Factors associated with depressive and anxiety symptoms among Jamaican women during the COVID-19 pandemic

Gabrielle Mitchell¹, Kayan Campbell Williams¹, Chinwendu Agu², Joy Harrison¹, Althea Bailey¹, Daniel Oshi¹, Wendel Abel¹, Patrice Whitehorne-Smith³

¹Community Health & Psychiatry, The University of the West Indies, Mona Campus
²The UWI School of Nursing, The University of the West Indies, Mona Campus
³School of Public Health, Curtin University

Corresponding Author

Gabrielle Mitchell
Community Health & Psychiatry,
The University of the West Indies, Mona Campus
ORCID iD: 0000-0003-2042-4516
Email: [email protected]

DOI:
DOAJ: 9f903b39f8f440e0894b409e13322adc

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

©2022 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association.

Abstract

Objectives: The study sought to examine the risk and protective factors associated with depressive and anxiety symptoms among women during the COVID-19 pandemic.

Methods: A cross sectional, population-based online survey was utilised. Jamaican women, 18 years and older, were recruited via the Facebook social media platform and routed to a separate survey platform. Data related to socio-demographics, effects of COVID-19, coping strategies and well-being was captured. Depressive and anxiety symptoms were assessed using the Patient Health Questionnaire (PHQ-2) and Generalized Anxiety Disorder (GAD-2) Questionnaire.

Results: There were 432 female respondents aged 18 to 83 years. The mean age was 41.5 years (±13.1, SD). About 98.4% believed that COVID-19 had affected their lives and 87.6% were worried or fearful of COVID-19. About 50% reported significant depressive symptoms and anxiety symptoms. Pearson’s correlation revealed significant negative associations between effects of COVID-19 on employment, finances, and family and significant depressive and anxiety symptoms (p<0.05). Regression analyses revealed that those who were worried about providing for their families, experiencing relationship problems, and feeling lonely had a greater risk for significant anxiety and depressive symptoms. Those who were hopeful about the future, found a new hobby and meditated/practiced mindfulness were less likely to have depressive and anxiety symptoms.

Conclusion: This study indicates that having good coping skills, increased social support and less interpersonal conflict helped to moderate the levels of psychological distress during the pandemic. Further, proactive adaptive methods of coping enhance the wellbeing and mental health of women.

Introduction

COVID- 19 is a global health crisis and is one of the greatest international health concerns in the last 100 years. ^1,2. The pace and severity of this pandemic has prompted governments to quickly enact strict public health measures. ^1,2 Social isolation, quarantine and partial restriction of movement, ranging from lock-down to nightly curfews were and are the norm in several countries. ³ However, extended isolation and lockdown have been associated with job loss, job uncertainty, financial stress and family strain, which may increase anxiety and depressive symptoms. ⁴

Extant literature suggests that COVID-19 related stressors have led to persistent feelings of fear, and anxiety. ^1,5 Uncertainty around the future and anxiety consequent to excessive rumination on COVID-19 has also been identified as major factors in the scope of COVID-19 psychological stressors. ^5-7 Although mitigation strategies such as social isolation and quarantine are important strategies in infectious disease prevention and control, they represent a major rapid shift in the lifestyle of the population, which may lead to the development or intensifying of mental health problems in the general public. ⁸ Researchers have linked quarantine measures to feelings of fear, restlessness, irritability and frustration, stress and difficulties managing with reduced social contact. ^3,6,7,11

International studies suggest that parents, public health orders and the pandemic create an especially stressful period with no stability or end in sight. ¹² The lock down orders and closure of schools also furthers the childcare load of parents due to the inclusion of home-schooling. ¹³ In some instances, parents are juggling working remotely or facing unemployment alongside home-schooling, furthering anxiety and stress. ¹³ Women, particularly single and employed mothers are experiencing further challenges due to disproportionate workloads within the home and the work environment. ^{12, 13}

Despite this, studies suggest that there are protective factors that influence the reports of COVID-19 specific anxiety and stress. Pearman, Hughes, Smith & Neupert, reported those adults who engaged in proactive coping strategies reported COVID-19 anxiety less than those older adults who did not. ¹⁴ Studies also imply that developing clear adaptive strategies and having available social support have been found to mitigate COVID-19 stressors. ^5,15 These adaptive changes range from the adoption of mindfulness techniques, positive attitude, seeking social support, consuming more nutritious foods, the inclusion of exercise or meditation and pursuit of hobbies. Studies report that these changes have a protective role on mental health. ^5,15-17 Therefore, the impact of psychological, social and economic stressors of COVID-19 is important. ¹³

