Stressful life events and social capital during the early phase of COVID-19 in the U.S.

Background A novel coronavirus disease (COVID-19) was reported in Wuhan, China late December 2019. The disease has as of the end of March 2020, affected over 35 countries (with over 570,000 cases and 26,000 deaths) worldwide. This includes the U.S., where cases are increasing by the thousands every day (100,000 cases with 1500 deaths as of April 2020). We set out to investigate new or increased stressful life events (SLEs) as a result of this pandemic in the U.S. Methods In this exploratory qualitative study, we examined new or heightened SLEs during an active phase of this outbreak. We used a list of SLEs acquired from the first phase of our study, whereby we conducted open-ended surveys and performed an in-depth focus group. We applied Lazarus and Folkman’s transactional model of stress and coping to understand diverse focus-group participants’ appraisal of events. We coded survey data and applied sentiment analysis. Results Participants varied in perceived threat and challenge appraisals of COVID-19, indicating both calm and fear. From 267 coded and sentiment analyzed events from survey text, 95% were predominantly negative; 112 (42%) very negative and 142 (53%) moderately negative. Social capital was unanimously emphasized upon as monumental for example: family, friends or technology mediated. We additionally identified seven major themes of SLEs due to the pandemic. Limitations Our sample profile is not inclusive of all subsets of the population. Conclusions Participants mostly shared similar frustrations and a variety of SLEs such as fear of the unknown and concern for loved ones as a result of COVID-19.


Introduction
The Corona Virus Disease of 2019  was first reported in Wuhan China in December of 2019 (WHO, 2020a). Since then, the disease has ravaged through populations worldwide paralyzing public health efforts and health systems with the continued devastating death tolls projected by the time of this publication. On March 11th , 2020, the World Health Organization (WHO) declared the disease a global pandemic (WHO, 2020b) and nations all over the world called for measures to combat the disease within their own countries. As of the writing of this article, March 28th , 2020, the global count includes 571,678 confirmed cases with 26,494 deaths (WHO, 2020c). In the U.S., there have been 101,242 confirmed cases and 1588 deaths (Chavez, 2020).
Stressful life events (SLE) have been studied over tens of decades and are postulated precursors of health behaviors, outcomes and quality of life (Holmes and Rahe, 1967;Cohen et al., 2019;Dong et al., 2019;Rafanelli et al., 2005;Lillberg et al.,2003;Muscatell et al., 2009). In health psychology, the overall physical and environmental effects of stress are often studied along with mediating and moderating factors, such as coping and social support (Hobfoll, 1998;Ward et al., 2003). Social capital is the collective term for various support initiatives available to members of social groups which have been shown to provide individuals and communities resources to deal with adversities (Nakhaie and Arnold, 2010;Wind and Villalonga-Olives, 2019). Studies have long demonstrated that variations of stress-related depressive moods depend on individual satisfaction with social capital from available social support systems (Krause et al., 1989;Nakhaie and Arnold, 2010;Wind and Villalonga-Olives, 2019).
In early 2020, while the COVID-19 crisis was still in a semi-latency period, at least for the U.S., we began our initial study on stressful life events (SLEs). We aimed to investigate SLEs for different demographic groups and assess differences, if any, in how the different demographic groups experience and appraise SLEs. We were also interested in whether there were differences in social capital for different demographic groups, particularly of varying nativity and whether appraisals of SLEs would vary due to perceived social capital. To help answer this question and others we embarked on a mixed methods study that assessed the variety of stressors largely faced by people in different demographic groups in the U.S. Through this phase of our study, we hoped to create, pilot test and validate a stress rating scale that can be used to assess the onset of disease as an enhancement to what has been previously presented by Holmes and Rahe (Holmes and Rahe, 1967) with their Social Readjustment Rating Scale (SRRS). Our intention was to develop a toolkit informed and appraised by individuals from diverse backgrounds and inclusive of modern-day stressors beyond the SRRS and its variants.
By the time we were done conducting the interviews and first surveys, the COVID-19 U.S. numbers had more than tripled with cases hitting over a hundred thousand. As we analyzed results for our ongoing study, it became clear that the pandemic, as a stressful life event, was becoming dominant. Researchers acknowledge the complexities in studying perceptions and reactions to unexpected and potentially stressful events especially where events unfolding could reveal changes in affect, cognitions and even behavior patterns (Gaspar et al., 2016). Our initial study participants underscored heightened stressful life events associated or as a result of the pandemic. We subsequently incorporated a COVID-19 based study and initiated a second guided-survey where we collected open-ended responses on COVID-19 associated or exacerbated stressors. We also conducted an in-depth focus group with a group of 15 diverse individuals from assorted professions.

