Psychological states of Bangladeshi people and associated factors during the outbreak of COVID-19: A cross-sectional survey

COVID-19 is imposing an extremely serious challenge to individuals’ physical and mental health. The enforcement of lockdown, restriction on public gathering, social distancing strategy, and unprecedented quarantine measures has affected many aspects of peoples’ lives in Bangladesh with potential consequences on their mental and physical health. This study aimed to assess the psychological states and their related factors among general people in Bangladesh during the COVID-19 outbreak. An e-questionnaire-based cross-sectional survey was conducted among 565 Bangladeshi general people between April and May, 2020. Measures included socio-demographics, chronic disease-related variables, the Self-Rating Depression Scale (SDS), and the Self-Rating Anxiety Scale (SAS). Descriptive analysis and bivariate linear regression with “depression” and “anxiety” as the dependent variables were carried out to identify the factors associated with these. Results showed that 30.1% and 32.6% of participants had mild to extremely severe levels of anxiety and depression, respectively. Females were 2.3 (OR = 2.26; 95% CI = 1.58-3.25, p < 0.001) and 2.2 (OR = 2.19; 95% CI = 1.51-3.16, p < 0.001) times more likely to have depression and anxiety, respectively compared to males. In contrast, the odds of depression and anxiety were 2.9 (OR = 2.85; 95% CI = 1.66-4.90, p < 0.001) and 2.0 (OR = 2.00; 95% CI = 1.20-3.36, p = 0.008) times higher, respectively among individuals aged above 40 years than those aged between 18-40 years. The healthcare authority should take necessary steps considering the psychological problems of the general people during the health emergency.


Introduction
The emergence of the novel coronavirus (SARS-CoV-2) that causes coronavirus disease 2019  in Wuhan, China, has raised great concern all over the world and is imposing an extremely serious challenge to global public health . More than 200 countries are currently struggling with the global pandemic of COVID-19 ( Yan et al., 2020 ). As of July 07, 2020, more than 11.3 million cases of COVID-19 have been confirmed with 532,340 deaths around the world ( World Health Organization, 2020 ). The pandemic is not only causing a serious threat to people's physical health and lives but also creating a wide range of psychological problems, such as panic disorder, anxiety, and depression both for persons with COVID-19 and healthy individuals ( Kar et al., 2020 ;Qiu et al., 2020 ). Because of the unexpected nature of the outbreak and the virus's contagious patterns, the people would undoubtedly experience anxiety, depression, and other stress reactions (Y. Wang et al., 2020 ). the COVID-19 outbreak ( Kar, Arafat, Sharma, et al., 2020 ;Pirnia et al., 2020 ). Common psychological problems including depression, anxiety, stress, etc. are linked to tobacco smoking during the COVID-19 pandemic Tzu-Hsuan Chen, 2020 ).
Evidence suggests that a long period of lockdown forcing mass quarantine would undoubtedly have an effect on people's psychological wellbeing, with underlying causes such as increased media reporting, the escalating number of new cases, and so on . In addition, the psychosocial impact of health emergencies seems to be even higher during quarantine measures ( Brooks et al., 2020 ). At the initial stage of the COVID-19 outbreak, a study was conducted among the general population in China which reported that 16.5% and 28.8% respondents had moderate to severe depressive and anxiety symptoms respectively (C. Wang et al., 2020 ). Furthermore, a study conducted among the general population in Italy also found high prevalence of depression (17.3%), anxiety (20.8%), and insomnia (7.3%) during the COVID-19 pandemic ( Rossi et al., 2020 ).
A previous study demonstrated that a substantial portion of the population is at high risk of psychological consequences during the COVID-19 outbreak in Bangladesh and suggested to pay attention to the mental health of the people who were home-quarantined following lockdown measures for protecting their physical health .
Although the COVID-19 outbreak has brought a great impact on individuals' psychological health in many different countries, it is poorly studied in Bangladesh. Therefore, we assessed the psychological states in terms of depression and anxiety as well as their associated factors among general people during the COVID-19 outbreak to provide a basis for the promulgation of national and governmental policies.

Participants and procedure
An online questionnaire-based cross-sectional survey was conducted among the general population in Bangladesh. Data were collected between April and May, 2020 via social media (e.g., Facebook, WhatsApp, Email, etc.). The purposes of the study were well informed to the respondents and they provided their informed consent prior to participating in the survey. We requited 565 individuals who met the inclusion criteria including: (i) being 18 years old or above, and (ii) having willingness to take part in the survey. Respondents whose ages were below 18 years old and incomplete responses were excluded.

Socio-demographic measures
Socio-demographic data were collected during the survey using a semi-structured questionnaire written in English concerning age, gender, marital status, educational qualification, family type, and living area (urban/rural). Cigarette smoking habits (yes/no) and chronic diseases profile (i.e., blood pressure, diabetes, kidney disease, heart problems, and asthma/ respiratory disease) were also asked during the survey.