In April 2020, the Jamaican government declared the island a Disaster Zone and implemented a period of lockdown and an island-wide curfew which has remained in effect to date. ^{18, 19} Jamaican women fall into these at risk categories due to current stay at home orders for children despite a lack of concrete stay at home orders for employed persons. This in tandem with the disproportionate roles of women within the home may lead to an increased vulnerability to the effects of stress. ¹³ Currently, scientific evidence on the relationship between COVID-19 and coping in Jamaica even at regional and global levels, is lacking despite the importance of understanding this relationship for evidence-based planning and policies. Similarly, little is known about the relationship between COVID-19 and mental health in Jamaica and the Caribbean region. Understanding the interplay between these factors and the strategies people use to cope during an infectious disease outbreak may help in guiding the provision of public enlightenment. ²⁰ This current study seeks to provide insights into the association between COVID-19 and health among Jamaican women. The study aims to investigate the relationship between COVID-19 coping and wellbeing and mental health among Jamaican women.

Methods

Study Design

This cross-sectional descriptive study used an online survey to gather data from Jamaican women aged 18 years and older who were active users of their Facebook account at the time of the study. Facebook was used to recruit participants through an advertisement campaign, which encouraged persons to click a link to take the study questionnaire. Using the Raosoft online sample size calculator (using a confidence interval of 95% and 5% margin of error and a response distribution of 50%) it was estimated that a minimum required sample size was 385  participants. Ethics approval for the study was granted by the Ministry of Health and Wellness Research Advisory Panel on Ethics and Medico-Legal Affairs Committee as well as from the University of the West Indies Faculty of Medical Sciences Ethical Research Committee. All participants provided online informed consent to participate in the study. The data was collected over the period August and September 2020. This study represents a subset of the data gathered as a part of a wider study exploring aspects of mental health COVID-19 among the Jamaican population. ²¹

Data Collection Instrument and Procedures

The survey instrument was a self-administered questionnaire on the Influence of COVID-19 on Coping and Wellbeing. A team of medical practitioners and public health specialists developed the questionnaire. The instrument asked questions related to the sociodemographic characteristics of participants, knowledge, attitudes and practices about COVID-19. It also asked ways in which COVID-19 had affected the lives of participants, their worries/fears, and methods of coping with COVID-19.  The Patient Health Questionnaire-2 (PHQ-2) and the Generalised Anxiety Disorder (GAD)-2 scales, which are both two-item Likert scale brief screening tools for depressive symptoms and anxiety symptoms respectively were also used in the study to collect data on depressive symptoms and anxiety. ²²  They each assess the presence of significant depressive or anxiety symptoms over the last two weeks and are indicative of the need for further assessment if significant symptoms are noted. ²³ Cronbach’s alpha for the PHQ-2 and GAD-2 are 0.83 and 0.81 respectively and both are validated scales. ²⁴

Analysis

Data were analysed using both descriptive and inferential statistics aided by the Statistical Package for the Social Sciences (SPSS) version 23 (IBM Corp, Armonk, New York, United States) and findings presented in tables and graphs. Descriptive statistics were used to compute the frequencies and percentages of participant’s report of the effect of COVID-19 on their lives, their worries or fears concerning COVID-19 and methods they used to cope with COVID-19. Pearson’s correlation analysis was used to analyse the relationship between continuous (quantitative) explanatory variables and significant depressive/ anxiety symptoms. The level of significance was set at 0.05 with a confidence interval of 95%. Also, binary logistic regression models (logit models) were used to assess for risk and protective factors associated with depressive and anxiety symptoms. For the logit models, the outcome variables, namely, depressive symptoms and anxiety symptoms, were transformed into binary variables, viz, significant depressive symptoms/ insignificant depressive symptoms, and significant anxiety symptoms/ insignificant anxiety symptoms. The level of significance was 0.05.

Results

There were 432 female respondents in the study between the ages of 18-83 years with the mean age being 41.5 years [±13.1, Standard Deviation (SD)]. Almost all respondents believed that COVID-19 had affected their lives (98.4%) and the vast majority were worried or fearful of COVID-19 (87.6%).