Methods
We incorporated triangulation to investigate the element of stress from a variety of cultural groups. Triangulation involves more than one method of data collection and can help determine completeness of data and transcend limitations of individual methods (Carter et al., 2014). We conducted key informant interviews (N ¼ 34), two open ended surveys (N ¼ 85 and 205 respectively) and two focus groups (N ¼ 10 and 15 respectively). We restricted participation to only eligible U.S. adult residents who were 18 years and older and were able to communicate in and read English. Interview and focus group scheduling were all done via online schedulers (www.calendly.com and www.doodle.com). Adult individuals from all races/ethnicities could participate, including undocumented U.S. residents as long as temporary status from a visa or other instrument was not an issue. We did not ask for verification or description of eligibility.
Our interviews and first survey occurred concurrently. The survey was hosted on Qualtrics (Qualtrics, Provo, UT) and used the same questions as the interviews. We used the research crowdsourcing website, Amazon's Mechanical Turk (MTurk https://www.mturk.com), which offers research tools including an Amazon verified diverse, heterogeneous population and verifying participants using active Amazon account information. MTurk's Human Intelligence Tasks (HITs) allow for a researcher to set requirements for subjects including demographics, country of residence and prior approval rate based on the worker's other MTurk work. Qualified MTurk participants received information about the survey and were routed to our online survey on Qualtrics where their informed consent was requested. A total of 120 participants responded.
A focus group was scheduled after the interview and survey data were completed to dig deeper into the stressful life events by select demographics and narrow down data into themes. This first 2-h focus group with ten participants entailed an in-depth discussion about social capital and a guided session on the second half. Poll-everywhere (www .polleverywhere.com), a website that allows for live participant interaction, was used to refine our coded stressful life events towards a scale creation in our ongoing study.
Dominant themes associated with the Coronavirus pandemic were investigated further using additional open-ended Qualtrics surveys via MTurk and a second 2-h in-depth focus group. We obtained data from 220 survey respondents and 15 focus groups participants. We used NVivo professional plus software (QSR International Pty Ltd. Version 12, 2018) to code all research data. The unit of analysis was the life events and stressful experiences described by participants and the social capital from person-centered coping mechanisms identified. Stressful life events (SLE) themes were coded and grouped for each demographic category. Sentiments were auto-coded for survey data and manually verified and refined on NVivo.

Demographic variations in stressful life events
We reported data from a diverse group of individuals of varying races, ethnicity and nativity status. Table 1 illustrates the demographic breakdown of all study participants. We informally defined stressful life events as distinct non-episodic events that would cause a significant change in mood or strain routine functioning and gave two specific examples (i.e. death of a loved one and loss of employment). We asked participants to identify at least five of these events that would be significantly stressful for them if they happened and any additional ones that others who shared the same demographics (specifically race, ethnicity and nativity) would experience. We coded data from 34 interviews and 120 surveys highlighting the most dominant (top 15) stressful life events by race, ethnicity and nativity status in Table 2. The table indicates how many code frequencies of the SLEs were recorded by participants from each demographic group. By the time we were gathering these data, the U.S.
had not yet reported any cases of COVID19 so any stressors related to disease outbreaks or global pandemics ranked low, at position 28. A complete list of identified SLEs from preliminary qualitative results from our ongoing study is shared in Appendix 1.