Self-Rating Depression Scale (SDS)
The Self-Rating Depression Scale (SDS) is a self-reported screening tool to assess the levels of depression in epidemiological surveys, developed by Zung (1965) . This scale consists of 20 questions concerning the past several days (e.g., "I feel down-hearted and blue ") with a four-point Likert scale ranging from 0 ( "a little of the time ") to 3 ( "most of the time "). Ten items in the SDS scale (i.e., 2, 5, 6, 11, 12, 14, 16, 17, 18, and 20) are stated using positive feelings, reverse integration in the order of 4 to 1, and the scores are summed up as the total score. The standard score is calculated by the multiplication of total sore by 1.25. The present study employed the English version of the SDS scale to screen the participants' depression levels which has recently been used in China to assess the levels of depression during early in the COVID-19 outbreak (Y. Wang et al., 2020 ). Depression levels were categorized using the following cutoffs: < 53 = non-depression, 53-62 = mild depression, 63-72 = moderate depression, and > 73 = severe depression ( Zung, 1965 ). In the present study, the Cronbach's alpha of the SDS was 0.8.

Self-Rating Anxiety Scale (SAS)
The Self-Rating Anxiety Scale (SAS) is a self-reported screening tool to assess the level of anxiety in epidemiological surveys, developed by Zung (1971) . This scale consists of 20 questions concerning the past several days (e.g., "I feel down-hearted and blue ") with a four-point Likert scale ranging from 0 ( "a little of the time ") to 3 ( "most of the time "). Five items (i.e., 5, 9, 13, 17, and 19) in the SAS scale are stated using positive words, reverse integration in the order of 4 to 1, and the scores are summed up as the total score. The standard score is calculated by the multiplication of total sore by 1.25. The present study employed the English version of the SAS scale to screen the participants' anxiety levels which has recently been used in China to assess the levels of anxiety during early in the COVID-19 outbreak (Y. Wang et al., 2020 ). Anxiety levels were categorized using the following cutoffs: < 50 = non-anxiety, 50-59 = mild anxiety, 60-69 = moderate anxiety, and > 70 = severe anxiety ( Zung, 1971 ). In the present study, the Cronbach's alpha of the SAS was 0.8.

Statistical analysis
Data were analyzed using Microsoft Excel 2019 and SPSS software version 25.0. Primarily, data were entered into Microsoft Excel file and after the completion of data input, the file was imported to SPSS software. Descriptive statistics (i.e., frequencies, percentages, means, standard deviations) and first-order analyses (i.e., chi-square tests, Fisher's exact tests, etc.) were performed using SPSS software. Binary logistic regression was performed with a 95% confidence interval to determine significant associations between categorical dependent and independent variables.

Ethics
The study was approved by the Research Ethics Committee of Sapporo Dental College and Hospital [Ref. No: SDC/C-7/2020/744] and all procedures were performed in accordance with the ethical standards of the Research Ethics Committee of Sapporo Dental College and Hospital, and Helsinki declaration. Confidentiality of data and anonymity to the participants were ensured.

General characteristics of participants
In this study, 63.5% of respondents were males and 36.5% were females. The average age of respondents was 32.2 years (SD = 8.6) ranging from 19 to 66 years. The majority of the respondents were married (65.8%), and had "Bachelor " level of education (53.3%). Most of them were non-smokers (85.0%) and lived in nuclear families (71.7%) as well as urban areas (69.7%) ( Table 1 ).
In the binary logistic regression analysis, both gender and age were correlated with depression and anxiety. Females were 2.3 times more likely to have depression (OR = 2.26; 95% CI = 1.58-3.25, p < 0.001) and 2.2 times more likely to have anxiety (OR = 2.19; 95% CI = 1.51-3.16, p < 0.001) compared to males. In contrast, the respondents aged between 18-40 years were 2.9 times more likely to have depression (OR = 2.85; 95% CI = 1.66-4.90, p < 0.001) and 2.0 times more likely to have anxiety (OR = 2.00; 95% CI = 1.20-3.36, p = 0.008) than those aged above 40 years old. Findings also showed that depression and anxiety were not significantly associated with chronic disease conditions during the pandemic ( Table 2 ).

