|Year : 2021 | Volume
| Issue : 3 | Page : 85-90
Differential manifestation of COVID-19 anxiety and adherence to precautionary measures as a function of socioeconomic status: A longitudinal study in coastal Andhra Pradesh
Pradeep Kandikatla1, Roopa Reddy Pandraveti2, Vikramsimha Bommireddy3, Raghudeep Darisi4, Anudeep Kapalavayi4, Srikanth Reddy Karra5
1 Department of Orthodontics, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
2 Department of Periodontology, Sree Balaji Dental College, Hyderabad, Telangana, India
3 Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh, India
4 Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
5 BDS, MS, IT/Health Informatics, Product Manager, EClinical Works, Framingham, USA
|Date of Submission||16-May-2021|
|Date of Decision||14-Jun-2021|
|Date of Acceptance||20-Jun-2021|
|Date of Web Publication||29-Sep-2021|
Dr. Vikramsimha Bommireddy
Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: There is a possibility that the coronavirus disease (COVID-19)-related anxiety may differ between people from varied socioeconomic status for a variety of reasons. Furthermore, the adherence to COVID-19 precautionary measures could be different between socioeconomic strata in light of the differences in opportunities to more effectively follow these measures for people from different socioeconomic status. Aim and Objectives: The aim of this study was to check the differences in COVID-19 anxiety and precautionary measure adherence between subjects from different socioeconomic strata and to conduct a stratified analysis of the association between anxiety and adherence based on socioeconomic status of the participants. Materials and Methods: This longitudinal study was conducted in the months of July and November 2020 among 648 subjects belonging to the coastal districts of Andhra Pradesh. The COVID-19 Anxiety Scale (CAS) was used to assess the disease-related anxiety among the study participants, and self-reported adherence (SRA) scores were collected to document the adherence of the study subjects to COVID-19 precautionary measures. Statistical analysis was performed using SPSS version 20 software. Results: Significant differences were found in the CAS scores between subjects from different socioeconomic strata in the month of July, while no such observations were made in November. For the outcome of SRA scores, there were significant differences between socioeconomic strata at both the study time points. Overall, the mean CAS and SRA scores decreased from July (20.35 ± 5.54 and 14.48 ± 3.45, respectively) to November (15.96 ± 5.67 and 12.57 ± 4.17, respectively). Conclusion: The study results highlight the need to reinforce the necessity and importance of adhering to COVID-19 precautionary measures in light of the potential danger of the second wave of COVID-19 in the country.
Keywords: Compliance, COVID-19 anxiety, health behaviors, socioeconomic status
|How to cite this article:|
Kandikatla P, Pandraveti RR, Bommireddy V, Darisi R, Kapalavayi A, Karra SR. Differential manifestation of COVID-19 anxiety and adherence to precautionary measures as a function of socioeconomic status: A longitudinal study in coastal Andhra Pradesh. J Prim Care Spec 2021;2:85-90
|How to cite this URL:|
Kandikatla P, Pandraveti RR, Bommireddy V, Darisi R, Kapalavayi A, Karra SR. Differential manifestation of COVID-19 anxiety and adherence to precautionary measures as a function of socioeconomic status: A longitudinal study in coastal Andhra Pradesh. J Prim Care Spec [serial online] 2021 [cited 2022 Dec 9];2:85-90. Available from: https://www.jpcsonline.org/text.asp?2021/2/3/85/327053
| Introduction|| |
Coronavirus disease (COVID-19) has been one of the largest pandemics the world has witnessed in the recent years. Worldwide, 42.3 million people were affected by the disease by the middle of December 2020. There have been 1.66 million COVID-19 deaths globally, and new disease-specific deaths have been adding to the tally every day. The number of COVID-19 cases in India accounted for 13.3% of the global burden of the disease, and the disease-specific deaths in India were 8.67% of the global COVID-19 deaths. The recovery rate in India is substantially higher at 95.2% compared to the global recovery rate of 56.4%. It has widely been established that COVID-19 has a significant impact on the mental health of people.,, Besides the fear of infection, there has been enormous economic pressure on populations. At this juncture, it is imperative to refer to the fact that there is no specific treatment available for COVID-19, and the medical support offered is predominantly symptom based. Many nations across the globe have been relying on practice of precautionary measures and imposing