Table 1 COVID-19 related effects and changes affecting coping and well-being of participants

Depressive and Anxiety Symptoms

On the PHQ-2 a score of three or higher is suggestive of a potential Major Depressive Disorder requiring further in-depth screening. ²²  While on the GAD-2, a score of three or more is suggestive of a Generalised Anxiety Disorder or another common anxiety disorder. ²³ For this study, scores of 0-2 were categorised as ‘insignificant depressive or anxiety symptoms’ while scores between 3-6 were categorised as ‘significant depressive or anxiety symptoms.

More than half, 255 (54.6%) of respondents reported significant depressive symptoms and almost half of respondents reported significant anxiety symptoms, 223 (49.2%). Table 2 shows Pearson’s correlation analysis revealed significant negative associations between the effects of COVID-19 on employment, finances, and family life and significant depressive and anxiety symptoms (p<0.05 in all cases). The table also shows other factors that have been associated with depressive or anxiety symptoms.

Table 2. COVID-19 related effects and changes affecting coping and well-being of participants and association with significant depressive and anxiety symptoms (Pearson’s correlation)

Binary logistic regression analysis was performed using models with variables identified as ‘risk’ factors that increase the susceptibility to depressive or anxiety symptoms and those identified as protective factors which decrease the susceptibility to depressive and anxiety symptoms.

Table 3 shows results from the multivariate models which variables were predictive significant depressive symptoms. Those who were worried about their ability to provide for their families (OR_DEP=4.132, 95% CI 1.996-8.553; OR_ANX=4.333, 95% CI 2.021-9.293), experiencing relationship problems (OR_DEP=5.759, 95% CI 1.848-17.956; OR_ANX =4.396, 95% CI 1.503-12.857 ) and feeling because they had to stay more lonely (OR_DEP=2.106, 95% CI 1.085-4.089; OR_ANX=3.032, 95% CI 1.534-5.995) were at greater risk for significant anxiety and depressive symptoms. While, those who were hopeful about the future (OR_DEP=0.303, 95% CI 0.160-0.574; OR_ANX= 0.259, 95% CI 0.137-0.491), found a new hobby (OR_DEP= 2.671, 95% CI 1.372-5.200; ORANX= 2.475, 95% CI 1.279-4.790) and meditated/practiced mindfulness (OR_DEP = .085, 95% CI 1.065-4.084; OR_ANX = 2.074, 95% CI 1.068-4.032) were less likely to have depressive and anxiety symptoms.  In the case of depressive symptoms, those who made the lifestyle change of eating more nutritious foods were also less likely to have significant depressive symptoms (OR_DEP= 0.424, 95% CI 0.209-0.864).

Table 3: Risk and protective factors for depressives and anxiety symptoms during COVID-19

Discussion

Risk factors and Mental Health

This study found that participants who were worried or fearful about COVID-19 had significant depressive and anxiety symptoms. This is in keeping with extant literature. ^{5,7, 25} Most participants responded that they were worried and/or anxious about not knowing what will happen in the future. This is in keeping with previous research which suggested that the female gender were susceptible to psychological distress and therefore more likely to develop internalizing disorders such as depression and anxiety. ^{4, 5, 7, 15, 25} In Jamaica, women are at a disproportionate risk for depression and anxiety disorders, as 3.7% have depression and 4.3% have anxiety, compared to just 2.3% of men for each disorder. ²⁶

Also in line with previous work, participants with both anxiety and depressive symptoms shared that COVID-19 had affected their family life, finances, and employment. ^7,12 In exploring the family life aspect, it was found that those with significant anxiety symptoms had difficulty with having their children at home all the time. An explanation garnered from previous work expounds on the additional child care stress parents have to face being at home with their children, while balancing working from home as well as organizing home-schooling activities. ^{12, 13} The challenge of managing work, school and home life simultaneously in one environment without having additional help and having to transition back to work while schools remain closed has been identified as a major stressor. ^3,12 An increase in parental stress and maladaptive coping could translate into psychological distress in their children as well.³

This study found that women who felt their children seemed anxious and fearful about Covid-19 all reported significant anxiety and depressive symptoms. This is in line with other studies which suggests that worrying over children’s wellbeing is a major stressor that furthers the dramatic increase in the maternal burden of care.¹⁵ It also contributes to feelings of helplessness due to the uncertainty surrounding the pandemic and the maternal instinct that leads to fears about their children’s coping, struggles with changes in home and school life as well as unhappiness. ^{27, 28} Mullings et al reported that urban females in informal communities were more likely to face increased stressors due to the characteristics of their environment and pattern of single parenting compounding their risk of depressive symptoms due to their focus on the survival of their children amidst an unsafe environment.²⁹

