Psychological responses and associated factors during the initial stage of the coronavirus disease (COVID-19) epidemic among the adult population in Poland - a cross-sectional study

The disease caused by the SARS-CoV-2 (COVID-19) virus infection was first diagnosed in December 2019 in Wuhan, China, spreading to other countries of the world [1]. On January 30, 2020, the World Health Organization (WHO) announced the outbreak of the COVID-19 epidemic [2]. High infectivity and the rapid spread of the virus have become a particular problem [3, 4]. In Poland, the first case of COVID-19 infection was detected on March 4, 2020. From that moment on, there was a gradual development of the pandemic in the country. On March 11, the Minister of National Education in Poland issued a regulation on the temporary limitation of the functioning of education system units [5]. Further restrictive restrains were introduced very quickly. At the beginning of the pandemic, the problem of the lack of masks, medical equipment and disinfectants appeared in Poland [6]. From March to July 2020, over 38,000 cases of infection and over 1,562 deaths were found in Poland [7].

The transmissibility of COVID-19 has been estimated at 4.08 [8, 9]. It is estimated that the average incubation period for COVID-19 is 5.2 days [10]. The course of the disease is very diverse [11‐14]. The mortality risk among confirmed cases is estimated at 3–6% [15]. The isolation of a large number of people in Poland in March affected many aspects of their lives. The COVID-19 epidemic has caused serious threats to people's physical health and lives. Society needs a quick understanding of mental health condition during a pandemic [16]. Research on the impact of health and life threatening situations and isolation on mental health is particularly important in the context of the uncertainty surrounding the outbreak of an epidemic on such an unprecedented scale.

Past studies in areas affected by epidemics have confirmed that the introduced restrictions and isolation negatively affect the emotions felt by individuals [17]. During the outbreak of acute respiratory syndrome (SARS) epidemic, many studies assessed the psychological impact on the community, revealing the activation of many previously unrecognized disorders and mental problems [18]. A high level of fear of illness and death, as well as a feeling of helplessness and stigmatization were found [19]. Elderly, female, more educated people, with a higher risk of perceiving SARS, with a moderate level of anxiety, with a positive contact history, and people with symptoms similar to SARS, were more likely to take preventive measures against infection [20]. Isolation from other members of the community, combined with other risk factors during an epidemic (SARS), increased the likelihood of developing depressive symptoms in the future and a 2-3-fold increase in the symptoms of post-traumatic stress disorder (PTSD) [21‐23]. Additionally, during a pandemic, isolation weakens important ways to combat stress, such as physical activity and spiritual coping, increasing mental and physical stress [24].

Our findings indicate the occurrence of significant psychological reactions of the Polish adult population, in general, in the first period of the COVID-19 pandemic. The psychological impact of the COVID-19 outbreak in Poland, measured using the IES-R scale, showed an average post-traumatic stress at the level of 29.75 (SD = 16.05). Out of all respondents, 38.71% reported a minimal psychological impact, 20.71% indicated a mild psychological impact, and a moderate and strong one occurred in 40.58%. A similar average level of suffering from traumatic events related to the outbreak of the pandemic occurred in China, with other countries that measured such it this, a lower level of post-traumatic stress has occurred. Wang et al., examining 1,210 people representing an average population in China using an online survey, found a slightly higher psychological impact of the pandemic measured with the IES-R scale (mean score 32.98, SD = 15.42). In China, a slightly smaller proportion of respondents reported a slight psychological impact of the pandemic (24.5%), a similar proportion had a mild impact (21.7%), and a slightly greater proportion had a moderate and severe impact (53.8% in total) [25]. Di Giuseppe et al. studied 5,683 Italians in the early period of the pandemic using the IES-R scale. The average IES-R value was slightly lower than in Poland and China and amounted to 24.72 (SD = 16.10) [36]. Hao et al. conducted an online survey of people with and without mental illness during the COVID-19 pandemic. They found statistically significantly higher levels of posttraumatic stress measured IES-R in people with mental disorders (mean IES-R = 17.7; SD = 14.2) than in people without such disorders (mean IES-R = 11.3; SD=10.1) [37]. Chew et al. studied 21,906 health care workers from major hospitals in Singapore and India. The authors found the average level of IES-R in the studied group at a lower level (8.29; SD 9.79) than in the studied population representing the general population in Poland, and this effect was also found in a lower percentage of respondents (7.4%) [38]. Tee et al. analyzed 2,037 questionnaires collected through an online survey among the Luzon Islands of the Philippine community. The psychological impact of the COVID-19 pandemic measured with the IES-R showed a sample mean score of 19.57 (SD = 13.12) [39].