nonpharmaceutical interventions such as lockdown to combat the spread of the disease. There has been a stronger emphasis on promotion of the importance of practicing precautionary measures to prevent COVID-19 ever since the initial outbreak of COVID-19. In India, this campaign was endorsed by noted people from different professions such as cinema, sports, and politics. Aarogya Setu, a mobile app developed by the Government of India, utilizes contact tracing in identification of information relating to people, the users of the app might have contacted. In case any of these people tests positive for COVID-19 in future, the app instantaneously conveys the information to the users and arranges for medical care. However, it is obvious that not everyone gets an equal opportunity to practice the suggested precautionary measures. While most cases of nonadherence are circumstances driven, there is a possibility that the perceived severity of the pandemic and the associated disease-related anxiety at an individual level would influence the adherence of individuals to precautionary measures suggested. Moreover, it is understandable that socioeconomic status of a person can influence the adherence to precautionary measures and may also influence the anxiety levels of the subjects. Till date, there were no studies conducted in India which evaluated the differences in COVID-19 anxiety and adherence to COVID-19 precautionary measures based on socioeconomic status. Furthermore, the relationship between anxiety and adherence in a stratified analysis based on socioeconomic status has not been explored. With this background, the aim of this study was to check the differences in COVID-19 anxiety and precautionary measure adherence between subjects from different socioeconomic strata and to conduct a stratified analysis of the association between anxiety and adherence based on socioeconomic status of the participants.
| Materials and Methods|| |
This longitudinal study was conducted from July 2020 to November 2020 among 648 subjects aged 18 years and older regardless of gender. Data were collected on two occasions from the same panel of participants in the months of July and November. This study was conducted in the coastal districts of Andhra Pradesh using a stratified systematic random sampling. All the participants were informed about the nature and purpose of the study, and written informed consent was obtained. The ethical approval of the study was obtained from the institutional review board (14/20/IRB/SBDC) on June 23, 2020. Sample size was calculated to be 449 using G*Power 220.127.116.11 software (Dusseldorf University, Germany). Based on the longitudinal nature of the study, a sample size of 650 was considered in the study.
A thorough review of literature was performed to identify the validated psychometric tools which measure the COVID-19 anxiety.,,,,,, Of all the scales assessed, the COVID-19 Anxiety Scale (CAS) developed among the Telugu-speaking population of the state of Andhra Pradesh was deemed relevant. CAS is a seven-item scale on a four-point semantic differential scale with overall scale scores ranging from 7 to 28. To measure the adherence of the study participants to COVID-19 precautionary measures, an interviewer-administered structured questionnaire with three questions rated on a six-point Likert scale was used. The three questions included in the questionnaire were the adherence to precautionary measures suggested to prevent the spread of COVID-19: use of face mask, frequent handwashing, and maintaining social distance. The score obtained by a participant in the adherence questionnaire is identified as the self-reported adherence (SRA) score and ranges from 3 to 18, with higher scores indicative of better adherence. Demographic details of the study participants such as age, gender, and socioeconomic status were also documented. Socioeconomic status of the participants was recorded using the modified BG Prasad scale updated in 2020 based on the per-capita monthly income. Since there were a very less number of participants in the lower and upper socioeconomic strata, subjects belonging to these strata were combined with subjects from lower-middle and upper-middle socioeconomic strata, respectively. There was a loss of 77 subjects to follow-up, and only 571 subjects were assessed for COVID-19 anxiety and adherence to precautionary measures during the follow-up in November. [Figure 1] presents the study flowchart. Statistical analysis was performed using SPSS version 20 software (IBM SPSS Statistics for Windows version 20, Armonk, NY, USA). Descriptive statistics, one-way analysis of variance with Tukey's post hoc tests, paired t-tests, and Spearman's correlation tests were used in data analysis.
