An investigation of the association between religious coping, fatigue, anxiety and depressive symptoms during the COVID-19 pandemic in Morocco: a web-based cross-sectional survey

Coronavirus disease 2019 (COVID-19) was first reported in China. Shortly thereafter, the disease spread all over the world to became a global pandemic [1, 2]. Since the severe acute respiratory syndrome outbreak in 2003, COVID − 19 is deemed to be highly contagious; it has affected 219 countries in record time [3]. On March 2nd, 2020, the first coronavirus case was officially confirmed in Morocco [4]. Up to April 10th 2021, 500,948 have been diagnosed as COVID-19 positive, of which 8885 were fatal [5]. Moroccan authorities, for the sake of control and prevention, have implemented urgently a package of restrictive measures, such as isolation of suspected and diagnosed cases, cancelling parties, extending holidays, closing schools, and complying with stay-at-home orders [6].

A couple of studies have reported that the outbreaks of fatal infectious diseases impact negatively people’s mental health and well-being [7]. Indeed, concerns about the mental health and psychological adjustment of the public have been arising due to the COVID-19’s quick outbreaks and high mortality. Accordingly, a couple of works have reported significant psychosocial impacts of the COVID-19 quarantine on mental and physical health, such as post-traumatic stress symptoms, depression, anxiety, fear, and confusion among general population and medical workers as well. The severity of psychological disorders varies depending on sociodemographic factors, such as age, gender, area of living, social media, income, social support, religiosity, having relatives infected or died from COVID-19 [8, 9], guilt about the effects of contagion [10], inadequate or fake information especially from unauthorized sources or media [11, 12], uncertainty and unpredictability around COVID-19 [13], quarantine duration, frustration, fear of losing friends and family [11], loneliness, boredom, inadequate supplies and health equipment, financial loss, and stigma [10, 14]. All these stressors increase anxiety and depression in the quarantined population. Moreover, studies showed that prolonged feelings of distress and worry can increase levels of fatigue [15].

On the other hand, people experiencing adverse life events tend to take religion as a source of comfort [16], and adopt more religious coping [17‐20]. Religious coping can be defined as the way individuals use cognitive or behavioral strategies based on religious beliefs or practices to cope with stress and life problems [21]. This can include reading holy scriptures, seeking counsel from religious leaders, and reducing unpleasant thoughts using religious means [19]. Literature has argued that religiosity can be seen as a framework of meaning-making that is associated with decreased psychological distress and thus a powerful resource for mental health [22, 23]. Positive religious coping provides a source of social support [24]. The majority of the Moroccan population is Muslim. Islamic beliefs state that every event, whether positive or negative, has a purpose, and spiritual growth requires enormous patience and commitment [17, 25]. Literature has mentioned that the Islamic religion plays an important role in protecting people from difficult mental health outcomes including attempts to suicide [19].

Although quarantine measures are successful in reducing or terminating the COVID-19 outbreak in different areas of the world, the adverse effects of quarantine have not previously been studied systematically. Literature has stated that there is not enough data available about the effect of the COVID − 19 pandemic on mental health problems among the general population [10, 26].

Up to our knowledge, information about the prevalence of depression, anxiety, and fatigue of Moroccan citizens, and their association with religious coping during the COVID-19 outbreak have not been studied yet. To this end, we conducted an online investigation during the first wave of COVID-19 pandemic to investigate the psychological effect of quarantine on people’s psychological symptoms, mainly depression, anxiety, and their associations with the sociodemographic, fatigue and religious coping factors.

Out of 1530 questionnaires collected, 1435 (93.7%) questionnaires were fully completed by Moroccan citizens aged more than18 years. The usage of an online snowball sampling does not permit assessing the survey response rate, as there is no way to determine exactly how many people received the link and did not respond to it.

Participant’s average age was 32.2 ± 10.5 years (age ranged from 18 and 74 years). More than half of the participants were male (n = 811, 57.0%), not married (n = 827, 58.0%), and employed in the public sector (n = 769, 54.0%). Most respondents were well-educated (n = 1332, 93.0%), and had no chronic disease (n = 1312, 91.0%) (Table 1).

Regarding knowledge about COVID-19, nearly all respondents (n = 1301, 91.0%) showed a need to be regularly updated with the latest information about COVID 19 (route of transmission, the availability of medicines, the number of infected cases and death, and advice on COVID-19 control and prevention). Most participants expressed a high level of compliance with quarantine and protective measures (n = 1213, 85.0%; and n = 979, 68.0% respectively), whereas 32.0% (n = 454) of participants expressed a high level of fear to contract COVID-19.