In Poland, mild depression was found in 14.71%, moderate in 22.00%, and severe and extremely severe in 11.34% of respondents. In their studies, Wang et al. found occurrence of depression in a smaller percentage of respondents, including mild depression in 13.8%, moderate depression in 12.2%, and severe and extremely severe depression in 4.3% [25]. In the Philippines, depression was found even less frequently, 11.9% reported mild depressive symptoms, 12.7% - moderate, and 4.2% - reported severe to extremely severe depression [39]. Hao et al. found a statistically significantly higher level of depression in patients with mental illness than in patients without diagnosed mental illness. The average level of depression in both groups was lower than in the average sample of the Polish population [37]. García-Álvarez et al. in the studied sample of Spaniards found mild depression in 28.0% of the respondents, moderate depression in 12.5%, and severe and extremely severe depression in 6.2% [40]. In the studied group in Poland, a mild level of anxiety was found in 7.14%, in 20.86% - moderate, and in 11.24% - a strong and extremely strong anxiety. In the study group in China, mild anxiety level was found in 7.5%, moderate - in 20.4%. Slightly fewer respondents in China (8.4%) than in Poland suffered from severe and extremely severe anxiety [25]. In the Philippines, 9.6% of respondents reported mild anxiety symptoms, 17.7% - moderate anxiety symptoms, and 11.1% - symptoms of severe to extremely severe anxiety [39]. The situation related to experiencing anxiety in the Philippines was similar to the situation in Poland.

In the studied group of Poles, mild stress was present in 37.29% of the respondents, moderate - in 11.86%, and severe stress in 25.71%. In the group of Chinese, the presence of stress was found in a smaller percentage of the respondents, in 24.1% mild stress was found, in 5.5% - moderate, and in 2.6% - severe and extremely severe stress [25]. Tee et al. found mild stress signals in 26.4% of Filipinos, moderate in 9.5%, and at least severe stress in 3.9% [39]. In general, it can be stated that the percentage of people experiencing stress in the Philippines was slightly lower than in Poland.

The average quality of life level in Poland was the lowest for the physical domain and it amounted to 49.56 (SD=11.71). The highest average standard of living was in the environmental domain and it was 65.83 (SD=15.12) and in the social domain and it was 65.82 (SD=19.41). The standard of living in the psychological domain was 60.26 (SD=13.14). The situation was slightly different for Cawla et al., who studied the population of medical students in India during the pandemic, and who found the mean WHOOL-BREF domains scores highest for the environmental domain (72.10 ± 13.0), then the physical domain (67.23 ± 13.74), social (57.13 ± 20.1), and the lowest for the psychological domain (52.10 ± 17.45) [41].

In Poland, significantly higher results of the IES-R scale during the first wave of the pandemic were found in older people, living in a relationship, with a lower level of education, with children aged 16 and over, and with insufficient or small financial resources to meet their needs. It was different in China, where women and students had higher IES-R scores [25]. In the Philippines, significantly higher psychological impact in the first period of the pandemic was found in young people and students, as well as in women, single people, people with lower education and non-health care workers [39]. In Italy, the highest level of post-traumatic stress was recorded in women and middle-aged people (30-49 years) [36]. In Poland, in the first period of the pandemic, a significantly higher level of stress was found in older people, with a lower level of education, with children aged 16 and over, and with insufficient or small financial resources to meet their needs. In China, a significantly higher level of stress was found in men [25]. In the Philippines, significantly higher levels of stress were found in women, young people, single people, people with lower education, students and non-health professionals [39].

In Poland, a significantly higher level of anxiety was characteristic of the female sex, the elderly, people with at most vocational education, with children aged 16+ and insufficient or small financial resources to meet their needs. Similarly, in the Chinese study, men had a significantly higher level of anxiety than women [25]. In the Philippines, significantly higher levels of anxiety were observed in women, younger people and students, single people, people with lower education and parents [39]. Among the surveyed Poles, a significantly higher level of depression was observed in people with at most vocational education, professionally inactive, with children aged 16 and over, and with insufficient or small financial resources to meet their needs. In China, a significantly higher level of depression was found in men and students [25]. In the Philippines, significantly higher levels of anxiety were found in younger people and students, single people, people with lower education, non-health professionals and parents [39]. In Poland, single people, with lower education and low income had a significantly lower quality of life. Gender had no effect on quality of life. In India, male medical students had a higher quality of life than female students [41]. In Italy, healthcare workers who had unprotected exposure to COVID-19 patients had an increase in physical and psychological symptoms, even without developing disease, while infected workers had a sharp increase in anxiety, depression, and sleep disturbances [42]. The prolonged stress associated with the pandemic increases the incidence of burnout syndrome in health care workers, characterized by emotional exhaustion, depersonalization, and low personal accomplishment [43, 44].