| Results|| |
The mean age of the study participants was 47.54 ± 8.9. There were no significant age differences between subjects from different socioeconomic strata. The mean CAS score was 20.35 ± 5.54 in the month of July which decreased to 15.96 ± 5.67 in the month of November. Similarly, mean SRA scores dropped from 14.48 ± 3.45 to 12.57 ± 4.17 during this time. Significant differences were found in the CAS scores between subjects from different socioeconomic strata in the month of July, while no such observations were made in November [Table 1] and [Figure 2]. For the outcome of SRA scores, there were significant differences between socioeconomic strata at both the study time points. Post hoc tests revealed similar CAS scores in the month of July between subjects from middle and upper-middle, upper socioeconomic strata [Table 2]. The middle and upper-middle, upper socioeconomic strata demonstrated similar SRA scores as well in the month of November. [Table 3] shows that in each socioeconomic stratum, there was a significant decline in the mean CAS scores and mean SRA scores from July to November. There was a significant strong positive correlation between CAS and SRA scores in upper, upper-middle socioeconomic strata (Spearman's rho = 0.69; p = 0.001*). A significant weak positive correlation was observed between these two parameters in the middle, lower-middle, and lower socioeconomic strata at any of the study time points
|Figure 2: Clustered bar charts showing differences in COVID-19 Anxiety Scale and self-reported adherence scores between socioeconomic strata at the two study time points|
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|Table 1: Differences in COVID-19 Anxiety Scale and self-reported adherence scores based on socioeconomic status|
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|Table 2: Multiple pairwise comparisons of COVID-19 Anxiety Scale and self-reported adherence scores based on socioeconomic stratification|
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|Table 3: Stratified analysis of differences in COVID-19 Anxiety Scale and self-reported adherence scores between the study time points based on socioeconomic status|
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| Discussion|| |
It is clearly evident from this study there has been a substantial decline in the COVID-19 anxiety levels of the population and also people's adherence to COVID-19 precautionary measures over the course of this study. While a decrease in anxiety levels is anticipated in light of the consistently reducing number of COVID-19 cases detected per day and the decreasing COVID-19 case fatality rates, poor adherence to precautionary measures is unwarranted. An area of significant concern is the difference in SRA scores between subjects from different socioeconomic strata. This observation persisted throughout the course of this study, the reasons for which could be found in the limited opportunities in adherence to precautionary measures for people from low socioeconomic strata possibly living in relatively overcrowded places and working in environments which are not conducive to the practice of social distancing. Furthermore, frequent handwashing and use of masks may not be financially feasible for this population resulting in poor SRA scores. Another significant area of concern is the magnitude of reduction in the adherence to COVID-19 precautionary measures among subjects from upper and upper-middle socioeconomic strata. A significant reduction in COVID-19 anxiety scores among these people could have contributed toward decreased adherence scores among these people in light of the strong positive correlation between CAS and SRA scores in the upper and upper-middle socioeconomic strata.
The results from this study were observed to be consistent with the results reported by Bazaid et al. in Saudi Arabia where increased adherence to precautionary measures was observed among participants with high socioeconomic status. Paykani et al. reported that socioeconomic status was not found to be associated with compliance to stay-at-home advice among Iranian adults. Nevertheless, it was observed that subjects who rated their social class to be relatively poor compared to others demonstrated limited compliance. Higher levels of anxiety were reported among subjects from higher socioeconomic strata in a study conducted by Salameh et al. in May 2020 in Lebanon which is consistent with the observations made in this study. In another study conducted by Agberotimi et al. in Nigeria, in the months of March and April 2020, results inconsistent with this study were demonstrated with similar anxiety levels between subjects from different socioeconomic strata; however, there were significant differences in depressive symptoms with higher prevalence among lower socioeconomic strata.
