A Multinational Pilot Study on the Lived Experiences and Mental Health Impacts from the COVID-19 Pandemic

Coronavirus, which is the causal agent of the current deadliest disease, belongs to the family of viruses. Coronavirus is zoonotic, meaning it is transmitted between animals and humans (Adhikari et al. 2020). In 2019, a new report of coronavirus disease known as COVID-19 emerged in humans. It was believed to have started in Wuhan, China. The World Health Organization (WHO) declared it a public health emergency on 30 January, 2020. Further, the name COVID-19 was assigned to the coronavirus disease on 11 February, 2020, and it was declared a pandemic on 11 March, 2020 (WHO, 2020).

Some common symptoms recorded of COVID-19 are fever at 38°C or above, dry cough and difficulty breathing (Adhikari et al. 2020). The same report shows that patients may report a general feeling of being unwell, nasal congestion, sore throat, aches and pains. Some people also become infected without developing symptoms (asymptomatic). People infected with COVID-19 may recover, especially if they are a younger population or living without underlying illness (Rothan & Byrareddy, 2020). This is suggestive that the aged population or persons living with underlying illness have poor chances of recovering from a COVID-19 infection. COVID-19, which is now a pandemic, has recorded over 3 million confirmed cases spread across 212 countries and 238,084 deaths worldwide at present and these figures are currently rising (WHO, 2020).

An implication of these figures that spread across 212 countries is suggestive that there likely would be varied lived experiences and health impacts arising from the novel COVID-19 pandemic among people who are directly or indirectly affected by the pandemic. In terms of the health impacts from pandemics, researchers have often argued that the mental health should often be a paramount focus for researchers interested in exploring the health impacts from pandemics (Nickell, et al. 2004; Cava, et al. 2005; Gardener & Moallef, 2015; Park, et al. 2018; Xiang, et al. 2020). Further, the same researchers opined that, sufficient research into the experiences of everyone affected, and mental health impacts of pandemics on everyone affected, is underscored for informing appropriate intervention or protection programmes for everyone affected during pandemics.

Therefore, we intend to embark on a multinational study that explores the lived experiences of everyone affected by the novel COVID-19 pandemic, and the mental health impacts of the pandemic among everyone affected. Our intention is driven by the earlier cited literature which suggested this as the procedure for arriving at a sufficiently educated decision that is designed to offer intervention or protection programs for everyone affected during pandemics. Before embarking on our multinational study, it is worthy to acknowledge that scholars have strongly opined that a pilot study is imperative for gaining insight into what is actually required for our main multinational study that is aimed at informing appropriate intervention or protection programs for everyone affected by the novel COVID-19 pandemic (Maunder, 2009; Bidarbakhtnia, 2020). Further, some other scholars have also submitted that pilot studies offer increased likelihood of success for a main study by establishing its feasibility (Teijlingen & Hundley, 2001; Thabane, et al. 2019; Malmqvist, et al. 2019). Thus, we decided to have this pilot phase as a starting point.

With regard to the focus of our current study, there have been vast amounts of literature dedicated to the lived experiences of people during infectious disease outbreaks, and the mental health impacts of infectious disease outbreaks, (Lazarus, et al. 2002; Sprang & Silman, 2013; Gardener & Moallef, 2015; Park, et al. 2018). However, there is very little knowledge that is available about this with respect to the novel COVID-19 pandemic. Therefore, the current pilot study is aimed at creating a starting point for bridging the existing knowledge gaps. The current pilot study would also serve as among the first sources of knowledge for other researchers with similar interests to that of ours, given the importance of sharing lessons learnt from pilot studies (Teijlingen & Hundley, 2001; Thabane, et al. 2019).

Some of the lived experiences and the psychosocial impacts of infectious disease outbreaks have been highlighted by researchers. For instance, Maunder et al. (2003) found negative lived experiences, stigmatisation, anxiety and stress as the common complaints presented by patients with severe acute respiratory syndrome coronavirus (SARS-COV). This was further shared in Gardener and Moallef’s (2015) review which established that stigmatisation, psychotic presentations, fear of survival and infecting others, PTSD and reduced quality of life among other symptoms were apparent across all stages of post-SARS.

Furthermore, literature has also demonstrated that during infectious disease outbreaks, those particularly vulnerable to mental health problems were shown to be the front-line health workers treating patients affected by the SARS-COV outbreak (Chen, et al. 2005; Gardener & Moallef, 2015). Nickell et al. (2004) further supported this argument in their findings which established that half of the nurses working with patients of SARS-COV displayed emotional distress during the SARSCOV outbreak. Quite differently, it has been argued that both healthcare workers and the general public were shown to constitute more than one fifth of the total number of persons who experienced mental issues resulting from the SARS-COV outbreak (Sim & Chua, 2004; Park et al. 2018). In a similar argument, Chua et al. (2004) reported that stress, fatigue and worries were among the major mental health impacts experienced by healthcare workers and the general public during SARS outbreak. Overall, this is suggestive that there is a need to consider the lived experiences and protection of the general public and specific vulnerable groups in the research and policies surrounding infectious disease outbreaks.

