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Volume 10, Issue 2 (2022)
Health Educ Health Promot 2022, 10(2): 333-340 |
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Received: 2021/09/21 | Accepted: 2022/03/11 | Published: 2022/06/15
Received: 2021/09/21 | Accepted: 2022/03/11 | Published: 2022/06/15
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Sadeghian E, Bashirian S, Soltanian A, Taheri M, Madineshat M. Relationship between Mental health, Perception of Illness, and Perceived Social Support in Hospitalized Patients with COVID-19. Health Educ Health Promot 2022; 10 (2) :333-340
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1- Department of Nursing, School of Nursing and Midwifery†and “Chronic Diseases (Home Care) Research Centerâ€, Hamadan University of Medical Sciences, Hamadan, Iran
2- “Department of Public Health, School of Health†and “Social Determinants of Health Research Centerâ€, Hamadan University of Medical Sciences, Hamadan, Iran
3- “Department of Biostatistics, School of Health†and “Modeling of Noncommunicable Diseases Research Center, Health Sciences & Technology Research Instituteâ€, Hamadan University of Medical Sciences, Hamadan, Iran
4- School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
2- “Department of Public Health, School of Health†and “Social Determinants of Health Research Centerâ€, Hamadan University of Medical Sciences, Hamadan, Iran
3- “Department of Biostatistics, School of Health†and “Modeling of Noncommunicable Diseases Research Center, Health Sciences & Technology Research Instituteâ€, Hamadan University of Medical Sciences, Hamadan, Iran
4- School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
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Introduction
Coronavirus disease 2019 (COVID-19) appeared in Wuhan, Hubei province in late December 2019 and then spread rapidly to other parts of countries via different ways such as airline traveling now, COVID-19 is the world’s pandemic problem [1, 2] As May 07, 2021, there have been 156,782,571 confirmed cases of COVID-19, including 3,272,076 deaths, reported to WHO [3]. Infectious disease epidemics not only damage the physical health of patients and consequently their deaths but also imposes irreversible psychological impacts on the general public [4]. The physical damage can be recovered in a short time, but the psychological consequences may persist for a much longer time [1].
Patients diagnosed with COVID-19 must be treated in isolation. Through clinical observation, many patients developed anxiety after isolation treatment. Anxiety, as a kind of psychological stress, will provoke a series of physiological circumstances and cause a decrease in immunity [5]. Fear of disease, anxiety, and more importantly, depression following losing friends and family are some of the issues people should deal with [4].
It has been reported that the COVID-19 pandemic causes negative effects on mental health in the general population, in groups such as healthcare workers where there is a high risk of transmission and violence, and especially in patients with the diagnosis/suspicion of COVID-19 [6-9]. Studies have been conducted in different populations to investigate mental health problems following the COVID-19 pandemic. For example, Wang et al. In a cross-sectional study assessed the levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak [10] in this study 1210 participants from 194 cities in China respond to an online questionnaire. Results showed that in total, 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms, and 8.1% reported moderate to severe stress levels. Al-Rabiaah et al. [11] surveyed 200 students from the College of Medicine. They found all students had stress but female students had a significantly higher mean stress level than males (p<0.001). In a study conducted in Iran on the general population perceived stress among the participants was significantly higher [12].
Social support plays an important role in maintaining individuals’ health and reducing the negative effects of stresses caused by the environment and society. As social support increases, the mortality rate of patients and the incidence of physical and mental illnesses in people decrease. Support is provided by family members, relatives, friends, co-workers, neighbors, or health care providers [13]. Social support is a social network that provides people with psychological and tangible resources to cope with stressful life situations and daily problems. The moderating role of social support in stress has been emphasized [14]. Social support includes subjective and objective support and its utilization. Yue et al., the study showed that a high level of social support plays a protective role in anxiety among pregnant women during the coronavirus disease 2019 [11].
Uncertainty and excessive fear are the main mediating factors that may affect the emotional response of an individual during the COVID-19 outbreak. In addition, fear may lead to both impaired risk perception [15]. Illness perceptions are based on past experiences, symptom severity, and information from others, including the medical team [16]. A person's perception of danger shapes their mental manifestations of the disease and affects their disease behavior. Perceptions of disease are cognitively organized representations that patients have of their disease, its effects, and the way they deal with their complaints [17]. The adoption of any action to deal with danger depends on the individual's beliefs and perceptions of the five variables. These variables are:
1) identity: how a participant describes their illness and the symptoms they experience;
2) consequences: anticipated outcomes of the disease;
3) cause: personal reasons for the cause of their disease;
4) timeline: duration of their illness;
5) cure or control: belief that treatments will improve their illness [16].