Similarly, those having more problems with their partner or reported feeling lonely and disconnected had higher levels of depression and anxiety.^{15, 30} Having low levels of social support and feeling isolated within the relationship especially when having problems with partners possibly contributes to stress and increased tension within the home space.³¹ This tension coupled with feelings of loneliness and the inability to connect with friends who they could once confide in intimately outside the home space could accentuate anxious and depressive symptoms.³¹ Problems with partners and feelings of loneliness can lead to anxiety and depressive symptoms.^30,31 Therefore, this may be a possible explanation of our findings with our female population.

Protective Factors and Mental Health

This study found that those who were hopeful about the future reported less anxiety and depressive symptoms implying that having a positive outlook on the future despite the uncertainty led to less psychological distress. The study also found that those who used meditation or engaged in a new hobby as a lifestyle change reported fewer depressive symptoms. Proactive coping strategies using available resources such as social support, hobbies, healthy dietary habits, and positive thinking were found to help mitigate increasing levels of psychological distress during COVID-19. ^{5, 6,15-17}

Additionally, the practice of mindfulness and meditation has also been found to be an effective  coping mechanism following disasters by helping  people to process negative emotions allowing them to better appreciate their circumstances and move toward practical goals for their future ^{15, 32, 33} Being in a marital union was also a protective factor for women in this study perhaps highlighting the role of relationship security and available social support mitigating feelings of loneliness. ¹⁵ Other interpersonal factors at play showed that those who got along better with their children or had someone to talk to reported fewer depressive symptoms and less anxiety symptoms respectively. ³⁴ It is possible that children in the family help to divert the mothers’ attention from fear and anxiety associated with the unknown outcome of COVID-19. ¹⁵

The process of finding other ways to engage with and appreciate life such as hobbies, consuming more nutritious foods, connecting with friends and family was key to building one’s psychological well-being and coping mechanisms.^{17, 33, 35-37} To this end, it is pertinent that developing a culture of resilience through proactive adaptive methods is crucial to enhancing the wellbeing and mental health of women and by extension their families during this pandemic, thereby increasing available social support.¹⁴

Strengths and Limitations

Given the cross-sectional design of the study, it can only present an association between variables and a snapshot of the issues over a brief period. In addition, the study used a convenient sample of women who utilise electronic platforms to collect data as such the findings may not be widely generalizable to women in the Jamaica population. It also excluded women who did not have access to the technology or lacked computer literacy skills. Nonetheless, this study represents the only one of its kind to date in Jamaica and provides some needed insights into the risk and protective factors affecting Jamaican women during the COVID-19 pandemic.

Conclusions

The present study found fear and worry; loneliness and relationship problems were risk factors for anxiety and depressive symptoms among Jamaican women during COVID-19. It  also found that the development of effective coping strategies such as feeling hopeful about the future, finding a new hobby, having a nutritious diet and meditation/practicing mindfulness were protective against depressive and anxiety symptoms. As the COVID-19 pandemic is ongoing, this study suggests the importance of proactive adaptive methods in alleviating psychological distress and enhancing the wellbeing and mental health of women.

Acknowledgements: None

Competing interests: The authors have no competing interests to disclose.

Ethics approval:    Ethics Approval for the study was granted through the Ministry of Health and Wellness Research Advisory Panel on Ethics and Medico-Legal Affairs Committee as well as from the University of the West Indies Faculty of Medical Sciences Ethical Research Committee.

Funding: No funding was provided for this project.

Author contributions to the article : Gabrielle Mitchell contributed to the conceptualisation, study design, critical review concept, literature review, formatting, and discussion. Kayan Campbell Williams wrote the discussion and was instrumental in framing and critically reviewing the article. Chinwendu Agu contributed to the conception of project and general methodology of the paper. Joy Harrison contributed to the method section and critical review of the paper. Althea Bailey contributed to discussion and critical review of the paper. Daniel Oshi contributed to the conceptualisation, study design and critical review of the paper. Wendel Abel contributed to the conceptualisation, study design and critical review of the paper. Patrice Whitehorne-Smith contributed to the conceptualisation, study design and developed the survey tool, implemented data collection, statistical analyses, and the critical review of the paper. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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