Impact of COVID-19 pandemic with respect to stress, coping mechanisms adopted by the individuals
COVID-19 (also called Coronavirus) is a respiratory disease which was first discovered in Wuhan, China, in December 2019. On 30th of January 2020, the World Health Organization declared COVID-19 a “Public Health Emergency of International Concern”. In India, the first case was reported in a 20-year-old female who had return from Wuhan city, China owing to the outbreak of the pandemic. The case was reported by the NIV, Pune, to District Control Cell on January 30, 2020 as positive for COVID-19 infection (1). The common symptoms of disease included cough, sore throat, pain in throat, shortness of breath and fever, however, some asymptomatic cases were also reported which showed no initial symptoms of the disease. This made the diagnosis and control of outbreak of infection even more difficult. Everyone could be prone to the infection but old adults, children, pregnant women and people dealing with comorbidity were more susceptible to the disease (National Institute of Mental Health and Neurosciences, 2020).
The pandemic COVID-19 proved to be one of the worst ever global health crisis which not only affected the world on physical basis but on mental and psychological basis too. The world-wide imposed lockdown due to the spread of the Corona virus resulted in the closure of the educational institutions, organizations, workplaces. National Institute of Mental Health and Neurosciences (NIMHANS, 2020) reported that the sudden lockdown in the country, along with the mandates such as isolation and social distancing during the pandemic caused anxiety, irritation, stress, boredom, frustration and aggressive behavior. A study shows that any severe epidemic or outbreak in society generally has severe negative effects on the society as well on the lives of humans (Dodgen et al., 2002) (2). Lockdown rules such as restrictions on social interactions associated themselves with the risk of developing stress and depression in the population. Studies which were carried out during the previous outbreak of pandemics have revealed that the restrictions on social behavior causes serious emotional and psychological changes (3, 4). In a study, parents who had experiences of lockdowns for the control of diseases were found to have 6% more trauma-related psychological symptoms than the parents who had no experience of the lockdowns (5).
As per the literature (6-8), the main reason for the stress during the outbreak of COVID-19 was the fear of its contraction by self or family. The triggers of anxiety and the coping mechanisms is aligned with the transactional model of stress and coping as reported by Lazarus and Folkman (9). The model explains that the individuals use behavioral and cognitive coping responses to control internal and external stressors. For some, the anxiety symptoms may be inherently frightening and/ or misperceived as signs of physical illness, thus increasing overall anxiety levels. When faced with threat social resources can play an important role in an individual’s coping mechanism and ultimately their ability to function (9-10). Similarly, a study carried out by demonstrated that mal-adaptive coping responses partially mediate the relationship between intolerance of uncertainty and both anxiety and depression scores using mediation modelling (11). The concept of ‘Coping’ may be defined as the conscious or unconscious cognitive and behavioral strategies an individual employs to manage stress (12, 13). Many of the coping strategies which have been identified include self-distraction, active coping, denial, substance use, use of emotional support, use of informational support, and behavioral changes. These different coping strategies are often categorized into different groups. Example, 'approach' strategies typically focus on the stressor and one’s actions towards it (e.g. seeking emotional support or planning to resolve and reduce stressors) (14), while on the other hand, 'avoidant' strategies seek to avoid the stressor and one’s reaction to it (e.g. withdrawal from others, substance use, and denying the reality of the stressor) (15,16). Evidences suggest that the lower socio-economic position (abbreviated as SEP) involves greater usage of the ‘avoidant strategies.’ These individuals have more susceptibility to exposure to the stressors in their life course and may have less efficient coping strategies as a result of the social resources needed to combat stressors as well as less access to social support (17). Avoidance strategies are typically the root cause of depression and anxiety (18), which is why the most effective therapies (i.e., cognitive-behavioral therapy) focus on cognitive reappraisal and problem-solving responses (19). For example, when a person faces a traumatic event, the adoption of avoidant strategies is more likely which further are associated with later mental health problems.
Stress on the other hand, is defined as an ‘overload due to situations that exceed the resources needed for coping’. Stressor’s presence triggers the coping strategies that emerge to reduce or eliminate the adverse effects of stress (20). It is reported that the stress levels increase when are exposed to inefficient strategies and have consequences for physical and mental health (21). This was reported by Endler, & Parker, 1990 that the relationship between the stressor induced overload, the low efficiency of the coping strategies, and mental health damage has been recognized as a bidirectional mechanism establishing a feedback cycle (22).