A previous study has demonstrated a correlation between negative illness perceptions and increased ratings of perceived stress [18-19]. Researchers must understand illness perceptions and their relationship to stress because of their impact on mental health. By identifying which illness perceptions are associated with stress, medical professionals can implement targeted interventions to promote mental health [20].
The epidemic has increased general fear and stress. Mental health is becoming an issue that cannot be ignored. Most studies have been performed in populations other than hospitalized patients, and the mental health status of patients hospitalized with COVID-19 remains unknown. Given that patients after diagnosis of COVID-19 may have psychological problems such as fear of disease progression, disability, or premature death, and due to being newfound of COVID-19 and the unknown nature of most of its aspects, including the mental health of hospitalized patients, while it is still spreading, recognizing the mental health status, we can help the treatment team to provide more appropriate services for hospitalized patients. Accordingly, this study aimed to determine the relationship between stress, anxiety, and depression with perceived social support and perception of the disease.
Instrument and Methods
The present study is a cross-sectional study that was conducted in 2020 for 10 months. The study population consisted of all patients with COVID-19 referred to Farshchian Sina, Hospital in Hamadan, Iran. Farshchian Sina Hospital in Hamadan is the only hospital for patients with coronavirus.
In this study, the correlation between depression and social support was considered to be around -0.3. Therefore, considering the error type I of 5% and the test power of 90%, the sample size of 143 people was calculated. Based on the available sampling, 143 patients with coronavirus who met the inclusion criteria participated in this study. Inclusion criteria are age over 18 years, full consciousness, lack of physical and mental disabilities, diagnosis of coronavirus with the approval of an infectious disease specialist, no history of mental disorders, and the ability to communicate with the researcher. Participants who did not complete the questionnaires were excluded from the study. In the present study, the researcher (MT: person third in this study) who has a history of nursing referred to the research environment and after selecting the participants according to the inclusion criteria, provided necessary explanations about the research.
The data collection tool consisted of 4 questionnaires: 1- The personal and clinical characteristics questionnaire (age, sex, job, marital status, place of residence, oxygen saturation rate, diseases history, drug history, smoking, abuse, vital signs), 2- 21-item depression, anxiety and stress scale (DASS21); 3- Zimet’s multidimensional scale of perceived social support; 4- The brief illness perception questionnaire (BIPQ).
- The stress, anxiety and depression scale (DASS-21) was first presented by Lovibond in 1995, which includes 21 questions on a Likert scale, of which 7 questions are related to stress (1-6-8-11-12-14-18), 7 questions are related to anxiety (2-4-7-9-15-19-20) and 7 questions related to depression (3-5-10-13-16-17-21). Each of the DASS-21 subscales contains 7 questions and the final score of each is obtained through the sum of the scores of the related questions. Each question is scored from zero (does not apply to me at all) to 3 (applies to me completely). Since this questionnaire is a shortened form of the main scale (42 questions), the final score of each subscale should be doubled [21]. The questionnaire interpretation of the severity of each subscale is as follows: depression (normal=0-9, mild=10-13, moderate=14-20, severe=21-27, very severe=+28); anxiety (normal=0-7, mild=8-9, moderate=10-14, severe=15-19, very severe=+20); stress (normal=0-14, mild=15-18, moderate=19-25, severe=26-33, very severe=+34). The validity and reliability of this tool have been confirmed by Aghebati et al. [22] and Khezerloo et al. [23] in Iran.
- The Multidimensional Scale of Perceived Social Support was designed in 1988 by Zimet, Dahlem, Zimet, and Farley. The Multidimensional Perceived Social Support Scale is a 12-item tool designed to assess perceived social support from three subscales of friends, family, and significant others. The purpose of designing a multidimensional scale of perceived social support is to measure the rate of receiving perceived social support from three subscales of friends, family, and significant others in the participants [24]. The scale of the multidimensional scale of perceived social support of Zimet et al. is considered as a 7-point Likert scale from strongly disagree (with a score of 1) to strongly agree (score of 7). Therefore, the subject scores from 1 to 7 on each question on this scale. In other words, the total score for each subscale ranges from 4 to 28 and for the whole scale from 12 to 84. Interpretation in terms of the average of obtained scores is as follows: average score of 1 to 2.9, low perceived social support; Average score of 3 to 5, moderate perceived social support; Average score of 5.1 to 7, high perceived social support. In Zimet et al.’s research, the reliability of the multidimensional scale of perceived social support has been reported for the whole scale as 0.88 by Cronbach's alpha coefficient and for the subscales of significant others, family and friends as 0.91, 0.87, and 0.85, respectively. Also, the reliability of this scale has been reported by the retest method for the whole scale as 0.85 and for the subscales of significant others, family and friends, respectively 0.72, 0.85 and 0.75 [24]. In the research of Alipour et al. [25], and Aliakbari Dehkurdi et al. [26], the reliability of this scale has been reported 0.94 by calculating Cronbach's alpha coefficient for the whole scale was 0.89, 0.90, and 0.90 for subscales of friends, family, and significant others, respectively.