Clark et al. reported that the feeling of vulnerability to COVID-19 had little influence on the subjects' compliance to precautionary measures among an international sample of 8317 people. Similar findings were observed in this study with a weak correlation between COVID-19 anxiety scores and the SRA to precautionary measures among subjects from lower, lower-middle, and middle socioeconomic strata. However, there was a strong positive correlation between anxiety and adherence to precautionary measures among the subjects from upper-middle and upper socioeconomic strata. Chandu et al. reported limited adherence to COVID-19 precautionary measures among a student population in India. While there were no studies in India which directly assessed the influence of socioeconomic status on the adherence to COVID-19 precautionary measures, it was identified from an Indian study that educational level, an integral component of socioeconomic status, of the subject is an important predictor for adherence to precautionary measures. Wong et al. reported that increase in COVID-19 anxiety between two given time points was a significant predictor for increase in adherence to precautionary measures between those two time points. This observation was similar to that made in this study among subjects from higher socioeconomic strata. Outside the COVID-19 context, a relation between anxiety and adherence was thoroughly explored. People with any severity of anxiety demonstrated reduced adherence to antihypertensive medication in a study conducted by Bautista et al. in 2012. Similar results were reported by Sundbom and Bingefors in 2013 where nonadherence was more common among those prescription drug users who were identified to have symptoms of anxiety. Gaining insights into the differential manifestation of COVID-19 anxiety among people belonging to different socioeconomic strata is important in the identification of people who require mental health services. The results observed in this study contribute to the primary care provision by population-level identification of the differing COVID-19 anxiety levels based on socioeconomic status which helps not only in preparing the health-care delivery systems for the provision of required mental health services but also enables the administrative authorities to focus on the reasons for the emergence of COVID-19 anxiety as a function of socioeconomic status. The limitations of this study include a substantial loss to follow-up and lack of information on the reasons for the dropout. Moreover, the study did not collect information on the COVID-19 infection status of the participants and their family members which could have a direct influence on both the outcome parameters of anxiety and adherence. The study findings of decreased SRA to COVID-19 precautionary measures from July to November 2020 highlight the need to reinforce the necessity and importance of adhering to COVID-19 precautionary measures in light of the potential danger of the second wave of COVID-19 in the country. Furthermore, people from lower socioeconomic strata must be provided with enough opportunities to more effectively practice the suggested precautionary measures. There is also a need to restructure the campaigns from delivering information to showing directions on how to effectively practice the precautionary measures.
| Conclusion|| |
Within the limitations of this study, the difference in COVID-19 anxiety scores was observed based on socioeconomic status at the beginning of the study, with people from lower socioeconomic status demonstrating the least anxiety. There had been a decline both in the COVID-19 anxiety scores and the SRA to COVID appropriate behavior with time.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis 2020;20:533-4.
Roy A, Singh AK, Mishra S, Chinnadurai A, Mitra A, Bakshi O. Mental health implications of COVID-19 pandemic and its response in India. Int J Soc Psychiatry. 2021;67:587-600.
Serafini G, Parmigiani B, Amerio A, Aguglia A, Sher L, Amore M. The psychological impact of COVID-19 on the mental health in the general population. QJM 2020;113:531-7.
Chandu VC, Marella Y, Panga GS, Pachava S, Vadapalli V. Measuring the impact of COVID-19 on mental health: A scoping review of the existing scales. Indian J Psychol Med 2020;42:421-7.
Pillai DD, Nagappan N, Dharani SV, Subramanian K, Champakesan B, D'Cruz TM. Socio-economic impact of coronavirus disease 2019 (COVID-19) – An Indian outlook. J Family Med Prim Care 2020;9:5103-6. [Full text]
Bo Y, Guo C, Lin C, Zeng Y, Li HB, Zhang Y, et al.
Effectiveness of non-pharmaceutical interventions on COVID-19 transmission in 190 countries from 23 January to 13 April 2020. Int J Infect Dis 2021;102:247-53.
Kodali PB, Hense S, Kopparty S, Kalapala GR, Haloi B. How Indians responded to the Arogya Setu app? Indian J Public Health 2020;64:S228-30.
Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, et al.
Mental health problems and social media exposure during COVID-19 outbreak. PLoS One 2020;15:e0231924.