Infectious disease outbreaks have also been shown to require preventive and control measures which often cause changes in our lifestyles and environments (Taylor, Agho, Stevens, & Raphael, 2008). These changes are often more impactful to our mental health than they are to our physical health (Wu et al. 2008). Quarantine and self-isolation are common control measures that are implemented during infectious disease outbreaks. Further, increased hygiene precaution (i.e. increased hand washing, wearing face masks, cleaning surfaces etc.) is another common control measure taken during infectious disease outbreak. Given the impacts of these control measures that are adopted to protect the general public’s physical health from infectious diseases, consideration of the implications of these measures on the mental health of public is paramount (Taylor et al. 2008).

Research has further indicated negative outcomes in relation to the measures implemented during infectious disease outbreaks. For instance, Bai, et al. (2004) determined the presence of acute stress disorders in persons who experienced quarantine during the SARS-COV outbreak. It was further determined that, such persons were also likely to report detachment from others, irritability, decreased work performance, and consideration of resignation. Sprang and Silman, (2013) embarked on a comparative study between parents and children quarantined, and those not. They found that anxiety, depression, and PTSD scores were higher in children who experienced quarantine than in those who did not experience quarantine. In that same study, over a quarter of quarantined parents met the classification for PTSD compared to six percent of those not quarantined. The longitudinal impact of having experienced restricted movement during infectious disease outbreak was highlighted in Wu, et al. (2008) study which demonstrated that three years after the SARS outbreak, alcohol dependency was positively correlated with having been quarantined and self-isolated. Overall, this demonstrates that peoples’ experiences of the preventive and control measures implemented during infectious disease outbreaks plays a crucial role on their mental wellbeing. It is therefore important to explore people’s experiences of both the novel COVID-19, and its control/ preventive measures.

Previous literature has further shown that apart from the impact of peoples’ experiences of control measures during infectious disease outbreaks, the awareness of and preparation for infectious disease outbreaks triggers mental health disturbances of anxiety (Lau et al. 2005; Lau et al. 2010). In some other studies, the levels of concern and knowledge of infectious disease outbreaks have also been identified to have impacts on mental health during such outbreaks (Almutairi et al, 2015), and this makes knowledge measurement of infectious disease an important concern during times of disease outbreaks. In another study, Taylor, et al. (2008) ascertained that greater anxiety levels were common quite early in the general public during infectious disease outbreaks, given the high levels of concern from the general public about the outbreak. The greater anxiety levels was further found to worsen by increased social distancing during infectious disease outbreaks. Therefore, this also supports our argument that the outbreak of infectious diseases have negative effects on the mental health of people. This underscores the urgency for studying the lived experiences, and mental health impacts from the novel COVID-19 pandemic (Xiang, et al. 2020).

Finally, some recent studies have been conducted on the mental health impacts from the novel COVID-19, and lived experiences of people in affected countries (Sun, et al. 2020; Nicomedes, et al. 2020; Zhang, & Ma, 2020). However, those studies failed to consider multinational data from people who are directly or indirectly affected by the pandemic. Consequently, such studies cannot provide multinational information from a pilot study or a main study that is required to offer intervention and protection programmes for everyone affected by the novel COVID-19.

Our respondents comprised 33 males and 58 females. Further, 13 of our total respondents reported having high school education as their highest education, whereas 78 reported having obtained degrees from tertiary institutions. In terms of religion, 41 respondents were Christians, 9 belonged to Islam and 41 had either no religion or other religion. In terms of the employment status, 39 were unemployed and 52 were employed. Lastly, the distribution of respondents by country showed that, of our total respondents, 11 were from China, 3 from Finland, 10 from France, 1 from Germany, 1 from Kenya, 4 from Malaysia, 3 from the Netherlands, 11 from Nigeria, 6 from Norway, 3 from Pakistan, 10 from Singapore, 7 from the United Arab Emirates, 11 from the UK and 10 were from the USA.

In Table 2, both scales were established to report very strong reliability coefficients as determined by Cronbach’s alpha. Furthermore, the mean score on each scale suggests a moderate and mild level of anxiety and depression, respectively.

Table 3 shows that among all respondents, the minimum score on the GAD-7 was 0, whereas the maximum score was 21. Further, 68 respondents had a total score < 10, whereas 23 respondents had a total score of 10 or >.