Discussion
The pandemic COVID-19 has brought an unbearable psychological pressure to people across the world ( Duan and Zhu, 2020 ;Xiao, 2020 ). Although previous studies in overseas demonstrated the psychological impact of the COVID-19 outbreaks on the general people, patients, medical staff, children, and older adults Chen et al., 2020 ;Li et al., 2020 ;Mazza et al., 2020 ;Moccia et al., 2020 ;C. Wang et al., 2020 ;Yang et al., 2020 ), there are limited studies in Bangladesh that evaluated people psychological states and potentially related factors during the COVID-19 outbreak. This study evaluated the psychological condition of Bangladeshi people during this pandemic and explored factors influencing their depression and anxiety.
The present study also reported that 32.6% participants had mild to extremely severe levels of depression which is consistent with the study of Sigdel et al. (2020) . During the COVID-19 pandemic, comparatively higher prevalence estimates of depression were reported in Bangladeshi students (62.9% among university students, and 46.92% among college and university students) Khan et al., 2020 ) and lower prevalence of depression have also been reported globally, including: 16.5% (C. Wang et al., 2020 ) and 17.17% (Y. Wang et al., 2020 ) among the general population in China and 17.3% among the general population in Italy ( Rossi et al., 2020 ).
The present study found that 30.1% participants had mild to extremely severe level of anxiety which is similar to the study of Khan et al. (2020) conducted among home-quarantined Bangladeshi students during COVID-19 pandemic and to the study of Sigdel et al. (2020) conducted among the general population of Nepal during COVID-19 pandemic. In contrast, differences in the prevalence of anxiety during the pandemic have been reported globally, including: 28.8% (C. Wang et al., 2020 ) and 6.33% (Y. Wang et al., 2020 ) among the general population in China and 20.8% among the general population in Italy ( Rossi et al., 2020 ).
Our study found significant gender differences regarding depression and anxiety. The findings revealed that during the pandemic females were more likely to have depression and anxiety than males which is consistent with several previous studies ( Moghanibashi-Mansourieh, 2020 ; Rossi et al., 2020 ;Sigdel et al., 2020 ;C. Wang et al., 2020 ) although the previous studies retained no gender differences regarding depression and anxiety during the pandemic Islam, Ferdous, & Potenza, 2020 ). Another similar study also found significant gender differences regarding anxiety but they found no significant gender differences regarding depression (Y. Wang et al., 2020 ).
The current reports found a significant influence of participants' age on depression and anxiety. Participants whose ages were between 18-40 years were more likely to suffer from depression and anxiety. Our findings are concurrent with the study of Ahmed et al. (2020) who showed that respondents' age was significantly associated with depression and anxiety during the pandemic . Some previous studies also showed a significant association between respondents' age and anxiety during the pandemic but no influence on depression was recorded for age ( Mazza et al., 2020 ;. There is also occasional inconsistent evidence that respondents' age has no significant effect on anxiety and depression (C. Wang et al., 2020 ).
In the present study, tobacco smoking was not associated with anxiety/ depression which is concurrent with previous reports in Bangladesh . In contrast, many studies conducted in Bangladesh retained a significant association between tobacco smoking and anxiety/ depression during the COVID-19 pandemic Tasnim et al., 2020 ). The participants' chronic disease profile (i.e., blood pressure, diabetes, kidney disease, heart problems, and asthma/ respiratory disease) was not significantly associated with psychological states in terms of depression and anxiety in the present study ( Table 2 ), which is inconsistent with previous reports in Bangladesh Sayeed et al., 2020 ). However, the findings also resonate with a previous study conducted in Bangladesh that retained no association between chronic diseases and anxiety/ depression .
In addition, findings of the correlation analysis between the SAS and SDS standard scores showed that people with anxiety were likely to be depressed, and individuals with depression were also likely to be anxious which corroborate with earlier reports Kalin, 2020 ;. Similar findings were found among Chinese people during the outbreak of COVID-19 (Y. Wang et al., 2020 ).

Strengths and limitations
This study provided baseline data on public psychological states in terms of depression and anxiety as well as their related factors during the COVID-19 outbreak in Bangladesh which will be helpful to plan and adopt appropriate interventions to overcome the negative impacts on peoples' mental health. Moreover, the study will contribute in the promulgation of national and governmental policies.
However, the study has several limitations. First, it is limited by the use of self-reported data which might have influenced the findings through well-known biases including: method biases, memory recall biases, and social desirability biases, etc. Second, the study adopted the online survey due to the COVID-19 outbreak. The survey questionnaire did not reach underdeveloped areas due to limited availability of technology and omitted people who are not comfortable using technology and the Internet; therefore, generalizability to other samples and other types of populations in the country and other countries may be limited. Third, since the current study was cross-sectional, causality cannot be identified. Due to a lack of pre-COVID-19 evidence, the current results cannot be justified as a consequence of COVID-19. Furthermore, the study was also limited by the relatively small sample size, and it was conducted using the online convenience sampling strategy without a random selection of the sample. The present study investigated limited measures which should be warranted a further study using comprehensive measures including participants' or their family members' COVID-19 test positive results and other COVID-19-related factors.

Conclusions
The study reported baseline information concerning public psychological states and related factors in Bangladesh. The findings showed that a substantial portion of population especially, females and younger are at high risk of psychological problems during the COVID-19 outbreak. The present study suggested that healthcare authorities should pay attention to individuals' mental health during the health emergency. Government and non-government stakeholders should take necessary steps to provide psychological counseling to the public through electronic devices and social electronic media which are mostly used by the people. The government needs to provide timely and accurate information to the public about the outbreak, especially curative ratio, and mortality. The public should avoid rumors and misleading information about the COVID-19 outbreak that inevitably can lead to depression and anxiety.

Financial disclosure
This research did not receive any specific grant from any funding agencies in the public, commercial, or non-profit sectors.

Declaration of Competing Interest
The authors have no conflict of interest to declare.