Sentiment analysis of text relevant to coronavirus
We asked participants to highlight any new stressors or exacerbated existing stressful life events due to the current pandemic and describe them in detail. Qualtrics validation was applied so that this was a required question on the survey. Out of 299 responses, 205 were deemed useable and were coded in NVivo. The software identified positive and negative sentiments in a high (very) and moderate extreme. Text analysis on software like NVivo is limited and does not fully analyze sentiment or recognize contextual phrases associated with some sentiment like sarcasm, slang or ambiguity. We thus manually refined these and coded overarching SLE themes. Ninety five percent of the 267 unique coded sentiments were predominantly negative for SLEs, with 112 (42%) 'very negative' and 142 (53%) 'moderately negative'. We classified 'very negative' stressors as those actually experienced by participants, for instance loss of a job or lack of amenities. 'Moderately negative' stressors had mostly to do with fears and worry, for example the indication of uncertainty. Positive themes included entries of readjustments of life that didn't show indication of stress or strain, for example, "I work from home now". A few entries explicitly stated they had no COVID-19 related stressors and were thus coded into 'very positive'. Table 3 highlights a few examples of survey entries coded at each sentiment.

Transactional model of stress and coping with COVID 19
Stress viewed within a transactional model was introduced in 1984 by Lazarus and Folkman (Lazarus and Folkman, 1984) where an individual's level of stress at a given time depends on the dynamic transaction between the individual and his/her environment. Stress levels were determined from the net transactional effect between personal and environmental SLEs and available resources such as coping mechanism. Lazarus and Folkman (Lazarus and Folkman, 1984) described cognitive appraisal as an evaluation of the stress effect to an individual. As a result of the appraisal, an event was categorized as irrelevant, benign, or a threat currently or potentially harmful. Cognitive appraisal was further subdivided into primary and secondary appraisal where primary appraisal considers encounters with the SLE while secondary appraisal evaluates available mediators and their efficacy in reducing the harm.
Coping was either problem focused, actively tackling the SLE, or emotional passively addressing the stressor by focusing on reducing effects of the SLE.
Our focus group was conducted with participants who represented different professional industries. A few were parents and most were still working either on the front line in healthcare or telecommuting in light of the pandemic. We used the same semi-structured questions inquiring about new or currently increased stressors due to the Coronavirus and had an open discussion where follow-up questions were based on participant responses. Fig. 1 shows Folkman and Lazarus' model of stress and coping applied to our study and Table 3 includes select excerpts    obtained from the 15-participant focus group. About half of focus group participants indicated an ability to cope or just experience calmness from a cognitive appraisal of their threat and challenges supporting the theory that threat and challenge are not mutually exclusive (Lazarus and Folkman, 1984). Responses highlighted support of the theory that coping serves either to regulate the emotions and distresses from the SLE (emotion-focused coping) or to manage the problem by directly tackling the element influencing the SLE (problem-focused coping). Participants appraise their new or heightened COVID-19 based SLE challenges as either threatening or non-threatening, and secondarily in terms of whether they had the resources to respond to or cope effectively. Participants reported making significant physical and psychological alterations in order to cope with the imminent threat, such as shutting off all news, incorporating new hobbies or adopting faith and spirituality. This was consistent with the "threat or harm" approach (Cohen et al., 2019) that significantly alters routine activities or status and poses a threat to available resources (Lazarus, 1974). If the perception is that there is a lacking capacity to respond to the challenge, the individual would most likely to lean on emotion-focused coping responses such as wishful thinking (Lazarus and Folkman, 1984).
Focus group participants acknowledged there were unknown variables towards problem-focused COVID-19 coping by considering things were 'out of their control' and they could not possibly do anything else beyond the measures they already had in place. Coping strategies varied from positive thinking to denial and/or optimism. All participants acknowledged their environmental influences, appraised their coping resources and ended up on opposite ends of the 'current or projected mental state' curve as shown in the examples highlighted on 'stress outcome' in Table 4.

Overarching themes of coronavirus related stressful life events
From survey data and focus group sentiments, we identified five major themes from the current pandemic: (a) financial constraints, (b) isolation from family, (c) dwindling mental health, uncertainty, (4) worry about the future and (5) work-related challenges. Demographic differences from the survey are shared where applicable. Select excerpts are shared as spoken by focus group participants (FGP) with code names used. We omitted any reference to people such as celebrities or politicians and political parties.