Lee SA. Coronavirus anxiety scale: A brief mental health screener for COVID-19 related anxiety. Death Stud 2020;44:393-401.
Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The Fear of COVID-19 Scale: Development and Initial Validation. Int J Ment Health Addict. 2020:1-9. doi: 10.1007/s11469-020-00270-8.
Arpaci I, Karataş K, Baloğlu M. The development and initial tests for the psychometric properties of the COVID-19 Phobia Scale (C19P-S). Pers Individ Dif 2020;164:110108.
Chandu VC, Pachava S, Vadapalli V, Marella Y. Development and initial validation of the COVID-19 anxiety scale. Indian J Public Health 2020;64:S201-4.
Taylor S, Landry CA, Paluszek MM, Fergus TA, McKay D, Asmundson GJ. Development and initial validation of the COVID Stress Scales. J Anxiety Disord 2020;72:102232.
Sakib N, Bhuiyan AKMI, Hossain S, Al Mamun F, Hosen I, Abdullah AH, et al.
Psychometric Validation of the Bangla Fear of COVID-19 Scale: Confirmatory Factor Analysis and Rasch Analysis. Int J Ment Health Addict. 2020:1-12. doi: 10.1007/s11469-020-00289-x.
Reznik A, Gritsenko V, Konstantinov V, Khamenka N, Isralowitz R. COVID-19 Fear in Eastern Europe: Validation of the Fear of COVID-19 Scale. Int J Ment Health Addict. 2020:1-6. doi: 10.1007/s11469-020-00283-3.
Debnath DJ. Kakkar R. Modified BG. Prasad socio-economic classification, Updated – 2020. Indian J Comm Health 2020;32:124-5.
Bazaid AS, Aldarhami A, Binsaleh NK, Sherwani S, Althomali OW. Knowledge and practice of personal protective measures during the COVID-19 pandemic: A cross-sectional study in Saudi Arabia. PLoS One 2020;15:e0243695.
Paykani T, Zimet GD, Esmaeili R, Khajedaluee AR, Khajedaluee M. Perceived social support and compliance with stay-at-home orders during the COVID-19 outbreak: Evidence from Iran. BMC Public Health 2020;20:1650.
Salameh P, Hajj A, Badro DA, Abou Selwan C, Aoun R, Sacre H. Mental health outcomes of the COVID-19 pandemic and a collapsing economy: Perspectives from a developing country. Psychiatry Res 2020;294:113520.
Agberotimi SF, Akinsola OS, Oguntayo R, Olaseni AO. Interactions between socioeconomic status and mental health outcomes in the Nigerian context amid COVID-19 pandemic: A comparative study. Front Psychol 2020;11:559819.
Clark C, Davila A, Regis M, Kraus S. Predictors of COVID-19 voluntary compliance behaviors: An international investigation. Glob Transit 2020;2:76-82.
Chandu VC, Lingamaneni KP, Pachava S, Baddam VRR, Marella Y. The Influence of Dissonance Induction and Assessment Reactivity in Improving Adherence to COVID-19 Precautionary Measures: A Cluster Randomised Controlled Trial. Int Dent J. 2021:S0020-6539(21)00067-8. doi: 10.1016/j.identj.2021.03.001.
Gupta P, Gupta A, Dixit S, Kumar H. Knowledge, attitude, and practices regarding COVID-19: A cross-sectional study among rural population in a northern Indian District. J Family Med Prim Care 2020;9:4769-73. [Full text]
Wong LP, Hung CC, Alias H, Lee TS. Anxiety symptoms and preventive measures during the COVID-19 outbreak in Taiwan. BMC Psychiatry 2020;20:376.
Bautista LE, Vera-Cala LM, Colombo C, Smith P. Symptoms of depression and anxiety and adherence to antihypertensive medication. Am J Hypertens 2012;25:505-11.
Sundbom LT, Bingefors K. The influence of symptoms of anxiety and depression on medication nonadherence and its causes: A population based survey of prescription drug users in Sweden. Patient Prefer Adherence 2013;7:805-11.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]