Among the 1435 participants, 53.0% (n = 766) subjects were found to be depressed, 43.0% (n = 621) were anxious, 32.0% (n = 453) were suffering from severe physical fatigue, and 26.0% (n = 372) were suffering from mental fatigue. Concerning religious coping, the participants’ mean score of P RCOPE was high (M = 17.8, SD = 4.5), while the mean score of N RCOPE was low (M = 9.3, SD = 3.2) (both Brief RCOPE subscales range from 7 (low) to 28 (high)).

The association between depression, anxiety and sociodemographic independent variables was assessed by the Chi-square test. As shown in Table 2, the younger age (≤ 45 years) (depression OR = 1.81, p < 0.001; anxiety OR = 1.67, p < 0.001), female gender (depression OR = 1.63, p < 0.001; anxiety OR = 2.28, p < 0.001), household income decline (depression OR = 1.63, p < 0.001; anxiety OR = 1.49, p < 0.001), tracking regularly COVID-19 news (depression OR = 1.79, p < 0. 01; anxiety OR = 1.97, p < 0.001), fear of contracting COVID-19 (depression OR = 2.24, < 0.001; anxiety OR = 3.28, p < 0.001), and fear of dying from COVID-19 (depression OR = 6.46, p < 0.001; anxiety OR = 11.03, p < 0.001) showed significant association with both anxiety and depression (HADS scores of 8 and above for both anxiety and depression).

The correlations between the studied scales and subscales were moderate to strong and generally significant. CFS-Physical and mental fatigue, HADS-A, and HADS-D were positively correlated with negative religious coping and inversely correlated with positive religious coping (Table 3).

Logistic regression analyses were conducted to examine the associations of sociodemographic factors, religious coping, mental fatigue, and physical fatigue with depression and anxiety under COVID-19 epidemic-related factors (Table 4). The results of single regression analysis confirm the significant association of most factors described by the chi-squared test with depression and anxiety (Table 2). Besides, it appears that depressive and anxious patients used more negative religious coping, while positive religious coping was only slightly associated with depression. The results showed also that mental fatigue and physical fatigue were associated significantly and positively with depression as well as with anxiety. The findings remained significant even after adjusted in the multiple logistic regression model. The latter indicated that physical fatigue was significantly associated with depression (aOR = 3.35, 95% CI: 2.51–4.50) and anxiety (aOR = 3.14, 95% CI: 2.37–4.18), and mental fatigue predicted significantly depression (aOR = 4.05, 95% CI: 2.91–5.71) and anxiety (aOR = 3.80, 95% CI: 2.78–5.20). Some sociodemographic variables remained significantly associated with depression and/or anxiety in multivariate logistic regression, including female gender, household income decline, tracking COVID-19 news, and having fear to contract this disease (aOR = 1.36 to 2.85). The model had a Nagelkerke’s R² of 0.29, and 0.36 for depression and anxiety, respectively. This suggests that about 29.0% of the depression variance and 36.0% of the anxiety variance could be explained by this model, though this should be interpreted with caution, since “pseudo” R2 values are derived differently in logistic regression compared with linear regression (Table 4).

This study is a web-based survey aiming to examine the prevalence and associated variables of probable depressive and anxiety symptoms among 1435 respondents during the COVID-19 lockdown in Morocco. Therefore, the survey could have targeted only highly educated people having internet access. Unfortunately, this is one of the limitations of this study, because it is not representative of the general population.

Importantly, the results of this survey revealed that most of the surveyed subjects expressed a high level of compliance with quarantine (n = 1213, 85.0%), and protective measures (always washing hands, wearing a mask, and covering mouth when coughing and sneezing) (n = 979, 68.0%). These results can be partly explained by the fact that most respondents (n = 1332, 93.0%) were highly educated, and might be attributed to the efficiency of authorities’ awareness campaigns in the initial stage of the pandemic. Like few success stories [38], Morocco has adopted early quarantine measures, community mobilization, as well as large-scale testing of the population, which enabled the country to avoid a massive outbreak. Interestingly, the compliance with quarantine and protective measures was associated neither with depression nor with anxiety.

For concerns about COVID-19, 32.0% (n = 454) of the subject’s study expressed a high level of fear to contract COVID-19, and only 7.0% (n = 100) expressed a high level of fear to die from this disease. The fact that 91.0% (n = 1312) of participants had no chronic disease might explain why they were less afraid to contract COVID-19 and to die if infected.