- The illness perception questionnaire was designed and validated by Brodbent et al. [16]. The questionnaire consists of 9 items. The questions measure outcomes, duration, personal control, treatment control, nature, concern, illness cognition, emotional response, and cause of the illness, respectively. The range of scores of the first 8 questions is from 0 to 10. Question 9 is open-ended and questions the three main causes of the illness, respectively. In order to interpret the scores, we collect obtained scores. Zero indicates the low limit of the questionnaire score, 40 the average limit, and 80 the upper limit of the questionnaire score. If the questionnaire score is between 0 and 20, the variable rate is weak in this population; if it is between 20 and 60, the variable rate is moderate and if the scores are above 60, the variable rate is very high. Cronbach's alpha for this questionnaire is 0.80 and the reliability coefficient of retest within 6 weeks for different questions has been reported from 0.42 to 0.75. In the research of Aliakbari Dehkurdi [26], the reliability of the questionnaire was reported to be 0.87 based on Cronbach's alpha coefficient.
After obtaining informed consent, the participant is asked to answer the questionnaire questions carefully. The time of completing the questionnaire is selected in such a way that it doesn’t interfere with the patient's rest and daily care. During the completion of the questionnaires, the researcher was present in the research environment and answered the participants' questions.
The collected data were analyzed in SPSS 26, using descriptive and inferential statistics (independent t-test, ANOVA, Spearman correlation coefficient, and multivariate regression).
Findings
A total of 143 patients with COVID-19 were included in the study. The mean±SD age was 53.6±13.67 years with a range of 28 to 88 years. In this study, more than half of the participants were over 40 years old, married, and illiterate, and half of the subjects were unemployed (Table 1).
The mean±SD of Systolic BP Diastolic BP, heart rate, temperature, and respiration of the patients were 111.6434±14.55, 76.90±10.23, 84.96±9.42, 39.46±27.43, and 19.65±2.96, respectively.
The average score of depression, anxiety and stress for all participants with COVID-19 was 8.12±7.12, 11.74±6.02 and 13.92±6.80, respectively.
The results of this study showed that most of the patients had moderate symptoms of anxiety, no symptoms of stress, and no symptoms of depression (Table 2).
The social support level for the patients was 35.7% and 59.4% of patients had moderate and high social support levels, respectively (Table 3).
Figure 1 shows factors that the participant believed caused his illness. Participants said that the most common cause of their illness was the failure to follow hygienic instructions and not wearing a mask (Figure 1).
The multiple linear regression model in Table 4 showed that Drug History, perception, and social support) were associated with depression for the COVID-19 patients. The same analysis showed that Drug History, perception, social support (and oxygen saturation were associated with anxiety among the patients with COVID-19. Moreover, the multiple linear regression analysis showed that two factors perception, social support, and oxygen saturation were associated with stress for the COVID-19 patients (Table 4).
Table 1) Demographic and clinical characteristics (n=143)
![src=./files/hehp/images/HTML_Publish/55003/55003-T_1.PNG]()
Table 2) Descriptive Statistics for Major Study Variables (n=143)
![src=./files/hehp/images/HTML_Publish/55003/55003-T_2.PNG]()
Table 3) Comparison of Mean±SD of depression, anxiety, and stress scores on patient's characteristics
![src=./files/hehp/images/HTML_Publish/55003/55003-T_3.PNG]()
![src=./files/hehp/images/HTML_Publish/55003/55003-F_1.PNG]()
Figure1) Factors that the participant believed caused his illness
1. Spouse; 2. Going to a party; 3. Failure to follow hygienic instructions and not wearing a mask; 4. Workplace; 5. Family members; 6. Go to the mall; 7. Go for a walk and have fun; 8. Use of public transportation
Table 4) Multiple linear regression analysis of factors associated with depression, anxiety, and stress
![src=./files/hehp/images/HTML_Publish/55003/55003-T_4.PNG]()
Discussion
This study aimed to determine the relationship between stress, anxiety, and depression with perceived social support and perception of the disease in patients with COVID-19. The results of this study show that 37% of patients had mild to moderate depression and only three patients experienced severe and very severe depression. One-third of patients had moderate anxiety and one-third had severe to very severe anxiety. About one-third also experienced mild to moderate stress.
Chen et al. found in their study that 21% of COVID-19 hospitalized patients had depression and 16.4% of them had experienced anxiety [27]. Findings from the Assefa study in COVID-19 patients reported a rate of 36.5% depression and 21.2% anxiety [28]. The study by Kandeger et al. Showed that the prevalence of anxiety and depression symptoms was 19% and 34.5%, respectively [15]. In the study by Kong et al., age, sex, and oxygen saturation were associated with anxiety, and age and family involvement with SARS-CoV-2 were associated with depression [29]. In this regard, the US Food and Drug Administration explains that the use of some general medications may be associated with the induction of depression [30, 31].
