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Year : 2020  |  Volume : 33  |  Issue : 4  |  Page : 1410-1417

Anxiety, depression, and commitment to infection control measures among Egyptians during COVID-19 pandemic

1 Department of Family Medicine, Menoufia Faculty of Medicine, Menoufia, Egypt
2 Department of Public Health and Community Medicine, Menoufia Faculty of Medicine, Menoufia, Egypt

Date of Submission17-Jul-2020
Date of Decision09-Aug-2020
Date of Acceptance16-Aug-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Zeinab A Kasemy
Gamal Abdel Nasser Street, 5th Floor, Department of Public Health, Faculty of Medicine, Shibin Elkom, Menoufia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_245_20

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The aim was to evaluate anxiety and depression among Egyptians during coronavirus disease 2019 (COVID-19) pandemic, its associated factors, and public commitment to infection control measures.
COVID-19 pandemic may be stressful for people. Fear and anxiety regarding a new disease can be overwhelming.
Participants and methods
A prospective study was conducted on 1080 Egyptians using four questionnaires: first, sociodemographic data and hearing about COVID-19; second, generalized anxiety disorders questionnaire; third, patient health questionnaire; and fourth, commitment to infection control measures during this epidemic. These questionnaires were applied twice, with 2 months apart, from March to May 2020.
Participants' age ranged from 15 to 50 (29.98 ± 7.95) years, with female sex predominance. Approximately 98.9% of the participants had heard about COVID-19 and 83.3% of them followed up the daily report of new cases and deaths. Prevalence of anxiety was 61.7%, whereas depression was 54.1%, and mixed depression-anxiety represented 33.3% of the participants. Anxiety and depression were significantly higher among participants who are highly educated, working, of lower socioeconomic status, and of urban residency. Moderate to severe anxiety toward COVID-19 declined with time from 24.4 to 18.6%, whereas severity of depression was increased among participants from 29.4 to 44.1% with time (P < 0.001). Commitment to infection control measures declined with time (P < 0.001).
Anxiety and depression were higher among public during COVID-19 pandemic. Female sex, being married, urban residency, and following up daily report about cases and deaths of COVID-19 were the likelihood associated factors. With time, anxiety and fear owing to pandemic may be reduced as well as people's commitment to infection control measures, whereas depression may increase among public owing to longevity of pandemic and its social and financial consequences.

Keywords: anxiety, coronavirus disease 2019, depression, Egyptians

How to cite this article:
AlKalasha SH, Kasemy ZA. Anxiety, depression, and commitment to infection control measures among Egyptians during COVID-19 pandemic. Menoufia Med J 2020;33:1410-7

How to cite this URL:
AlKalasha SH, Kasemy ZA. Anxiety, depression, and commitment to infection control measures among Egyptians during COVID-19 pandemic. Menoufia Med J [serial online] 2020 [cited 2021 Apr 19];33:1410-7. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1410/304498

  Introduction Top

Recently, the world has witnessed a number of epidemic outbreaks with devastating effects that can be mitigated. Effective management of such events calls for better approaches encompassing all the different aspects that can influence the outcome, including the cultural aspect[1]. Coronavirus disease 2019 (COVID-19) pandemic, also known as the coronavirus pandemic, is an ongoing pandemic of COVID-19, first identified at the end of 2019 in China[2]. Widespread outbreaks of infectious disease, such as COVID-19, are associated with psychological distress and symptoms of mental illness[3]. Social distancing includes infection control actions intended to slow the spread of infectious disease by minimizing close contact between individuals. Methods include quarantines; travel restrictions; and the closure of all public places like schools, shopping markets, and entertainment places. Social distancing methods may include home stay, less travel, avoidance of crowded areas, no-contact greetings, and standing or sitting one meter apart[4]. Several studies have examined the effect of social isolation on patients' mental well-being and behavior, and majority of them showed a negative effect, including higher scores for depression, anxiety, and anger among isolated patients[5]. Symptoms of depression and anxiety are, to a large extent, a normal reaction to stressors. In stressful situations, control loss is a reality reflection and may be accompanied by a more or less pronounced sense of helplessness[2]. According to the American Psychiatric Association, anxiety disorders are the most common type of psychiatric disorders. Some physical symptoms may be cause by anxiety disorders, which despite being prevalent, often are underrecognized and undertreated clinical problems[6]. Globally, the high persistent prevalence of depression across countries and regions ascertains the growing seriousness of this disorder[7]. Between 2005 and 2015, the number of people living with depression increased by 18.4%[8]. So, this study was conducted to evaluate anxiety and depression among Egyptians during COVID-19 pandemic, its associated factors, and public commitment to infection control measures.