Financial constraints and loss of employment
An assortment of financial challenges was identified as the dominant stressor during the pandemic. Survey participants indicated job loss, lost hours and other pressures from bills. We did not notice any demographic specific differences other than by educational attainment and socioeconomic status. Participants who particularly relied on or were qualified for government assistance indicated financial struggles and fears such as how they would pay for essentials and medical care. Slightly more participants below a bachelor's degree attainment (36%) indicated new or increased financial stressors compared to 20% of those with bachelor's degrees and higher. Participants from higher-ranking socioeconomic categories (can make do without government assistance or can make do with plenty to spare) largely described financial uncertainty for the future including downturns in their retirement, stock and savings accounts as a result of the pandemic. No personal financial concerns were discussed by the focus group, but participants did share professional experiences and concerns particularly those in community-based professions including public health working with disadvantaged communities.

Dwindling mental health
Poor mental health was noted across demographics with a few noticeable intensities. More males than females indicated mental illness, albeit without further description as a stressor, caused by the pandemic. Increased substance use, (e.g. alcohol and tobacco), also accompanied entries of reduced mental health for males. Females, however, elaborated on stressful life events they were experiencing, such as job loss due to being in the hospitality or food industry, highlighting potential underlying mental dysregulations. Females in the study also reported multiple stressors as a result of the pandemic compared to fewer responses from males.
FGP: Echo: Yes, I am stressed out actually last week. I was having panic attacks.

Isolation and loneliness
Isolation was an overarching theme with most demographic groups sharing the same sentiment. Immigrants particularly had a lot to share as their isolation included sentiments of being away from their families in their home countries.
FGP Yucca: I've been living by myself for the last couple years … most of my peers are married or have children or other responsibilities, …but I so need to be socially connected to so, you know, I do see that my social media using has increased significantly.

Misinformation and fear of the unknown
No major patterns were observed when this theme was analyzed by demographics as fear was almost equally reported. Younger participants (under 45 years old) however shared more context. FGP X: But the problem is you're not getting proper information from anywhere the news or the media …. You don't know what's actually out there and first they say "we already know this is an RNA virus". Then they say "it's more like the flu", but now we just learned or they're telling us that it can actually last for 24 hours outside the host and stable which is very rare for an RNA virus.

FGP Silver: So, I follow a lot what's going on in Europe and especially
Latin America … Some of them goes aligned with the rest of the world and some of them are not … It's quite puzzling here. For some reason, they think that this is going to be done in two weeks for some odd reason.
FGP: Bila Shaka: I see misinformation everywhere … … trying to pass Green New Deal with the stimulus package to using Chloroquine to prevent corona … I worry about people believing some of the nonsense.
FGP: Ruth: I think I've had conversations with a couple of people, and everybody is sort of the armchair virologist geneticist. … how this started, why this started, why it's so big in Italy why it's big here. I just think nobody knows no not even the experts not even the virologists. Not even the infectious disease specialist. … so much of it is speculation you hear one day it only lasts on surfaces for 24 hours. You hear the next day it lasts on surfaces for five days, and I just think there's too much uncertainty right now.

