Pandemics have a myriad impact on the mental health of people . In the recent outbreak of COVID-19, it has been reported that COVID-19 itself with many other factors has increased mental issues in various countries [4, 8, 32-34]. To the best of our knowledge this is the first study to examine the psychological typhoon eye effect or ripple effect from the epicenter among Pakistani adults. The findings of psychological distress and anxiety scales revealed the prevalence of moderate distress and anxiety in our sample. Compared to other recently published studies, the results showed that the rate of anxiety and distress among Pakistani adults was greater as compared to those in China , whereas lower as compared to Italy, Spain and United States [6, 35, 36]. These differences might be due to less number of reported cases and deaths as compared to the countries that have high distress and anxiety. With regard to the variables associated with distress, anxiety and mental health in Pakistan, family size and exercise were worth noting predictors found in our sample. Previous literature revealed that geographical distance from the epicenter as an important prognosticator during catastrophic events . In the present study the findings overall showed that participants residing distantly from the epicenter have better mental health with less distress and anxiety, supporting the ripple effect rather than the typhoon eye effect [7, 17]. However, the association can diverge based on individuals’ family size. The mental disorder decreased by the distance to the epicenter for individuals in small families, indicating the typhoon eye effect. By contrast, mental disorder increased by the distance to the epicenter for individuals in larger families, showing the ripple effect.
Our results on the ripple effect vs. typhoon eye effect, together with other studies on the same topic in China, Brazil, and Peru [7, 17, 20], suggest the prediction of these two opposing theories may differ based on the countries studied. Such differences are understandable, as countries vary in their geography, media and social media reporting, medical systems, cultures, the availability of personal protective equipment (PPE), labor and employment conditions, the policies of lockdown, the ease of working from home, and maintaining a living in a pandemic, and the information in both mainstream and social media, etc. . The results therefore suggest we need to identify the predictive effect of the ripple effect vs. typhoon eye effect as a predictive model of mental health in individual countries during the Covid-19 pandemic. Our results suggest such studies can focus on identifying relevant contingency factors in individual countries. In Pakistan, we focused on family size, and the possible explanation for family size to reverse the effect of the ripple effect vs. typhoon eye effect might be due to socio-economic burden on the families due to lockdown in the country. As studies have shown that financial constraints or economic hardships not only increased behavioral problems but also damaged the physical and mental health status of individuals and their families . Thus, our findings identify family size as a critical contingency factor in the prediction of typhoon eye effect and ripple effect. Future research can focus on identifying unique contingency factors in the country of the study.
As in previous studies in Brazil, China and Iran [4, 5, 20], our sample also identified exercise hours as one of the predictors of distress, anxiety and mental health during COVID-19. The results showed that participants who put in more hours for physical activity in terms of daily exercise in their routine, had better mental health and were less likely to develop distress and anxiety symptoms. Many studies have reported that performing daily exercise might have an impact on anxiety and distress symptoms [38, 39]. Due to the sedentary life style in COVID-19 pandemic, it has been observed that people gave less attention to their physical health than in normal circumstances . Thus, particularly in this pandemic era when people were extra stressed, adding physical activity in the daily routine can play a role in reducing distress and anxiety. In comparisons with the recent studies of Iran, China and Brazil [41-43], age also predicted mental health in the Pakistani population. The results showed that older people had better mental health, which might be due to the joint family system in Pakistan. It has been reported that traditional family systems, such as those in South Asia, can contribute to healthier mental states among older people as compared to those living in smaller nuclear family systems . The positive attitude from a lack of information about COVID-19 could also be another factor for better mental health of older people . As compared to older people, younger people rely more on social media and the internet that have helped to spread negative information on the pandemic [18, 30].
The overall findings of the present study can help to identify the vulnerable individuals in Pakistan during this crisis of COVID-19. Exercise, family size, age and distance to the epicenter are the key predictors of distress, anxiety and mental health in Pakistan during this pandemic. More specifically the relationship of the geographical distance to the epicenter with distress, anxiety and mental health represented the ripple effect in large families. However, the relationship varied depending on family size and showed the typhoon eye effect in small families. Thus, results suggest psychiatrists and mental health care providers that the geographical distance to epicenter, with an important contingency of facility size, can play a major role in screening of people with high risk.
This study had some limitations. During the survey dates, the total active cases of COVID-19 in Pakistan had yet to reach its peak, and the situation continues to evolve. In addition, as the study was conducted through an online questionnaire, selective participation and coverage area error might be present. While we aimed for broad coverage of the adults in various parts of Pakistan, we do not claim our sample to be representative of the adults’ population in Pakistan.