The results from the supplementary single-item scale showed that, 33 respondents reported no difficulty in their daily living as a result of the COVID-19 pandemic. Further, 43 respondents reported they found it somewhat difficult, whereas 12 respondents reported that it was very difficult for them in terms of their daily living due to the COVID-19 pandemic. Lastly, three respondents reported extreme difficulty in terms of their daily living due to the pandemic.

Table 5 shows that among all respondents, the minimum score on the PHQ-9 scale was 0, whereas the maximum score was 25. Further, 70 respondents had a total score < 10, whereas 21 respondents had a total score of 10 or >.

The results shown in Table 6 reveal that more than half of the respondents had high knowledge level of COVID-19. The criteria for judging their knowledge included: history of the disease, the causal agent, early and late symptoms, the transmission process, preventive measures, the most vulnerable population and help-seeking approaches for persons living with or at risk of COVID-19. Therefore, respondents who met all the criteria were grouped as having high knowledge, while those who met some but not all these criteria were grouped as having partial knowledge. On the other hand, respondents who did not meet any of these criteria were grouped as having poor knowledge or no knowledge.

We noticed that respondents who demonstrated partial knowledge often reported good knowledge on either the history of the disease, early and late symptoms, or transmission process of the disease. Furthermore, regarding the total respondents who had high knowledge level of COVID-19, they mostly stated that the major sources from which they gained knowledge were from the television, radio, online academic papers and other internet materials.

Our pilot study found that more respondents had scores of 10 or greater on the GAD-7, as compared with the PHQ-9. We also found that more than half (58, 63.7%) of the total respondents demonstrated high knowledge level of the COVID-19 pandemic, with their major information sources as television, radio, online academic papers, and other internet information. These findings were obtained from our quantitative insight, and they were in consonance with literature where anxiety and depressive symptoms have been reported among people who were directly or indirectly affected by infectious disease outbreaks (Lau, et al. 2005; Maunder, et al. 2003; Taylor et al. 2008; Sprang & Silman, 2013; Gardener & Moallef, 2015). Going further, the findings from our knowledge assessment of COVID-19 was in agreement with Lau, et al. (2005) who found in a diverse sample that although respondents were not psychologically prepared for the SARS-COV outbreak, more than half of the total respondents showed good knowledge of the disease, and this good knowledge possibly limited the mental health impacts of the disease outbreak on respondents. Therefore, the fact that more than half of the total respondents in our pilot study showed high knowledge level of the COVID-19 pandemic could likely justify the extent of mental health impacts (anxiety & depression) resulting from the COVID-19 pandemic that was observed in our results.

Our qualitative study explored the lived experiences of respondents from the COVID-19 pandemic, and the findings revealed five (5) themes which were; changes in lifestyles which was the first theme reported by most respondents in the qualitative study. Second theme was the disruption of schooling activities. Third was impact on options for health services. Fourth was disruption of works and economy, and fifth was anxious and worrisome impacts of the COVID-19 pandemic. In further details, the first theme demonstrated that most respondents in our qualitative study experienced changes in their lifestyles. For instance, restricted movements, increased socializing via social media due to lockdowns, and increased use of face masks and hand sanitizers. Further, it was obvious that most respondents were not used to nor prepared for these changes in lifestyle before the pandemic started. Therefore, the first theme which accommodated most responses from our respondents was in consonance with literature which submitted that preventive/control measures implemented during infectious diseases outbreaks play crucial roles in affecting people (Bai, et al. 2004; Sprang & Silman, 2013).

The second theme which showed that respondents felt disruption of schooling activities as their major lived experience showed that most respondents in this theme stated that their school had either stopped operation or they had to do schooling from home which they were obviously not used to before COVID-19 became a pandemic. Also, some respondents in this theme reported that their examination has been cancelled due to the pandemic. The third theme was formed from a respondent who reported that the COVID-19 pandemic has affected his health service options for illnesses other than COVID-19. This is, therefore, suggestive that clinical populations other than patients with COVID-19 may have limited practice of professional help seeking for any health problem that they are living with, and this is due to the novel COVID-19 which has disrupted the normal way of life for almost everyone.

The fourth theme showed that the major experience of some respondents caused by the pandemic was the disruption of works and economy caused by the pandemic. In further detail, respondents in this theme stated that the COVID-19 pandemic had significantly affected their work procedures, and they were not prepared for this. Some others stated that the pandemic had affected their job security, caused their businesses to struggle and increased telecommuting for them. There were also respondents who strongly stated that there was a drastic increase in the prices of foods and other items due to the pandemic. Some other respondents in this theme also reported that they were currently experiencing scarcity of essential items at supermarkets. Therefore, the first, second, third and fourth themes identified in our study can be linked to the fact that the novel COVID-19 pandemic has brought about drastic changes among our respondents in these themes, and it is also evident that our respondents were mostly not prepared for these changes as reflected in most of their responses in the “Qualitative results” section of this paper. From the responses of respondents in these themes, it is also evident that most of them are still on the process of coping with the changes caused by the novel pandemic. The first, second, third and fourth themes are thus quite in agreement with Lau et al. (2005), who reported that psychological preparation for infectious disease outbreak was imperative for coping during such outbreaks.