  Participants and methods Top

A prospective study was conducted during the period from March to May 2020 through personal interview and online (through social media) questionnaires. Four questionnaires were used and they involved questions about first, sociodemographic of the participants, such as age, sex, residence, marital status, and socioeconomic standard according to Fahmy et al.[9]. Moreover, the questionnaire involved questions to assess the participants' knowledge about COVID-19. Second, Anxiety was assessed by generalized anxiety disorders (GAD) questionnaire (a translated form)[10], which consisted of seven simple questions. The GAD-7 score is calculated by assigning scores of 'not at all = 0', 'several days = 1', 'more than half the days = 2', and 'nearly every day = 3', and adding together the scores for the seven questions. The cutoff points of the scores were 5 for mild, 10 for moderate, and 15 for severe anxiety. Third, depression was assessed by using patient health questionnaire (a translated form), and it is used to assist clinicians with diagnosing depression and monitoring treatment response. This scale is based on the nine diagnostic criteria for major depressive disorder in the DSM-IV[11]. Depression severity is calculated by assigning scores of 0 for not at all, 1 for several days, 2 for more than half the days, and 3 for nearly every day with a range of 0–27 total score distributed as 0–4, meaning minimal depression; 5–9 mild; 10–14 moderate; 15–19 moderately severe; and 20–27 means severe depression. Fourth, assessment of public commitment to infection control measures (author designed questionnaire) such as hand hygiene, social isolation, and their usage of personal protective equipment (PPEs) such as face mask and gloves during COVID-19 outbreak was also assessed. The questionnaires were chosen based on being easy to understood, less time taken, and to the point, and all these criteria were assessed through the pilot study. The study was carried out through two steps:

  1. A pilot study: the questionnaires were pretested on 50 participants (10 online and 40 personal interviews) to ensure its validity and feasibility. The online questionnaires were translated to help the participants to share. The personal interviews were interviewer-based questionnaires with the same language used for the online questionnaires to avoid any bias concerning understanding of the questions. After analysis of the questionnaires' feedback, some modifications were done, such as reduction of its questions to avoid annoying participants by too many questions. The online recipients could forward the link to friends and acquaintances, in a snowball strategy. The involved questionnaires were distributed twice with two months apart. Anxiety and depression questionnaires had been previously validated. The author-based questionnaire that involved assessment of public commitment to infection control measures was validated and revised by experts in public health, family medicine, and infection controls. Cronbach's αwas calculated, and it equaled 0.74
  2. A convenience sample technique was applied. The participants were recruited from outpatient clinics, offices, and governmental services. A total of 1340 questionnaires were collected in the first time (281 online plus 1059 personal interviews). All participants were advised to leave their phone numbers for second time analysis of the questionnaires. The online participants left their e-mails or phone numbers for second time analysis. The second time returned 1080 answered questionnaires (109 online plus 971 personal interviews).

An approval of local Ethical Committee was obtained. Consent was obtained after explanation of the aim of the study.

Statistical analysis

Data were analyzed using SPSS V.22. SPSS (SPSS Inc., Chicago, IL, USA) Descriptive statistics in the form of percentage, mean ± SD, median, and range were performed. χ2 and Wilcoxon signed rank were used for nonparametric data. P value less than 0.05 was set as statistically significant.