Other results show that more than half of the patients have a moderate understanding of the disease and enjoy high social support. Consistent with the present study, the study by Kandeger et al. indicates that hospitalized COVID-19 patients had perceived high social support [15].
Linear regression analysis showed that perception of illness and social support and history of medicine use were significantly associated with depression, perception of illness and social support and history of medicine use and oxygen saturation were significantly associated with anxiety and perception of illness and social support and oxygen saturation were significantly associated with stress. Thus, more perception of illness leads to increased stress, anxiety, and depression, and less social support leads to increased stress, anxiety, and depression. It is noteworthy that among the variables included in the regression model, social support showed a stronger relationship with stress, anxiety and depression than the other variables.
Consistent with the present study, Kandeger et al. study indicated that high perceived social support had a significant relationship with depression symptoms [15]. A review of studies shows that the relationship between social support and depression is more important than the relationship between social support and anxiety and stress in studies. However, the results for both of them are consistent with the findings of many studies in different communities [32-34]. Consistent with the results of this study, the findings of a study by Yue et al. in Chinese pregnant women with COVID-19 show that social support can directly regulate anxiety, while it is negatively or indirectly related to perceptions of disease risk. Perception of disease risk is positively related to anxiety and negatively or indirectly related to social support. In the study by Yue et al., only the relationship between anxiety and social support and perception of disease risk is reported [1]. A study by Kong et al. in China also shows that the less social support for patients with COVID-19, the more anxiety and depression they report. In this way, social support can improve assessment and coping skills in individuals, reduce the severity of the perceived risk of stressful events, and thus play an indirect protective role in mental health [29]. Another explanation for the findings of this study may be that there is a close relationship between anxiety, stress, depression and social support. According to the stress buffer model, perceived social support by decreasing the perception of situations as a threat and increasing the belief in available resources can play a protective role for psychological problems such as stress, anxiety and depression [35, 36]. As the results of this study show, patients with COVID-19 have moderate to high social support. The study by Paykani et al. [37], and Jalaei et al. [38] shows that perceived social support can be both a facilitator and a barrier for people with the disease. This study explains that it depends on the people from whom patients receive social support. Social support from family has a greater effect on relieving the negative effects of the disease on the psychological dimension, while social support that patients receive from friends causes more maladaptive behaviors and increases the negative effects of the disease on the psychological dimension. Of course, studies show that how to use social support is different in different cultures. In collectivist cultures, such as East Asia, people are dependent on their families and give priority to the family. The family is a very important resource in the issue of social support and has a protective role against anxiety and depression. Of course, in East Asian cultures, the support that people with the disease receives from their family members can reduce the negative effects of stressful life events. The family is the first and most important source of social support. In addition, good family social support can also provide a good individual emotional experience for coping with stressful situations [39, 40]. Consistent with the present study, the results of the study by Miceli et al. showed that there is a positive and significant relationship between perceived stress and perceived risk [20]. The study by Li & Lyu showed that risk perception was positively associated with perceived stress, anxiety and depression [41]. Hospitalized patients who had lower levels of perceived social support were at a higher risk of depression and anxiety [27]. The study by Zandifar et al. showed that perceived stress was significantly associated with anxiety and depression [42].
This study has some limitations that can be a guide for future studies, including the fact that this study was performed on a small sample of patients with COVID-19 and only in one hospital. It may be necessary to do a larger sampling to generalize the results. The use of self-report tools may cause more or fewer reports of anxiety, stress, depression, and social support which is recommended in addition to quantitative tools, qualitative tools be used in future studies. It is important to follow up in future studies that what kind of perceived social support and from which source is most effective in reducing stress, anxiety, and depression in patients with COVID-19, Although this study has limitations, it can provide new insights to moderate the effects of COVID-19 on the mental health of these individuals using a perceived social support environment source and reduce the risk of perception of illness.
Conclusion
In general, the results of the present study indicated that COVID-19 patients hospitalized in the hospital experienced anxiety, stress, and depression. Most patients with COVID-19 have high social support and moderate perception of illness. Depression, anxiety, and stress in patients with COVID-19 are associated with the perception of illness and social support, which is more strongly associated with social support. Therefore, strengthening social support in patients with COVID-19 as well as improving patients' perception of illness by providing the necessary training and counseling by health professionals may be able to alleviate their anxiety, stress and depression.
Acknowledgments: The authors would like to thank the Honorable Vice Chancellor for Research of Hamadan University of Medical Sciences, and Farshchian Hospital (Sina) and patients with COVID-19.
