDS), septic shock, disseminated intravascular coagulation (DIC), and acute renal failure. Severe manifestations of the disease are usually seen in elderly adult males with chronic co-morbidities like chronic lung diseases, obesity (body mass index >40), liver disease, chronic kidney disease, diabetes mellitus, under immunosuppressant drugs which can weaken the immune functions of these patients. 6,7 COVID-19 pandemic has a close association with anxiety, depression, distress, sleep disturbances, and suicidality. [8][9][10][11][12][13][14] Ever increasing number of cases and deaths related to COVID-19 has lead to over thinking about the disease. Attention and reflection on COVID-19 can help people stay safe during the crisis but only if it is reasonable, however too much of disturbing thinking about it can be debilitating and unhealthy. 15

MATERIALS AND METHODS
This cross-sectional survey was conducted from 12 th of June 2020 to 20 th of June 2020. Study was conducted online because the country was in the state of national lockdown and it was not possible to do a communitybased national sampling survey. Online questionnaires were prepared based on corona anxiety scale (CAS) and Obsession with COVID-19 scale (OCS). 16,17 Corona anxiety scale is a 5-item scale. It is based on anxiety over the corona virus. It discriminates nicely between persons with and without dysfunctional anxiety using an optimized cut score of ≥ 9 (90% sensitivity and 85% specificity). Results support the CAS as an efficient and valid tool for clinical research and practice. 16 Obsession with COVID-19 scale (OCS) is a 4-item scale. From a psychometric perspective, too much COVID-19 thinking means scores greater than or equal to 7 on the OCS. OCS total scores ≥ 7 classified people as having (sensitivity values of 81% to 93%) or not having (specificity values of 73% to 76%) dysfunctional COVID-19 thinking patterns. 17 Prior permission was taken from the original author for the use of these scales. Google forms were used for the survey. Only those participants who opted yes to participate in consent question were included in the study, and questionnaires were sent via email, Facebook, WhatsApp, Twitter. Questionnaires were also filled after telephone interviews. Only Nepalese professionals were included in the study. The Institutional Review Committee of National Medical College approved our study protocol and procedures before the formal study.
The questionnaire consisted of four parts: Demographics, Corona Anxiety Scale, Obsession with COVID-19 Scale and measures to cope with COVID related anxiety and obsession. Questionnaire included brief description about the study and also a separate question for consent. Respondents who agreed to participate were included in the study. Demographic variables included age, gender, marital status, residency address, profession and religion. These online questionnaires contained five questions on CAS, four on OCS and 1 question with coping measures. Coping measures included positive approaches like talking to friends, parents, relatives; playing games, watching TV, doing yoga and meditation, talking to doctor while negative approaches included were crying, substance use, keeping within oneself.
Statistical Analysis: Microsoft excel was used for data entry and IBM SPSS 21.0 software was used for the analysis of data. Descriptive statistics was calculated to describe the characteristics of the sample and cross-tabulation for the obsession and anxiety related to COVID-19 among the Nepalese professionals. To examine the association obsession and anxiety of the participants with OCS and CAS, binary logistic regression was done to calculate odds ratio with 95% confidence interval and p=0.05.

RESULTS
A total of 244 participants filled the questionnaires online. Among them, majority were in the age group of 20-45 years of age, 209 (85.7%). Whereas 16(6.6%) were below the age of 20 and 18(7.4%) were in the age group of 45-65. Male respondents were 166(68%) of total. More than half were married 132(54.1%). Most of the participants were from Province 2 and Bagmati province, 132(54.1%) and 63(25.8%) respectively. Health care workers (doctors, nurses and lab technicians) comprised of about one third (30.3%) of respondents whereas 112(45.9%) were teachers and service holders and the rest belonged to the professions of business, politics, journalism and law enforcement. Almost 3/4th of the participants were Hindu 181 (74.2%) ( Table 1).    Table 3).
Multiple positive methods to cope with their obsessive and anxiety symptoms were adopted by highest number of participants 85(34.8%). Fair number of the participants, 72(29.5%) reported talking with friends helped them relieve them of these symptoms. Only a small percentage of the participants adopted negative coping methods such as crying, sleeping and keeping to oneself, as presented in table 4. Participants with higher obsession score also had higher anxiety symptoms. The co-relation is significantly positive with (r=0.592, p=<0.001) as shown in table 5.

DISCUSSION
Ever increasing number of cases and deaths related to COVID-19 has forced the implementation of lockdown. Lockdown has devastating effects over all the aspects of normal living. Efforts are being made all over the world to bring back life to normalcy and also to gradually lift the lockdown. In our country Nepal also, efforts are being made for the same. High morale is a must among the professionals for the purpose of bringing back normal life proceedings back to pre COVID era. Psychological distress can be a major setback if not addressed properly. In this study we studied about obsession and anxiety related to COVID-19 among Nepalese professionals and identified associated demographic factors which can be useful for policy makers for formulation of strategies to minimize psychological distress among professionals and boost their morale. Many of our participants 85(34.8%) adopted multiple positive methods to cope with their obsessive and anxiety symptoms. 72 (29.5%) of the participants reported talking with friends helped them relieve them of these symptoms. Only a small percentage of the participants were involved in negative coping methods such as crying, sleeping and keeping to oneself. It can be concluded that Nepalese professionals have good coping capabilities.
Participants with higher obsession score also had higher anxiety symptoms. The corelation is significantly positive with. Association between anxiety and obsession is an established fact. 21

CONCLUSION
Majority of participants had only subclinical obsession and anxiety related to COVID-19. Yet a significant number of participants' especially front liners in the form of Healthcare workers, law enforcement personals and journalists were having problematic symptoms. More similar studies needed to be conducted and efforts need to be concentrated towards formulation of policies for safe and productive environment for these professionals.

Limitations of the study
Limitation of the study is its online nature because of which it lacks complete representativeness. More studies are warranted to investigate psychological distress among Nepalese professionals.

Acknowledgements
Authors would like to thank all the participants involved in the study.