  Results Top

The study was conducted on 1080 participants, aged 29.98 ± 7.95 years, with female sex predominance, representing 64.4% of the sample; they were nearly equally distributed from both rural and urban areas. In the online questionnaires, most of the participants were females, from urban areas, with young ages (range: 15–25 years). Approximately 98.9% of the participants had heard about COVID-19 and 83.3% of them followed up the daily report of new cases and deaths. Approximately half of them depended on data from daily official report of ministry of health (48.3%). Overall, 64% of them said that they did not perceive Ramadan month by happiness as they used to before COVID-19 [Table 1]. The prevalence of anxiety was 61.7%, depression was 54.1%, and mixed depression-anxiety represented 33.3% of the participants [Figure 1]. The main causes of participants' fear of COVID-19 were fear of death (50%) and fear of losing their beloved persons (30%). Participants' response to the seven questions of GAD questionnaire is demonstrated in [Table 2]. Severe anxiety showed higher levels among females, who were keen to follow daily report about new cases and deaths from multisource (P < 0.001) and who were from urban areas (P = 0.009). Severe anxiety was reported among participants with secondary education (P = 0.020), working (P = 0.010), of low socioeconomic standard (P = 0.001), and those who had past history of psychiatric disorders (P = 0.006). Most participants who had severe anxiety perceived Ramadan month this year badly owing to social isolation by COVID-19 (P = 0.02) [Table 3]. Moderately severe depression was found to be higher among married participants, from urban areas, having high education, working, having low socioeconomic status, and who were following daily report about new cases and deaths from more than one source, whereas there was an insignificant difference between depression and past history of psychiatric disorders [Table 4]. Moderate to severe public anxiety by COVID-19 declined with time from 24.4 to 18.6%, whereas severity of depression was increased among participants from 29.4 to 44.1% with time (P < 0.001). Commitment to infection control measures declined with time (P < 0.001) [Table 5].
Table 1: Demographic data and knowledge about COVID-19 among the studied participants (n=1080)

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Table 2: Distribution of the studied participants regarding generalized anxiety disorder questionnaire findings (n=1080)

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Table 3: Relation between generalized anxiety disorder and demographic data and perception of COVID-19 among the participants

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Table 4: Relation between depression disorder and demographic data and perception of COVID-19 among the participants

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Table 5: First and second interview assessment of generalized anxiety disorder, depression severity and commitment to infection control measures among the participants

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Figure 1: Distribution of the studied participants regarding anxiety and depression severity.