Xenophobia and racism
A significant theme of racism and xenophobia was reported by race. Asian participants highlighted acts of hate perpetrated upon them and others due to Coronavirus, which other races resonated with, based on past similar event.
FGP Unicorn: I identify as Asian Pacific Islander person … whenever we talk about a disease or a virus coming from a specific area and it and if it's from somewhere not in Western European areas people tend to become extremely racist towards that community and so since the virus came from Wuhan China, now Chinese folks but not even just Chinese folk anyone that's Asian is being targeted … Not that it's just discrimination, but it's now leading to actual violence ….
FGP: Tiffany: … he [President Trump] says it's a Chinese virus or whatever, but everybody knows that he's talking about all Asians … And I feel like this country is pretty much born on fear on stirring up that type of fear and that type of hatred and it just bounces around from community to community.
FGP Jo: And everything I mean and I understand the xenophobia because I remember like when Ebola was a big thing … it's a sad but it's a reality that I think that people you know who look like me or not from where I'm from have experience for so long. It's almost like second nature like we're so used to it. But you know, I can sympathize with you know, with all the Asians and Asian-Americans and everybody that's going through it now because that's how we felt for a very long time and continue to feel.
3.6.1. Work related and associated challenges Focus group participants represented diverse industries (Appendix 2) including education, health and healthcare. None of them indicated loss of employment except for the substitute teacher who was also a graduate student. Frustrations shared were based on professional experiences and readjustment. For instance, professors having to transition to an online format, or public health practitioners sharing frustrations and challenges experienced or on behalf of those they serve. Examples shared include lack of COVID-19 tests and personal protective equipment, economic effects of the pandemic on disparate communities and increased workloads. FGP Panda: …. like in public health, we work with so many families that are already kind of living on the Edge, you know and all that it takes is one little push over the edge for them to have something go wrong and the disparities to really, you know, just blow out of the water.
FGP JJ: Because of the coronavirus I just have so much more free time now FGP Baraka: I've lost my sense of purpose because I'm so used to getting up every morning and going to school and I am teaching online and everything has transitioned to online but it doesn't feel the same. It just feels like the distance between me and my students

Concern for loved ones
This was a dominant theme particularly among female participants who indicated they were parents concerned about their children; 6 females vs. only one male. Highlights of such concern included homeschooling challenges. Immigrant survey and focus group participants particularly indicated concerns for older parents and relatives (particularly relatives) who have family in their home countries.  FGP Echo: I'm worrying about my parents who you know, they are sickly and I'm like if they get this disease, they won't survive it. It and if they don't survive it, I won't be able to go to their funeral because there's no plane to take me there.

Social capital at a time of social distancing
Adequate social support alleviates the etiology of mental disorders and can moderate ensuing depression. Social isolation is a mental health determinant exhibited along racial and ethnic lines, and might be worse for some demographic groups such as immigrants (Viruell-Fuentes et al., Coping resources Physical Material Social Psychological I do reflect on my privilege … I've been organizing mutual aid drives for folk …. that gives me a sense of pride and destresses me … Online Yoga and working out in the park I just shut off every electronic in my house for two days and just had a meditation and that kind of helped Catching up on sleep and spending time growing my faith My hands are completely dry and cracked from washing and bleaching and sanitizing ….and that's how I can exercise control Sometimes I can turn it off and I watch Real Housewives of Atlanta and kind of laugh … I've been reading books Eating a lot … A lot of drinking and sulking … Being informed is one thing but being inundated with all the bad news isn't helpful. The memes are fun though. I've been finding myself going for walks, like multiple times a day and smiling at everybody. I see on the street just because I'm hoping it's some kind of like human interaction." Stressed and worried but I put on a professional calm mask in order to not cause panic. I think it's just to take it day by day as opposed to thinking about. What is the next week going to bring? What's the next month going to bring? What's the next year going to bring because I feel like that's really beyond my control and beyond anyone's knowledge or awareness That's why I'm so calm, you know for me. I'm the kind of person who I'm like if I can't control it then, you know, you know, I don't worry about it. 2012). Survey sentiment analysis on social support was entirely positive (96%) with a few neutral stances; for instance, a participant stated: They are helpful but not needed at the time when everyone is facing the same problem as I.
Focus group participants emphasized support systems including religious and community helping them cope. Others accentuated stresses from not being close or having to social distance themselves from their support systems. Technology mediated social support was a dominant emerging social capital theme. Participants shared anecdotes of virtual playdates for children and informal meetings such as happy hour with friends. All participants indicated amplified use of phones, messaging apps and social media to keep in touch with family, friends, coworkers and others in the community. Excerpts from focus group participants (FGP) and survey participants (SP) on social capital are shared below FGP Tito: It's starting to wear on me because I feel like I am getting trapped in my own house, and it's not I'm not even so concerned about the whole aspect of society falling apart so much. I'm just kind of feeling a little claustrophobic in my own house. I've been finding myself going for walks, like multiple times a day and smiling at everybody I see on the street just because I'm hoping it's some kind of like human interaction.
SP 1: I like to be out and about, being in a home alone with no one around me is hard to cope with at time. SP 3: We talk about it. We reassure each other that everything is going to be ok.