Concerning the psychological impact of COVID-19 and quarantine measured by HADS, results revealed that 53.0% (n = 766) and 43.0% (n = 621) of the participants were respectively found to be depressed and anxious (HADS scores of 8 and above for both anxiety and depression). The elevated rates of depression and anxiety found in this study could be caused by other factors which were not measured in this study, mainly sleep disturbance. The latter was ascertained to be associated with anxiety, depression, and suicidal behavior [39]. Indeed, the prevalence of depression (14.6 to 48.3%) and anxiety symptoms (6.33 to 50.9%), stress disorder (7 to 53.8%), psychological distress (34.43 to 38%), and stress (8.1 to 81.9%) is higher during the COVID-19 outbreak than before in many countries [40]. In the United States, the depression prevalence was 3-fold higher during the COVID-19 outbreak than before [41], 32.7% of adults from the Chinese general population experienced elevated anxiety or depressive symptoms [42]. Moreover, nearly half of the Libyan population suffered from depressive symptoms, and one-fifth presented severe anxiety symptoms [43, 44].

Univariate logistic regression showed that depression and anxiety were associated with younger age and female gender, while multivariate logistic regression indicated that only female gender remained significant. Our results showed that depression and anxiety were more likely to occur in younger people age 45 years or younger. These findings are corroborated by a previous study in Morocco, which revealed that people aged less than 35 years present more depressive and anxiety symptoms than those aged 35 years or older [45]. Moreover, previous studies undertaken on the Chinese population have demonstrated that younger participants are more likely inclined to undergo unemployment, income decline, high frequency of access to pandemic news through social media, and prone to develop anxiety and depressive symptoms during COVID-19 outbreak than those aged above 40 years [42, 46, 47]. Concerning the female gender, its association with depression and anxiety during COVID-19 pandemic was found in several epidemiological studies [45, 48‐50]. In Morocco, the prevalence of depression and anxiety among women is high compared to men [35, 36]. The differential risk of depression and anxiety may stem from biological sex differences, and COVID-19 related factors, such as lockdown, unemployment, and family violence [51, 52]. Previous studies have ascertained that violence against women leads to subsequent depression and anxiety [53, 54]. Accordingly, the rate of violence toward Moroccan women is estimated at around 54.4% [55], and it is susceptive to rise significantly under pandemic and resultant shutdowns [14, 49, 52, 53, 56]. In this regard, it is reasonable to hypothesize that violence against Moroccan women may be one stressor among others that are associated with the higher prevalence of depression and anxiety recorded during the COVID-19 outbreak. Of Note, other stressors such as chronic health issues, exercise, financial problems, excess information from mass media, and infection fears were reported to be associated with depression, anxiety, distress and life satisfaction [14, 57‐60].

The present study demonstrated that the likelihood of having depression and/or anxiety was higher in participants reporting mental and/or physical fatigue. Indeed, fatigue and depression share specific symptoms such as sleep disturbances, poor concentration, and memory difficulties [43, 61]. This explains why patients with either fatigue or depression are reported to be two-fold prone to show an increased risk for the comorbid presentation of both traits, compared to the general population [62].

Fatigue, depression, and anxiety in the present study were negatively correlated with positive religious coping, and positively correlated with negative religious coping. These findings confirmed the widespread belief that religiosity provides a source of attitudes that can reframe negative events into less stressful frames [63]. Thereby, positive religious coping and the trust in God correlate with less stress and increased positive impact [64, 65], when negative religious coping is usually linked to undesirable physical and mental health indicators such as depression, anxiety, and fatigue [64‐66]. The weak association found in this study between positive religious coping and depression, was reported in other studies which mentioned that in samples experiencing a specific challenge, the association between positive religious coping and depression is somewhat weaker or conflicting [67].

The results of this study should be interpreted in light of the following limitations. First, due to the limited resources available and the time-sensitivity of the COVID-19 outbreak, the snowball sampling strategy was adopted as a safe and the only option available during the total lockdown. The sampling was somehow biased since the questionnaire was administered to highly educated people who are the most internet users. Hence, these findings cannot, however, be extrapolated to all Moroccan populations. Second, this study did not collect contact details and personal information from the respondents mainly due to the ethical requirements on anonymity and confidentiality. As a result, we could not conduct a prospective study on the same group of participants in the future. Third, our findings were based on self-report data. Self-reported levels of depression, anxiety, and fatigue might be biased and may not always be aligned with assessment by health professionals. Notwithstanding the above limitations, this study provides invaluable information, from respondents across Morocco, about the initial psychological impact, fatigue, and religious coping associated with the spread of the COVID-19 and the lockdown on the Moroccan population.

Overall, this study is one among few studies that have assessed the effects of the COVID-19 pandemic on depression, anxiety, fatigue, and religious coping among the Moroccan general population. It showed that the likelihood of having depression and anxiety was higher in participants reporting mental or physical fatigue and who had experienced negative religious coping. However, the likelihood of having depression and anxiety was lower in participants with positive religious coping. This highlights the importance of the development of psychological interventions to minimize psychological impact, anxiety, and depression, during the outbreak of COVID-19. Further research about the psychological impact of COVID − 19 and religious coping in Morocco is recommended especially to be compared to our work that was carried out at the beginning of the pandemic.