Dealing with the distress of surviving through the worldwide spread infection poses a threat to the maintenance of mental well-being. A proper and thorough investigation of coping strategies can be an excellent utility tool for the understanding of the risks associated with the mental health issue. This is pertinent for the mental health service providers to understand the measure and protective factors that could be applied to address the issues. For example, reduction in negative coping strategies (e.g self-blame) may prove to be useful to achieve subsequent reduction in negative adjustment (e.g. depressive symptoms) (Heffer & Willoughby, 2017) (23).
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Objectives
The aim of this research is to investigate the effect of the pandemic on the physiological as well as mental well-being of the people and also to explore the coping strategies and mechanisms adopted by the populations so as to overcome the lockdown and social restrictions induced stress, anxiety and depression among the people. Specifically, this study was designed with reference to different theories (on stress and coping) and research articles to examine (i) the psychological impact (with respect to stress) of the pandemic, (ii) the coping strategies/ mechanisms adopted by the adult population in India during the lockdown during the COVID-19 pandemic and (iii) whether the living situation of the individual had an influence on the application of the coping strategies.
Methodology
This study reviews secondary data available through various models, past journals, published research papers and other sources pertaining to information and studies related to coronavirus pandemic as well as the psychological impacts of pandemic on people. The principal objective is to review different articles comprehensively, which are related to psycho-social coping mechanisms to reduce stress level among individuals.
The databases explored to identify the relevant papers and articles included NCBI (National Center for Biotechnology Information), PubMed, Google Scholar, Medline and various other journals.
Various coping strategies and mechanisms adopted by individuals
Experts are of the view that coping up with the prevailing conditions due to a stressful event is not an event but rather, it is a process which goes on for long and is to be practiced continually. Stress coping, as described by researchers such as Lazarus and Folkman, indicates a ‘specific process of cognitive appraisal to determine whether an individual believes he or she has the resources to respond effectively to the challenges of a stressor or change’ (Folkman & Lazarus, 1988; Lazarus & Folkman, 1987). When a person encounters a challenge or a provocation, he either designates that challenge as either threatening or non-threatening followed by appraisal that whether the person can or has the capacity and or resources to respond to the same effectively. And if the persons deduce that he/ she is not able to or do not have the resources to deal with the challenge then it is more likely that the person will adopt an emotion focused coping response, for e.g, wishful thinking.
Problem focused coping: this is the type of coping strategy which involves the implementation of active efforts to manage and control the stressful situations. This approach helps to alter a troubled person-environment relationship and eliminates the sources of stress via individual behavior. This can be done either by improving the relationship the people have or they can lower the expectations between themselves. This is a problem-solving technique in which the individual addresses a problem or stressor directly to alleviate or eliminate it. It is also referred to as problem-centered coping. For example, if a person is scared of climbing the heights, then he may take help from someone to accompany him to the location and with someone’s help and practicing climbing each day, he can eliminate his fear of heights.
Problem-focused coping is more likely to predominate when the encountering stressors we perceive as something that can be challenged and can be alleviated.
Problem-solving was another factor identified as a protection against depression (for both moderate and severe) and anxiety (severe). As this is a strategy which rests on a a problem-focused approach, more active behaviors are characterized by a plan to resolve stressful events using a collection of information about the stressful situation for decision making (Sawhney, Klinefelter, & Britt, 2018) (27). It has also been reported by Cantave et al., 2019 that the active coping strategies are less likely to be used under repeated stress conditions for long periods, and when the situation appears uncontrollable and unpredictable (28).
Emotion-focused coping: the emotion- focused coping includes all the regulative efforts to diminish the emotional consequences of stressful events. This actually involves having a control over your feelings, potential emotional response and beliefs towards the problem instead of addressing the problem. Emotion-focused coping skills assist you in processing and navigating through unwanted or painful emotions and reactions. To put it another way, it can be said that this approach facilitates emotions management in comparison to the outside occurrences. This is the approach which will be eliminating the source of the stress but helps a great deal in dealing with your negative or painful feelings/ responses in the situations which cannot be changed or can be controlled. It has been suggested that the individuals who turn to the emotion focused coping strategies are more immune to stress and enjoy more overall wellness.