SP 4:
My immediate family is safe together, we can have social distancing get-togethers with neighbors outside, friends and extended family can keep in touch by phone.
FGP: Giraffe: I'm working from home on telework I'm able to as I walk around and meet my neighbors and you can sort of you can feel their fears as you talk to them. And you get to know the names of their dogs …, you can to see that they're kind of afraid about the unknown and I'm able to leverage what I know to kind of calm their nerves a little bit and let them know that this too shall pass …

Discussion
With news and current events dominated by COVID-19 related stories, we had limited challenges meeting our sample quotas. Open-ended online surveys were adequately responded to. Demographic-specific disparities were seldom reported except on xenophobic and racist events surrounding Asian individuals as described by both survey and focus group participants. Our observation matches recent reports highlighting a backlash of discrimination and xenophobia against Asian Americans (Reny and Barreto, 2020). The backlash is comparable to those during the SARS outbreak in 2003 (Person et al., 2004), H1N1 in 2009(Sparke and Anguelov, 2012), and Ebola in 2014-2016(Kim et al., 2016 where communities are vilified leading to racialized behavior such as avoidance and bullying (Reny and Barreto, 2020). The use of technology has reportedly skyrocketed with cell phones, messaging apps, web conferencing technologies (e.g. Zoom and Skype), email and social media being the main avenue that the majority of the population can keep in touch with their friends, families, and loved ones or keep up with the news. Furthermore, because of advances in technology, participants described fewer disruptions to their daily routine due to ability to work from home or attend classes online. It was additionally clear that everyone felt it necessary to be informed yet struggled with the changing and overload of COVID-19 related news and guidelines.
To our knowledge, previous studies have not examined the association of social capital and stressful life events during a global scale pandemic. Results from our study highlight that greater social support is indeed associated with lower perceived stress during the early phase of the COVID19 pandemic. Our study participants who were parents of young kids emphasized challenges of homeschooling their children but reiterated during focus groups that it was more important to create a calm environment with a redefined normalcy for growing children whose future could very well be shaped by this crisis. One focus group participant highlighted that her child's school organized a weekly online class session via Zoom for students during the school closure and even had loaner electronic devices for children in need. Additionally, focus group participants appreciated the opportunity to vent and share some fears and frustrations in a group setting, some reiterating that the session has been the most human communication they have had outside their work and family in while.
On coping, participants differed in their emotion vs. problem focused coping based on their appraisal of the COVID-19 threat and its current or potential challenges. Social capital, operationalized as social support is positively associated with health outcomes in the population and can provide resources to deal with adversities (Wind and Villalonga-Olives, 2019) such as those related to COVID-19. Due to the unprecedented nature of the current pandemic, research is lacking that would highlight the benefits of social capital in an era where distancing is encouraged to save lives. Nonetheless, previous studies have highlighted improved health outcomes from impacted health behaviors and influenced psychosocial processes due to connectedness (Kawachi et al., 2008;Nieminen et al.2013). Kawachi specifically highlights lower levels of social trust associated with major causes of death particularly from chronic diseases such as heart diseases and cancer. The widespread disparities in health among racial, ethnic and socioeconomic groups particularly during emerging epidemics have been described in the literature (Des Jarlais et al., 2005). Additionally, highlighted in the literature is the stress of contracting a disease due to worry and lack of information (Nieminen et al.2013), a concept we also observed in the early phase of the pandemic. Our focus group purposely deviated from a discussion of a political nature. Nonetheless, the rhetoric of uncertainty in communication especially from political leaders was not absent. Historical evidence regarding epidemics suggests that it is impossible to disentangle such events from the politics (Ebook central, 1024).
Social capital can improve health outcomes by influencing access to health services and amenities, impacting health-related behaviors, and affecting individual psychosocial processes (Xu et al., 2020). Participants particularly emphasized perceived dire effects if they were devoid of any form of social capital. Their family, friends, coworkers, religious and community associates or even social media comrades helped cope, share news and tips or just divert their attention from the current world-wide chaos. Despite the coping strategies discussed, the novelty of the pandemic and current events had participants leaning on multiple coping methods. The general scheme of social capital discussion was that both sets of participants either longed for interactions, held on to connections, or invented new ways to interact and maintain or enhance social capital. This concept is in accordance with Wind and Villalonga-Olives (Wind and Villalonga-Olives, 2019) who describe a manipulation that consists of activities that directly build or strengthen social capital when social capital is the intervention target. Snowden particularly discusses pandemic situations, and the effectiveness of quarantines (Ebook central, 1024) which would add value to future similar studies that investigate coping during social distancing and whether the enhanced survival is perceived as a worthy tradeoff from the lack of connectedness.
A nascent concept towards the end of the group session touched on the aftermath of the pandemic; those who had lost loved ones, those who had been without or emerge from the pandemic without social capital and those with various forms of trauma due to the pandemic. In summary, the more pragmatic and objective problem based coping efforts (see Fig. 1) was more pronounced in participants during this early pandemic phase. Participants efforts were more directed at defining the problem and finding solutions, which included enhancing their social capital. The protective effect of social capital on stress warrants further exploration. As the COVID-19 upheaval continues to unfold and the unknown evolves into fruition, it is clear that SLEs, having the potential to impact health and wellbeing, will continue to be experienced or exacerbated for most people.