Ethical Permissions: This study was approved by the Ethics Committee of the Hamadan University of Medical Sciences, with approval no.: IR.UMSHA.REC.1399.230 This study was conducted under the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The subjects were assured of the following: their participation was optional; they could withdraw at any time without facing any negative consequences. All participants provided their written informed consent.
Conflicts of Interests: This article is the result of a research project at Hamadan University of Medical Sciences, approved by project number 9904242496.
Authors’ Contributions: Sadeghian E (First Author), Introduction Writer/Main Researcher/Discussion Writer (20%); Bashirian S (Second Author), Methodologist (20%); Soltanian A (Third Author), Assistant Researcher (20%); Taheri M (Forth author), Assistant Researcher (20%); Madineshat M Assistant Researcher/Statistical Analyst (20%)
Funding/Support: This research project was supported by vice-chancellor of research and technology of Hamadan University of Medical Sciences.
Coronavirus disease 2019 (COVID-19) appeared in Wuhan, Hubei province in late December 2019 and then spread rapidly to other parts of countries via different ways such as airline traveling now, COVID-19 is the world’s pandemic problem [1, 2] As May 07, 2021, there have been 156,782,571 confirmed cases of COVID-19, including 3,272,076 deaths, reported to WHO [3]. Infectious disease epidemics not only damage the physical health of patients and consequently their deaths but also imposes irreversible psychological impacts on the general public [4]. The physical damage can be recovered in a short time, but the psychological consequences may persist for a much longer time [1].
Patients diagnosed with COVID-19 must be treated in isolation. Through clinical observation, many patients developed anxiety after isolation treatment. Anxiety, as a kind of psychological stress, will provoke a series of physiological circumstances and cause a decrease in immunity [5]. Fear of disease, anxiety, and more importantly, depression following losing friends and family are some of the issues people should deal with [4].
It has been reported that the COVID-19 pandemic causes negative effects on mental health in the general population, in groups such as healthcare workers where there is a high risk of transmission and violence, and especially in patients with the diagnosis/suspicion of COVID-19 [6-9]. Studies have been conducted in different populations to investigate mental health problems following the COVID-19 pandemic. For example, Wang et al. In a cross-sectional study assessed the levels of psychological impact, anxiety, depression, and stress during the initial stage of the COVID-19 outbreak [10] in this study 1210 participants from 194 cities in China respond to an online questionnaire. Results showed that in total, 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms, and 8.1% reported moderate to severe stress levels. Al-Rabiaah et al. [11] surveyed 200 students from the College of Medicine. They found all students had stress but female students had a significantly higher mean stress level than males (p<0.001). In a study conducted in Iran on the general population perceived stress among the participants was significantly higher [12].
Social support plays an important role in maintaining individuals’ health and reducing the negative effects of stresses caused by the environment and society. As social support increases, the mortality rate of patients and the incidence of physical and mental illnesses in people decrease. Support is provided by family members, relatives, friends, co-workers, neighbors, or health care providers [13]. Social support is a social network that provides people with psychological and tangible resources to cope with stressful life situations and daily problems. The moderating role of social support in stress has been emphasized [14]. Social support includes subjective and objective support and its utilization. Yue et al., the study showed that a high level of social support plays a protective role in anxiety among pregnant women during the coronavirus disease 2019 [11].
Uncertainty and excessive fear are the main mediating factors that may affect the emotional response of an individual during the COVID-19 outbreak. In addition, fear may lead to both impaired risk perception [15]. Illness perceptions are based on past experiences, symptom severity, and information from others, including the medical team [16]. A person's perception of danger shapes their mental manifestations of the disease and affects their disease behavior. Perceptions of disease are cognitively organized representations that patients have of their disease, its effects, and the way they deal with their complaints [17]. The adoption of any action to deal with danger depends on the individual's beliefs and perceptions of the five variables. These variables are:
1) identity: how a participant describes their illness and the symptoms they experience;
2) consequences: anticipated outcomes of the disease;
3) cause: personal reasons for the cause of their disease;
4) timeline: duration of their illness;
5) cure or control: belief that treatments will improve their illness [16].
A previous study has demonstrated a correlation between negative illness perceptions and increased ratings of perceived stress [18-19]. Researchers must understand illness perceptions and their relationship to stress because of their impact on mental health. By identifying which illness perceptions are associated with stress, medical professionals can implement targeted interventions to promote mental health [20].