Meditation, journaling is some of the examples of emotion focused coping which provide a meaningful emotional outlet for the distressing feelings and ideas. Cognitive reframing also allows oneself to have a shift in the perspective through which the problem was being approached or seen. This can actually bring about the difference if the situation is really creating distress or not. According to Folkman & Lazarus, 1980, this approach is more likely to occur when there is an awareness that the said problem ‘cannot be changed or resolved, only the outlook can be changed towards it. Hence it is quite clear that the emotion-focused coping is more suitable in handling the situations of uncontrollable stressors.
Coping strategy focused on emotions: Research developed with American Orthodox Jewish in the context of COVID-19 revealed that coping strategy focused on emotion, such as religiosity and belief in God, was directly impacting lesser stress and a positive impact on individual’s mental health. Religious beliefs can be considered as positive reappraisal strategies since religiosity is perceived by most as harmless and the problem seems ‘not so important’. It is also interpreted as an approach which bring learning or more proximity to spirituality (Pirutinsky et al., 2020) (29).
Stress and coping social support theory: The stress and coping social support theory proposed by Cohen and Wills (1985) stated that the coping method involves social support also which protects the people from the stresses & its harmful physical effects. Further, this theory states that support from the society inculcated the feeling of adaptive appraisal and coping techniques in handling the stressful events (Thoits, 2010) (24). According to Glanz et al. (2015), there are four types of social support which are helpful in handling and adapting to stressful environments: emotional support which involves providing love, care and compassion to the individual, information support which involves guiding and counselling the individual, appraisal support which involves providing the evaluative help to concerned and finally the instrumental support involving giving physical or action- oriented help to the person.
Research (2021) carried out in Ghana, during the COVID-19 pandemic, revealed that it was financial security and optimism about the disease increase one’s chances of coping well while having pre-existing medical conditions, praying and sleeping more during the pandemic than before reduces one’s chances of coping well (26).
Humor associated strategy: Humor was reported to be an effective strategy to help individuals cope up during the outbreak of the pandemic and deal with the adverse effects. It has also been found to be helping individuals have regular activities in the Malaysian population (Perveen et al., 2020) (30). Furthermore, research reveals that a good sense of humor is related to muscle relaxation, control of pain and discomfort, positive mood states, and overall psychological health including a healthy self-concept (Deaner and McConatha 1993; Hudak et al. 1991; Kuiper and Martin 1993; Kuiper et al.1992; Kuiper et al. 1995; Labbott et al. 1990; Martin et al. 1993; Overholser 1991; Prerost and Ruma 1987; Ruch and Kohler 1998; Thorson et al. 1997). The positive aspect of the humor associated strategy is that humor not only helps the person to cope with the stress sensor/ event at hand but also ensures overall mental health of the being.
Accepting responsibility: This is reported to be another coping mechanism focused on emotion found as a risk of moderate anxiety for people without previous mental disorder. Aware of one’s responsibilities is said to induce the tendency of self-blame and punitive behaviors (Stiegelis et al., 2003) (31). The people have the belief that the said problem have been caused by them and they are the root-cause for it. In patients with cancer, this strategy reduces actions promising the treatment (Miller, Manne, Taylor, Keates, & Dougherty, 1996) (32).
Negative coping mechanisms: To counter the effect of lockdown induced stress, it was observed that majority of the population turned to social media use, sleeping since were at home without a schedule and eating junk food. These all were associated with the negative impacts of the stress on both the genders. It was found that increased frequency of sleep was generally associated with a greater negative impact on academic performance, social relationships, stress and mental health. Moreover, while students were typically sleeping more in response to the COVID-19 pandemic, this might not necessarily mean their sleep quality is good, as sleep disturbances have been reported during the pandemic (33-34) However, the increase in the use of social media was primarily observed in the female population. Another negative impact of stress included the increase in the consumption of alcohol which was significantly higher in the case of male population than the females. Further, the use of cannabis and vaping nicotine to cope were also related to greater negative impacts on stress levels, but for males only. Conclusively, it can be interpreted that COVID-19 pandemic had a substantial impact on post-secondary students' academic experience, social relationships, and mental well-being. This is very problematic, as prior to the COVID-19 pandemic one in three university students had a mental health and/or substance use disorder (35), indicating that this is already an at-risk group. it has been seen that the female students especially are showing greater negative impact and adversities owing the COVID-19 pandemic. The data with respect to the coping strategies and negative impact of the lockdown is shown in the Table-1 given below:
Table 1: Spearman correlations between coping strategies and the negative impacts of COVID-19 on school work, social relationships, stress levels and mental health (Source: Coping With the COVID-19 Pandemic: Examining Gender Differences in Stress and Mental Health Among University Students, Front. Psychiatry, 07 April 2021)
Sec. Public Mental Health.