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  Discussion Top

As the coronavirus pandemic rapidly invades the world, it is driving a significant degree of attention particularly among older adults, care providers, and people with underlying health conditions. Disease itself and associated obligatory lockdown to limit its spread can lead to anxiety, depression, or other stress-related mental disorders. The prevalence of anxiety among adults was reported at 61.7%, which is much higher than that reported in National Mental Health Survey (3.6%)[12] and Ghanem et al. (4.8%)[13]. This could be explained by extra effect of epidemic, as this result is much higher than that of Chinese, Indian, and British studies, where 35.1, 25.3, and 23.8%, respectively, of adults developed anxiety related to epidemics [14–16]. The reasons behind the high prevalence of anxiety among Egyptians are fear for one's health or missing of beloved person, unemployment, social isolation, disruption to daily life, and the unknown aspect of disease, which are included as significant reasons for anxiety as recorded by the participants in the current study. This comes in line with that suggested by El Terk[17]. As uncertainty increases feelings of alarm, it results in behaviors that regain control of situations which people fear for two reasons; i. COVID 19 is perceived as a true threat expected to last ii. No one knows when or how to regain control. Moreover, Rubin and Wessely[18] stated that the current state of the COVID-19 illness already paints a picture of inevitable and large-scale quarantine. People may experience social isolation, an inability to tolerate this stress, fear of being trapped, loss of control, and the spread of rumors. Depression was detected among 54.1% of the participants in this study, which is parallel to the results of the studies conducted in Africa and Australia by Jalloh et al.[19] and Taylor et al. [20], who reported that 48 and 34% of the participants showed depressive symptoms owing to Ebola and Influenza epidemics in Africa and Australia, respectively. However, this result was higher than the prevalence of depressive symptoms owing to COVID-19 in a Chinese study by Huanga and Zhaoa[14], as the study denoted that 20.1% of the study sample had depressive symptoms. Approximately 33.3% of the participants in the current study showed mixed forms of depression and anxiety. The possible causes may be that anxiety and depression are often similar to one another and the comorbidity of the two disorders is quite high, with 60% of those with depression also having some form of anxiety disorder as reported by Ballenger[21]. In addition, Möller et al.[22] mentioned that mixed anxiety and depression appears to be prevalent, especially in primary care. Female sex is associated with a higher severity of anxiety, which is similar to the findings reported in Turkey by Özdin and Özdin[23]. On the contrary, a Chinese study by Lai et al.[24] revealed a significant relation between anxiety- depression and male sex, whereas Huanga and Zhaoa[14] and Taylor et al.[20] did not reveal any significant relation between anxiety-depressive symptoms and sex. The present study showed that urban residents were significantly associated with severe anxiety and depression and agrees with Özdin and Özdin[23], who suggested that the groups most psychologically affected by the COVID-19 pandemic are individuals living in urban areas. Marriage (vs never married) was associated with reduced risk of first onset of most mental disorders in both sex, as reported by Scott et al. [25]. Depressive symptoms were significantly higher among married, highly educated, working, females, who were from urban areas, and had low socioeconomic status. Mirzaei et al.[26] found a significant difference between the symptoms of depression, anxiety, and stress and sex, education, employment, and marriage status. The explanation for higher prevalence of depression among married individuals and who were resident in urban regions may be owing to their excessive fear of losing any of their beloved family members. Generally, individuals who are living in urban areas are vulnerable to develop mental disorders more than others from rural region, and this risk increases in the presence of pandemic such as COVID-19, where risk for infection is expected to be higher in urban areas owing to overcrowding and other environmental factors within urban areas. The current study revealed that people who were following the daily report about new cases and deaths from many sources seemed to develop anxiety and depressive symptoms than others. The relation of being a cause or a result between both was undetected here, but we suppose that it is a normal association in the current COVID-19, where all international and national efforts were explored for public in the form of mass and continuous recording of new cases and deaths with its broadcasting on different channels as TV, radio, and social media, which in turn would improve public commitment for infection control measures and social distancing to limit the viral spread. However, in spite of these great and respectful efforts from all health organizations all over the world, these continuous notifications were associated with increase public stress and fear related to COVID-19. Spiritual health is a portion of health that should be taken into consideration, so we assessed effect of COVID-19 through asking the participants about their perception of Ramadan (the fasting month) and its ritual this year in presence of COVID-19, and a significant association was found between anxiety, depressive symptoms, and bad perception of the participants, it may be related to social isolation and absence of all pictures of celebration by Ramadan month. The study revealed that most participants were compliant to social isolation and infection control measures such as hand hygiene and wearing PPEs during early stage of COVID-19 pandemic, and this goes parallel to Alhazmi et al. [27], who in a Saudi study reported 59.7% always washed their hands with water and soap and 34.8% used antibacterial soap. Gaygisiza et al.[28] declared that the first most commonly reported protective behavior against respiratory tract infection was frequent hand washing with hot water and soap (70.4%), followed by using a handkerchief more often than usual when sneezing (61.5%). Public health action is effectively feasible by paying attention to the public's knowledge of epidemics, their fears, psychological responses, and compliance level with public health measures. Putting into consideration and understanding of these factors would improve preparedness for and control of such epidemic crises[29]. The current study revealed reduction in compliance of public to infection control measures by time and this may be owing to long time of infection, and also it is too boring for non-medical personnel to wear PPEs as a part of their daily life routine. Finally, social distance leads to limitation of public activities, so public sense of fear from losing is the trigger to break this form of restriction and practicing their works and social activities. Anxiety among public owing to COVID-19 was seen to be reduced by time, and from our point of view, it may be related to improved disease prognosis by time and discovery of the treatment that reduces its complications. The reverse was seen regarding depression, which may result from different drawbacks of COVID-19 (social and economic causes or frequent updating of incidence of new cases and death rate).

Strengths and limitations

As far as we know, this is the first study discussing depression and anxiety among Egyptians during a pandemic on two occasions. The main challenge we met was how to collect the data in such circumstances, and this was the main reason to use social media, but fortunately, we could collect a representative sample dependency.

  Conclusion Top

Anxiety and depression were higher among public during COVID-19 pandemic. Female sex, being married, urban residency, and following up daily report about cases and deaths of COVID-19 were the likelihood associated factors. With time, anxiety and fear owing to pandemic may be reduced as well as people's commitment to infection control measures, whereas depression may increase among public owing to longevity of pandemic and its social and financial consequences.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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