Limitations
Due to the novel COVID-19 being a new pandemic currently ongoing as of the writing of this article, this study could present some gaps in stressful life events as the situation unfolds. Because of the caliber of its global effect, there seems to be a lot of uncertainty about the future which in itself is a huge stressor for most. People from different demographic groups could exhibit renewed or increased devastations as the ravaging effects of the disease continue. Only two out of 205 survey participants indicated educational levels lower than a high school diploma and all focus group participants were professionals with at least a bachelor's degree. Efforts to sample other minority groups proved futile with no American Indian and Pacific Islanders responding to the survey HITs. Additionally, those without computers or with lower literacy levels may not have been able to access the survey or focus group scheduling. As a result, experiences and perceptions of a subset of the population is lacking.

Conclusion
Our study highlights the broader effects of the pandemic. In the U.S. with exceptions by demographics, financial strains, racism and isolation increased due to reduced travel to home countries of immigrants. At the preparation of this manuscript, (April 2020), the pandemic has not been controlled and various cities in the U.S. were on recommended or mandatory lockdown with all K-12 schools closed, most public universities transitioned to online and workers either temporarily displaced, telecommuting or deemed 'essential and are reporting to work'. To the best of our knowledge, this is the first study to explore stressful life events during the COVID-19 pandemic and associated social capital in terms of coping. Our findings suggest that as part of public health preparedness and health promotion, policies should be explored that fund increased social capital such as online religious events and district-wide K-12 class sessions via video hosting capabilities such as Zoom. Ultimately, social capital can effectively lower stress which can decrease the health and quality of life associated outcomes from unexpected or unavoidable stressful life events such as those from a global pandemic like COVID-19.
Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases has recently stated that the effects of the coronavirus pandemic would be imprinted on the personality of the country for years to come, stating "I think there's going to be some subliminal posttraumatic stress syndrome that we're all going to face" (Forgey, 2020). Future studies and health promotion efforts should address each stressor independently, particularly those who were already living on the edge before COVID-19 emotionally, socially or even financially.

Human participation protection
This study was approved by Loma Linda University Institutional Review Board. All study participants provided informed consent and had the option to decline or withdraw from participation at any time. No identifying information was requested. Anonymity was maintained through coded names for interview or focus group participation. Webbased survey did not query for any identifying information, and participants were reminded to maintain their anonymity. Unexpected interview personal identifiers were anonymized in the analytical datafile to prevent participants from being identified from any sensitive information that may have been inadvertently shared. All eligible participants equally participated in all aspects of the study selected. Completed transcripts have no personal identifiers. The Internet Protocol (IP) address collection feature was disabled on Qualtrics. All research information including interview recordings is stored in password protected shared folder hosted on a cloud-based portal only accessible to the study team.

Role of the funding source
This research was funded, in part, by a doctoral dissertation stipend to the first author from the Loma Linda University, School of Public Health.

Declaration of competing interest
None.