The epidemic has increased general fear and stress. Mental health is becoming an issue that cannot be ignored. Most studies have been performed in populations other than hospitalized patients, and the mental health status of patients hospitalized with COVID-19 remains unknown. Given that patients after diagnosis of COVID-19 may have psychological problems such as fear of disease progression, disability, or premature death, and due to being newfound of COVID-19 and the unknown nature of most of its aspects, including the mental health of hospitalized patients, while it is still spreading, recognizing the mental health status, we can help the treatment team to provide more appropriate services for hospitalized patients. Accordingly, this study aimed to determine the relationship between stress, anxiety, and depression with perceived social support and perception of the disease.
Instrument and Methods
The present study is a cross-sectional study that was conducted in 2020 for 10 months. The study population consisted of all patients with COVID-19 referred to Farshchian Sina, Hospital in Hamadan, Iran. Farshchian Sina Hospital in Hamadan is the only hospital for patients with coronavirus.
In this study, the correlation between depression and social support was considered to be around -0.3. Therefore, considering the error type I of 5% and the test power of 90%, the sample size of 143 people was calculated. Based on the available sampling, 143 patients with coronavirus who met the inclusion criteria participated in this study. Inclusion criteria are age over 18 years, full consciousness, lack of physical and mental disabilities, diagnosis of coronavirus with the approval of an infectious disease specialist, no history of mental disorders, and the ability to communicate with the researcher. Participants who did not complete the questionnaires were excluded from the study. In the present study, the researcher (MT: person third in this study) who has a history of nursing referred to the research environment and after selecting the participants according to the inclusion criteria, provided necessary explanations about the research.
The data collection tool consisted of 4 questionnaires: 1- The personal and clinical characteristics questionnaire (age, sex, job, marital status, place of residence, oxygen saturation rate, diseases history, drug history, smoking, abuse, vital signs), 2- 21-item depression, anxiety and stress scale (DASS21); 3- Zimet’s multidimensional scale of perceived social support; 4- The brief illness perception questionnaire (BIPQ).
- The stress, anxiety and depression scale (DASS-21) was first presented by Lovibond in 1995, which includes 21 questions on a Likert scale, of which 7 questions are related to stress (1-6-8-11-12-14-18), 7 questions are related to anxiety (2-4-7-9-15-19-20) and 7 questions related to depression (3-5-10-13-16-17-21). Each of the DASS-21 subscales contains 7 questions and the final score of each is obtained through the sum of the scores of the related questions. Each question is scored from zero (does not apply to me at all) to 3 (applies to me completely). Since this questionnaire is a shortened form of the main scale (42 questions), the final score of each subscale should be doubled [21]. The questionnaire interpretation of the severity of each subscale is as follows: depression (normal=0-9, mild=10-13, moderate=14-20, severe=21-27, very severe=+28); anxiety (normal=0-7, mild=8-9, moderate=10-14, severe=15-19, very severe=+20); stress (normal=0-14, mild=15-18, moderate=19-25, severe=26-33, very severe=+34). The validity and reliability of this tool have been confirmed by Aghebati et al. [22] and Khezerloo et al. [23] in Iran.
- The Multidimensional Scale of Perceived Social Support was designed in 1988 by Zimet, Dahlem, Zimet, and Farley. The Multidimensional Perceived Social Support Scale is a 12-item tool designed to assess perceived social support from three subscales of friends, family, and significant others. The purpose of designing a multidimensional scale of perceived social support is to measure the rate of receiving perceived social support from three subscales of friends, family, and significant others in the participants [24]. The scale of the multidimensional scale of perceived social support of Zimet et al. is considered as a 7-point Likert scale from strongly disagree (with a score of 1) to strongly agree (score of 7). Therefore, the subject scores from 1 to 7 on each question on this scale. In other words, the total score for each subscale ranges from 4 to 28 and for the whole scale from 12 to 84. Interpretation in terms of the average of obtained scores is as follows: average score of 1 to 2.9, low perceived social support; Average score of 3 to 5, moderate perceived social support; Average score of 5.1 to 7, high perceived social support. In Zimet et al.’s research, the reliability of the multidimensional scale of perceived social support has been reported for the whole scale as 0.88 by Cronbach's alpha coefficient and for the subscales of significant others, family and friends as 0.91, 0.87, and 0.85, respectively. Also, the reliability of this scale has been reported by the retest method for the whole scale as 0.85 and for the subscales of significant others, family and friends, respectively 0.72, 0.85 and 0.75 [24]. In the research of Alipour et al. [25], and Aliakbari Dehkurdi et al. [26], the reliability of this scale has been reported 0.94 by calculating Cronbach's alpha coefficient for the whole scale was 0.89, 0.90, and 0.90 for subscales of friends, family, and significant others, respectively.