Our last theme which showed that anxious and worrisome impacts were the major experiences of some respondents demonstrated fears about contracting or dying from COVID-19. It also demonstrated fears about family members who were most vulnerable because of certain underlying illnesses that they had. It also established fears about the pandemic from conversations that respondents have been having with their friends in recent days. Given the anxious concerns of respondents, the last theme suggests that the pandemic could have triggered anxiety because of likely catastrophising which the respondents engaged in, and this is a theoretical agreement with the cognitive theory of mental illness (Beck, 1967). This was also supported by the last response in the qualitative study which was from a female, who stated that she was scared that her family and friends will contract the virus and die from it. The last theme reported in our study was in collaboration with Gardener and Moallef (2015) who argued that fear of contracting, fear of survival and fear of infecting others were among the experiences of people during infectious disease outbreaks. It was also in agreement with Maunder et al. (2003) who opined that anxiety was common among people during the outbreak of SARS-COV.

Finally, apart from the consistency of our findings with literature, we also observed that there was a consensus between our quantitative and qualitative findings (Wisdom & Creswell, 2013). For instance, in our quantitative results, we observed that in comparison with the PHQ-9, more respondents submitted total scores of 10 or greater on the GAD-7. An implication of these scores is that the COVID-19 pandemic had more anxious than depressive impacts on our respondents. This was therefore in agreement with our qualitative results where in comparison with reporting depressive experience about the COVID-19 pandemic, respondents often reported anxious experiences about COVID-19 pandemic. This consensus is suggestive that our research instruments were valid, by truly measuring what they were designed to measure. It is also an indication that the content validation conducted before this pilot study which we reported in “the methods section” of this paper was efficacious.

Our study being a pilot study has offered great insights into what is actually needed for our main multinational study. These insights include that the quantitative and qualitative instruments used in this pilot phase are feasible for an actual multinational study of this kind, and this is given the high psychometric reports, and consensus in findings from the data gathered by our instruments (Fink, 2003; Saunders, et al. 2009; Wisdom & Creswell, 2013). Another insight offered suggests that the inclusion of measures that quantifies psychosocial preparedness for pandemics may be considered in the later study given that most respondents’ reported lived experience was changes in lifestyle, disruption of schools, works and economy. These respondents also submitted unpreparedness for these changes, and this probably might have triggered the extent of anxiety levels found in this pilot study. The psychosocial preparedness for pandemics measure may thus be considered for the purpose of analyzing the interactions between scores on such measure and scores on the GAD-7.

Further, we dedicated a very short timeframe with our little available financial resources to the recruitment of respondents for this pilot study via Linkedin. Despite this, our recruitment strategy enabled us to recruit respondents from fourteen (14) countries, and the highest number of respondents from each country was 11, with 8 countries having more than half of 11 respondents. This is a plus to our recruitment strategy (Lin, et al. 2010); it has thus revealed that, in order to access a large sample that is representative enough of everyone who are directly or indirectly affected by the pandemic, a sufficient timeframe with adequate financial resources, and more social media platforms will be required. The ability of this pilot study to reveal the requirements for our main study is in line with scholars’ opinions about the importance of pilot studies (Teijlingen & Hundley, 2001; Maunder, 2009; Thabane, et al. 2019; Malmqvist, et al. 2019; Bidarbakhtnia, 2020).

Another offered insight suggests that, it was not obvious whether patients or survivors of COVID-19 were among our respondents, as we were restricted from accessing them (Adhikari, et al. 2020). Therefore, the need to ensure that this population is included in a later study is also underscored. Given all insights gained from our pilot study, it thus presents a consensus with the criteria for judging the feasibility of our main study that was mentioned in our methods section (Fink, 2003; Saunders, et al. 2009; Lin, et al. 2010; Wisdom & Creswell, 2013).

From all above, there is a very strong agreement that the current study succeeded in providing great insights for our main study. Therefore, the main study is very feasible, with minor addition needed on the protocol.

We conclude that our main study is very feasible, with minor additions required on the protocol. Finally, full-scale studies are needed in order to provide sufficiently educated decisions that are aimed at addressing the mental health needs of everyone who are directly or indirectly affected by the experience of the novel COVID-19 pandemic.