Behavioral strategy and Acceptance and Commitment Therapy Act: The use of behavioral and mindful coping strategies may help alleviate anxiety, through a process akin to acceptance and active engagement, supporting previous research on the putative benefits of mindfulness (36) and Acceptance and Commitment Therapy (ACT) (37) for health anxiety. There are possibilities that higher level of mindfulness may lead to the perception of the internal experiences as less frightening or intimidating which eventually increases one’s propensity to handle uncertainty and thereby reducing the need to get involved in adopting the safety behaviors, such as information seeking, seen in the youngest group, that may maintain health anxiety (38).
Meaning-focused coping: ?More recently, a third higher-order way of coping has been introduced, which is appraisal-based coping whereby an individual draw on beliefs, values, and existential goals to motivate and sustain coping. This is a coping strategy for the distressful situations that can’t be immediately solved and require a consistent action to resolve it for over a period of time. ?It generally necessitates positive reappraisal of a difficult issue by acting toward someone’s deepest emotions, beliefs, value and goals. It is known to realistically acknowledge the situation at hand and then look for the opportunities of alleviating the problem that coordinate with one’s beliefs, values and goals, some optimism. This can be of relied in the most terrible situations.
Cognitive Behavioral Therapy: Cognitive behavioral therapy (CBT) is a category of psychotherapeutic treatment which facilitates people to identify the disturbing or destructive thoughts or a pattern which have a negative impact on his behavior and mental being (39). This therapy aims at altering the automatic negative thoughts which contribute to and further worsen the emotional issues, depression and anxieties. These impulsive and unprompted negative thoughts leave a detrimental impact on the mood. Previous studies have indicated that techniques such as Cognitive Behavioral Therapy, stress management apps, and seeking social support can be used to increase adaptive coping strategies (18). People who were diagnosed with mental health issues were reported to have experienced a reduction in negative symptoms when shifting from avoidant to adaptive coping through the use of cognitive behavioral therapies (41). People who had a history of mental issues are recognized as more susceptible to getting affected by the pandemic. This makes them even more worthy of extra attention, care and support otherwise the earlier problem has the chances of relapse. The results in various studies showed that coping strategies in sample group did not have a protective effect, which can be explained by the difficulty in developing strategies that are cognitive or even more active in dealing with the pandemic's consequences. In this group, every strategy for coping has roots in coping mechanism towards emotional focus, collision and escape. The effect of emotional coping as confrontation and escape were predictors of less mental health.
Cognitive redefinition: Cognitive redefinition refers to a psychological coping strategy to redefine or change the perception through which we visualize, understand and feel about a series of events or circumstances. Instead of identifying this situation of world-wise crisis of pandemic as something stress inducer, cognitive redefining helps in utilizing this time to reconnect with family and also to get indulged in creative activities and self-care. One study shows that cognitive redefinition or change in mindset is helpful in dealing with stressful situations (Crum et al., 2013) (42).
Psycho-education: This refers to educating people about various psychological disorders and their consequences. A study showed that psycho-education has helped people to deal with psychological disorders more successfully than those who were not given psycho-education (Vieta, 2005) (43).
Escape-Avoidance strategy: Avoidance coping—also known as avoidant coping, avoidance behaviors, and escape coping—is a maladaptive form of coping in which a person changes their behavior to avoid thinking about, feeling, or doing difficult things (44). This type of coping involves trying to steer clear of the stress inducing situations and environment rather than confronting them. The avoidance coping is an example of emotion-focused coping is escape-avoidance strategies that comprise wishful thinking and behavioral efforts to escape or avoid the problem at hand through regulation of stressful emotions related to the problem. Although coping strategies are generally perceived as adaptive behavior towards the stressors aiming to decrease the burden on mind, it might also become dysfunctional in certain cases.
Table 2 represents the types of the coping strategies used by the students (source: PubMed Central)
Table 2: Coping strategies used by students during the COVID-19 pandemic.