- The illness perception questionnaire was designed and validated by Brodbent et al. [16]. The questionnaire consists of 9 items. The questions measure outcomes, duration, personal control, treatment control, nature, concern, illness cognition, emotional response, and cause of the illness, respectively. The range of scores of the first 8 questions is from 0 to 10. Question 9 is open-ended and questions the three main causes of the illness, respectively. In order to interpret the scores, we collect obtained scores. Zero indicates the low limit of the questionnaire score, 40 the average limit, and 80 the upper limit of the questionnaire score. If the questionnaire score is between 0 and 20, the variable rate is weak in this population; if it is between 20 and 60, the variable rate is moderate and if the scores are above 60, the variable rate is very high. Cronbach's alpha for this questionnaire is 0.80 and the reliability coefficient of retest within 6 weeks for different questions has been reported from 0.42 to 0.75. In the research of Aliakbari Dehkurdi [26], the reliability of the questionnaire was reported to be 0.87 based on Cronbach's alpha coefficient.
After obtaining informed consent, the participant is asked to answer the questionnaire questions carefully. The time of completing the questionnaire is selected in such a way that it doesn’t interfere with the patient's rest and daily care. During the completion of the questionnaires, the researcher was present in the research environment and answered the participants' questions.
The collected data were analyzed in SPSS 26, using descriptive and inferential statistics (independent t-test, ANOVA, Spearman correlation coefficient, and multivariate regression).
Findings
A total of 143 patients with COVID-19 were included in the study. The mean±SD age was 53.6±13.67 years with a range of 28 to 88 years. In this study, more than half of the participants were over 40 years old, married, and illiterate, and half of the subjects were unemployed (Table 1).
The mean±SD of Systolic BP Diastolic BP, heart rate, temperature, and respiration of the patients were 111.6434±14.55, 76.90±10.23, 84.96±9.42, 39.46±27.43, and 19.65±2.96, respectively.
The average score of depression, anxiety and stress for all participants with COVID-19 was 8.12±7.12, 11.74±6.02 and 13.92±6.80, respectively.
The results of this study showed that most of the patients had moderate symptoms of anxiety, no symptoms of stress, and no symptoms of depression (Table 2).
The social support level for the patients was 35.7% and 59.4% of patients had moderate and high social support levels, respectively (Table 3).
Figure 1 shows factors that the participant believed caused his illness. Participants said that the most common cause of their illness was the failure to follow hygienic instructions and not wearing a mask (Figure 1).
The multiple linear regression model in Table 4 showed that Drug History, perception, and social support) were associated with depression for the COVID-19 patients. The same analysis showed that Drug History, perception, social support (and oxygen saturation were associated with anxiety among the patients with COVID-19. Moreover, the multiple linear regression analysis showed that two factors perception, social support, and oxygen saturation were associated with stress for the COVID-19 patients (Table 4).
Table 1) Demographic and clinical characteristics (n=143)
Table 2) Descriptive Statistics for Major Study Variables (n=143)
Table 3) Comparison of Mean±SD of depression, anxiety, and stress scores on patient's characteristics
Figure1) Factors that the participant believed caused his illness
1. Spouse; 2. Going to a party; 3. Failure to follow hygienic instructions and not wearing a mask; 4. Workplace; 5. Family members; 6. Go to the mall; 7. Go for a walk and have fun; 8. Use of public transportation
Table 4) Multiple linear regression analysis of factors associated with depression, anxiety, and stress
Discussion
This study aimed to determine the relationship between stress, anxiety, and depression with perceived social support and perception of the disease in patients with COVID-19. The results of this study show that 37% of patients had mild to moderate depression and only three patients experienced severe and very severe depression. One-third of patients had moderate anxiety and one-third had severe to very severe anxiety. About one-third also experienced mild to moderate stress.
Chen et al. found in their study that 21% of COVID-19 hospitalized patients had depression and 16.4% of them had experienced anxiety [27]. Findings from the Assefa study in COVID-19 patients reported a rate of 36.5% depression and 21.2% anxiety [28]. The study by Kandeger et al. Showed that the prevalence of anxiety and depression symptoms was 19% and 34.5%, respectively [15]. In the study by Kong et al., age, sex, and oxygen saturation were associated with anxiety, and age and family involvement with SARS-CoV-2 were associated with depression [29]. In this regard, the US Food and Drug Administration explains that the use of some general medications may be associated with the induction of depression [30, 31].
Other results show that more than half of the patients have a moderate understanding of the disease and enjoy high social support. Consistent with the present study, the study by Kandeger et al. indicates that hospitalized COVID-19 patients had perceived high social support [15].
Linear regression analysis showed that perception of illness and social support and history of medicine use were significantly associated with depression, perception of illness and social support and history of medicine use and oxygen saturation were significantly associated with anxiety and perception of illness and social support and oxygen saturation were significantly associated with stress. Thus, more perception of illness leads to increased stress, anxiety, and depression, and less social support leads to increased stress, anxiety, and depression. It is noteworthy that among the variables included in the regression model, social support showed a stronger relationship with stress, anxiety and depression than the other variables.