The six most common infectious symptoms of the studied group of Poles in the first weeks of the pandemic occurred in the following order: headache, sore throat, coryza, dizziness, cough and muscle pain. In China, these were also the most common symptoms [25]. In the study group in Poland, linear regression showed that high temperature, headache, sore throat, dizziness, cough, muscle aches, difficulty breathing, and chills were significantly associated with higher IES-R, stress, anxiety and depression, and lower levels of quality of life. The Chinese analogous linear regression similarly showed that: chills, muscle aches, cough, dizziness, coryza and sore throat were significantly associated with higher IES-R scores, higher levels of stress, anxiety, and depression [25]. The same was true in the Philippines [39]. Linear regression conducted by Chew et al. revealed that the presence of physical symptoms in health care workers was associated with higher mean scores on the IES-R and on all subscales of the DASS-21. This relationship was especially present in three respiratory symptoms (sore throat, dyspnea and cough) [38]. Hao et al. found similar results [37].

In Poland, due to the infectious symptoms, 10.14% of respondents consulted a doctor. During the 14 days preceding the study, 1.14% of respondents were hospitalized, 3.71% were tested for COVID-19, and 10.86% were quarantined. In the Chinese study group, a significantly smaller percentage of respondents consulted a doctor (3.5%) in the two weeks preceding the study, were admitted to the hospital (0.3%), were tested for COVID-19 (0.9%) and were quarantined (2.1%) [23]. In Poland, the majority of respondents assessed their health as good (44.29%) or very good (37.86%). Similarly, in China, 68.3% reported good or very good health. However, in Poland (54.00%), significantly fewer people than in China (93.6%), reported that they did not suffer from any chronic disease [25]. In Poland, people who consulted a doctor during the last 14 days, were hospitalized, tested for COVID-19, or were in quarantine, had significantly higher IES-R, stress, anxiety and depression level, and a lower level of quality of life. The same was true in China [25] and the Philippines [39]. In Poland, people who assessed their health worse and suffered from chronic diseases had a significantly higher level of IES-R, stress, anxiety and depression. The same was true in China [25] and the Philippines [39].

In Poland, people who confirmed close or indirect contact with a person infected with COVID-19, or suspected of such infection, or contact with materials potentially infected with COVID-19 had significantly higher IES-R scores and a significantly higher level of stress, anxiety and depression as well as a lower quality of life in relation to people who did not have such contact. In China, no such intensification of emotional symptoms was recorded in similar situations [25].

The main source of information about the pandemic in Poland for the majority of respondents was the Internet (62.14%) and television (30.29%). In China and the Philippines, the Internet was by far the most common source of information about the pandemic [25, 39].

Most respondents in Poland stated that in the initial stage of the pandemic, the probability of contracting the Sars-Cov-2 virus for them and their families was moderate, high or very high. These people had significantly higher IES-R scores and higher levels of stress, anxiety and depression, as well as a lower quality of life. The same was true for the respondents in China and the Philippines [25, 39]. In people who claimed that they had little chance of surviving this infection, psychological indicators were significantly higher, and the quality of life was significantly lower. It was similar in other countries [25, 39].

Most of the surveyed Poles always covered their mouths when coughing and sneezing, avoided sharing dishes with meals, washed their hands with soap, wore a mask regardless of the presence or absence of symptoms, and washed their hands after touching potentially contaminated objects. Unfortunately, always washed their hands immediately after coughing, sneezing or rubbing their nose, about one in five people only. Linear regression analysis showed that Poles who always adhered to the rules of hygiene had a significantly lower level of emotional symptoms compared to people who did not. Interestingly, no such relationship has been reported for wearing masks. Similar relationships were reported in China, except that wearing masks was associated with lower psychological impact scores. The rarity of wearing masks, regardless of the presence or absence of symptoms, was significantly associated with higher IES-R scores [25]. In Poland, people taking precautions against COVID19 infection had a significantly higher quality of life.

The pandemic is having a significant impact on human mental health. In Poland, this impact appears to be higher than in other countries that have made such an assessment. Relatively high average level of post-traumatic stress, stress, anxiety and depression as well as low quality of life make it necessary to consider interventions that will favor the use of more adaptive defense mechanisms and build mental resilience during an infectious disease pandemic and its long-term consequences. Our research made it possible to identify groups of special risk to which psychological support should be addressed in the first place.

In a pandemic and changing world situation, psychological support services are urgently needed and should be based on coping strategies. The intervention plan should provide broad access to appropriate information, training and responses to life-threatening situations, and psychological support in coping with anxiety and stress, especially in groups most exposed to psychological stress related to potentially life-threatening situations. The use of psychologists' cooperation with schools and universities in this area and the introduction of mental health monitoring during periodic medical examinations performed by occupational medicine doctors should be considered. These activities should take into account the principles of military psychology in crisis situations [45, 46]. In addition, consideration should be given to using various spiritual care programs and other approaches to reduce anxiety, stress and emotional exhaustion, especially in the most vulnerable groups [47, 48].