Apart from above, other coping strategies that might work or some common coping mechanisms are as listed below:
1.??????Try to avoid to have a lot of expectations.
2.??????There is no issue in asking for help or assistance from others.
3.??????Do not blame the other for any mishap or any wrong doing that has happened.
4.??????Instead of the avoidance strategy, try to navigate the problem and solve it.
Discussion
The findings of the study indicate that the mental and cognitive health of a population need to be further analyzed so as to reach any concrete status on the psychological and mental impact of the pandemic that has affected the whole world. The onset of the pandemic has been the reason for the most stress during the last few years and has left a considerable impact on the lives of people including their lifestyle, mental and physiological health. Symptoms of the has been different on different people such as depending upon gender, socio-economic status, regional laws and restrictions which not only brought afear of uncertainty but also adversely affected the coping tendencies of people. The results of this study thus reveal that the coping strategies adopted by the individuals are different depending upon various parameters across the globe.
Outbreak of COVID-19 is not the only pandemic that the world has seen but it certainly is one of the most life-threatening one and most recent one which has induced the sense of uncertainty in the people. It is a pertinent matter that a failure towards an attempt at coping to the prevailing circumstances, may leave a lasting effect on the minds especially on the younger ones. Financial issue on the other hand, absence of proper healthcare infrastructure and safety issues are also comprising the resistance towards the coping strategies and mechanisms. According to a study which was based on Indian population, it was reported that a major shortage of hand sanitizers, hand gloves, masks was experienced followed by surge in the price of the items. This indicated towards the growing weariness and concern of the people against the infection of COVID-19. The strategies which are focused on emotion positive reappraisal are generally analogous with cognitive mechanisms. These are proved to be quiet appropriate for situations where people do not directly control the problem or practice the avoid-acceptance mechanism.
It has been established from various studies and researches the ‘Coping strategies are directly associated with anxiety levels’. It is also observed that most extreme levels of anxiety and stress factors were seen in cases of students which may be attributed to their concern towards their academics and their careers. On an average of 20% of the students in any study are reported to have the experienced the ‘extreme anxiety level’ which generally was more than one- fourth of the total sample size of the study. In one of the studies, students’ ability to seek social support, their isolation and mental disengagement and responsiveness to humanitarian issues are all assessed when measuring their copying strategies. For all the four cases, p-value is <0.001 between coping strategies and anxiety levels. This result indicates a strong positive relationship between coping strategies and the anxiety level of students. The contributors in this study had a satisfactory level of awareness concerning COVID-19 and the majority of them took the recommended preventive measures 20.
Conclusion:
COVID-19 has been the new face of the pandemic, and has put the whole world on a pause. It proved to be a significant threat to the entire civilization of mankind. It not only affected the physical health but also affected the mental health and well-being of the people irrespective of the infection or not. People who got cured also were left with post disease effects forcing them to deal with newer health issues. Nationwide lockdowns, social isolation, and restrictions on mobility increased the appearance of mental health issues. Usage and dependency on social media, junk food, sleeping, alcohol and other types of substances use increased during the lockdown. The frustration, boredom and loneliness also reported to increase the cases of domestic violence. So, it was an imperative mandate for the people working in healthcare sector to not only deal with the physical health status but to give the same amount of attention to the mental well-being of the people as well. Therefore, it is absolutely necessary to follow all the guidelines and rules laid out by government and health care professionals so as to avoid further spread of the disease and also take care of the people around us practicing social coping strategies on our own for the better quality of life and well-being of us and people around in the community.
Practice of mandatory social distancing was actually a risk which could escalate the issue of mental health in individuals. The findings of this study indicated that the adoption of the coping strategies can reduce the frequency of depression and stress among the individuals and might just provide better adaptation to the conditions. Participants who have a history of mental health issues are needed to be given extra support and affection to reduce stress, anxiety, and depression. Various coping strategies have not only provided a significant and conclusive explanation to the negative impacts induced by the pandemic such as depression and anxiety, it has also provided people ways to cope or come out of them to mark safe their mental wellness. Coping strategy such as Social support is proved to be one of the important ones and predicted positive impacts which eventually lead to decrease in negative impact on physical symptoms. However, Avoidant coping related to spike in adverse impacts which ae directly related to more physical symptoms.
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