Consistent with the present study, Kandeger et al. study indicated that high perceived social support had a significant relationship with depression symptoms [15]. A review of studies shows that the relationship between social support and depression is more important than the relationship between social support and anxiety and stress in studies. However, the results for both of them are consistent with the findings of many studies in different communities [32-34]. Consistent with the results of this study, the findings of a study by Yue et al. in Chinese pregnant women with COVID-19 show that social support can directly regulate anxiety, while it is negatively or indirectly related to perceptions of disease risk. Perception of disease risk is positively related to anxiety and negatively or indirectly related to social support. In the study by Yue et al., only the relationship between anxiety and social support and perception of disease risk is reported [1]. A study by Kong et al. in China also shows that the less social support for patients with COVID-19, the more anxiety and depression they report. In this way, social support can improve assessment and coping skills in individuals, reduce the severity of the perceived risk of stressful events, and thus play an indirect protective role in mental health [29]. Another explanation for the findings of this study may be that there is a close relationship between anxiety, stress, depression and social support. According to the stress buffer model, perceived social support by decreasing the perception of situations as a threat and increasing the belief in available resources can play a protective role for psychological problems such as stress, anxiety and depression [35, 36]. As the results of this study show, patients with COVID-19 have moderate to high social support. The study by Paykani et al. [37], and Jalaei et al. [38] shows that perceived social support can be both a facilitator and a barrier for people with the disease. This study explains that it depends on the people from whom patients receive social support. Social support from family has a greater effect on relieving the negative effects of the disease on the psychological dimension, while social support that patients receive from friends causes more maladaptive behaviors and increases the negative effects of the disease on the psychological dimension. Of course, studies show that how to use social support is different in different cultures. In collectivist cultures, such as East Asia, people are dependent on their families and give priority to the family. The family is a very important resource in the issue of social support and has a protective role against anxiety and depression. Of course, in East Asian cultures, the support that people with the disease receives from their family members can reduce the negative effects of stressful life events. The family is the first and most important source of social support. In addition, good family social support can also provide a good individual emotional experience for coping with stressful situations [39, 40]. Consistent with the present study, the results of the study by Miceli et al. showed that there is a positive and significant relationship between perceived stress and perceived risk [20]. The study by Li & Lyu showed that risk perception was positively associated with perceived stress, anxiety and depression [41]. Hospitalized patients who had lower levels of perceived social support were at a higher risk of depression and anxiety [27]. The study by Zandifar et al. showed that perceived stress was significantly associated with anxiety and depression [42].
This study has some limitations that can be a guide for future studies, including the fact that this study was performed on a small sample of patients with COVID-19 and only in one hospital. It may be necessary to do a larger sampling to generalize the results. The use of self-report tools may cause more or fewer reports of anxiety, stress, depression, and social support which is recommended in addition to quantitative tools, qualitative tools be used in future studies. It is important to follow up in future studies that what kind of perceived social support and from which source is most effective in reducing stress, anxiety, and depression in patients with COVID-19, Although this study has limitations, it can provide new insights to moderate the effects of COVID-19 on the mental health of these individuals using a perceived social support environment source and reduce the risk of perception of illness.
Conclusion
In general, the results of the present study indicated that COVID-19 patients hospitalized in the hospital experienced anxiety, stress, and depression. Most patients with COVID-19 have high social support and moderate perception of illness. Depression, anxiety, and stress in patients with COVID-19 are associated with the perception of illness and social support, which is more strongly associated with social support. Therefore, strengthening social support in patients with COVID-19 as well as improving patients' perception of illness by providing the necessary training and counseling by health professionals may be able to alleviate their anxiety, stress and depression.
Acknowledgments: The authors would like to thank the Honorable Vice Chancellor for Research of Hamadan University of Medical Sciences, and Farshchian Hospital (Sina) and patients with COVID-19.
Ethical Permissions: This study was approved by the Ethics Committee of the Hamadan University of Medical Sciences, with approval no.: IR.UMSHA.REC.1399.230 This study was conducted under the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The subjects were assured of the following: their participation was optional; they could withdraw at any time without facing any negative consequences. All participants provided their written informed consent.
Conflicts of Interests: This article is the result of a research project at Hamadan University of Medical Sciences, approved by project number 9904242496.
Authors’ Contributions: Sadeghian E (First Author), Introduction Writer/Main Researcher/Discussion Writer (20%); Bashirian S (Second Author), Methodologist (20%); Soltanian A (Third Author), Assistant Researcher (20%); Taheri M (Forth author), Assistant Researcher (20%); Madineshat M Assistant Researcher/Statistical Analyst (20%)
Funding/Support: This research project was supported by vice-chancellor of research and technology of Hamadan University of Medical Sciences.