To gain insight into relevant components of mental health in Belgian adults during the COVID-19 lockdown, this study investigated some potential predictors of their mental health and focussed on the role of meaning in activities in particular.
We could confirm our hypothesis, stating that meaningful activities do contribute to general mental health in adults during COVID-19 lockdown.
The COVID-19 pandemic caused significant changes to peoples’ daily lives as their movements were restricted in support of efforts to slow down the spread of the virus. Faced with new realities of working from home, online meetings, temporary unemployment, home-schooling (of children), and lack of social contact with friends and family, the mental health of people was affected .
Based on the discussion of Allsop and colleagues , the number of people suffering from mental health problems during a major event is often greater than the number of people suffering from physical problems. Results of our study showed low mental health in Belgian adults. This is not unexpected as current COVID-19 research showed similar results. Using the same measure instrument GHQ, the researchers from the United Kingdom Household Longitudinal Study (UKHLS)  did a comparison between mental health pre-COVID-19 and during COVID-19. They found that adults had worse mental health during COVID-19 than pre-COVID-19. A follow-up study found in the first COVID-19 wave that 29.2% of their respondents scored above the threshold on the GHQ, which indicates a case of psychiatric disorders . Furthermore, from April 2020 until June 2020, all sociodemographic groups showed significant increases in mental health problems in the UK .
The loss of mental health can, according to our study results, be partly explained by the loss of meaning in activities. Hierarchical regression showed that meaning in activities (EMAS) accounted incrementally for 9.2% of the variance in mental health (GHQ), beyond the effects of demographic and personal variables. The subjective experience of meaning associated with engagement in activity may be a key mechanism through which daily activities influence personal well-being and, according to the study results, mental health [68–70]. As stated before, meaning in activities is a key outcome of human health and well-being and our study demonstrated that this also holds times of a pandemic where anxiety and stress prevail [41, 43].
As the forced adaptation to the lockdown measures likely caused an unintended disruption or even (temporary) loss of daily activities (e.g. work, hobbies) for most people (e.g. children, adults, and elderly), one might expect that one’s day-to-day living, behaviour, and well-being might be blurred [4, 65]. People were forced to adapt their daily activities. Activities that could not easily be adapted had to be discontinued such as volunteering work, student jobs, and most affected of all, social activities outdoors . At the start of the lockdown, people experienced the measures like a temporary disruption of the situation and people adapted themselves to the situation by trying to find new ways to experience meaning in the performed activities by changing the form of the activity or searching for other activities, or changing their time investment in their activities . As the lockdown persisted, people struggled to find meaning and started to attribute the negative effects of the measures to features out of control of the person (e.g. people started blaming the government that the measures were too hard). Hereby assuming, based on an occupational therapy model, that the temporary disruption turned into experiences of deprivation in which the people are restricted from participation in necessary meaningful activities due to circumstances outside their control .
It can be presumed that the longer the COVID-19 pandemic lasted, the more difficult it was to remain satisfied with these activities, and the more people lost meaning in activities. Due to the imposed measures, the form in which people were forced to perform their activities was reduced to its basic function (e.g. the function of shopping is to ensure oneself of the necessary ingredients to stay alive) . People became task-oriented, yet were less to engage in creative thinking which is primarily driven primarily by enjoyment and meaning in the activities [74, 75]. Consequently, the form of the activities did not leave enough room for aspects of meaning, such as shopping together for fun. Therefore, this could be an explanation of why most of the participants experienced moderate meaning in activities.
Next to the largest contribution of meaning in activity, resilience was the second strongest contributor to mental health. These results are in line with other recent studies. In the face of COVID-19, people need to cope with these ongoing stressors and minimalize psychological distress . Therefore, being resilient can protect against these events and thrive from adversity [77–79]. In a COVID-19 study across healthcare and non-healthcare professionals, higher resilience scores were associated with lower COVID-19 related worries. Moreover, higher scores on resilience were associated with a reduced rate of anxiety and depression .
Furthermore, the demographic factors gender, having children, marital status, living space, and current health condition contributed statistically significantly to lower mental health in our study sample. Women had lower mental health than men in this study, which is in line with other COVID-19 studies of mental health in women [12, 18, 19, 21]. Females’ sense of identity in activities is more affected by the social connections formed rather than by other aspects in the activity setting . Women seem to attach more meaning to social activities and these could hardly or no longer be carried out during COVID-19 lockdown while men attach more meaning to physical activities that could still be performed during the lockdown. Moreover, the care and household tasks, in which women are more active usually, interfered much more with the other activities than usual. In Belgium, parenting adults could request corona leave to manage the care of the (home-schooled) children. Seventy-five percent of the parents who claimed the leave appeared to be women . In general, women were found more susceptible to mental related symptoms than men because they show greater emotional responses . It can be concluded that women were found to be slightly more vulnerable in mental health than men.
It seems that being married in COVID-19 helped to have better mental health. There is a considerable amount of evidence showing that married people have better mental health than never-married and divorced people [82, 83]. It can be explained by the importance of satisfaction and support associated with such a dedicated relationship . Our study results suggest that living alone can cause lower mental health in the COVID-19 crisis compared to adults who are widows or living together. Previous research confirmed that living with a partner is a protective factor for general psychiatric disorders during the COVID-19 crisis .
Next, our study results demonstrated that chronically ill adults need to have specific attention in this study. They are less affected in mental health during the COVID-19 lockdown compared to mentally and acutely ill adults. Moreover, it is remarkable that chronically ill persons even did not differ statistically significantly from healthy people. They may have been better able to adapt to the changing situation in COVID-19 lockdown because they already experienced a loss of activity and prolonged isolation due to their illness and may therefore be better able to cope with this crisis [85, 86].
To our knowledge, living space is not yet described in the COVID-19 literature as a contributor to mental health. During the COVID-19 lockdown, the strict measures prohibited outdoor activities. People only could leave the house to provide for the necessities of life or to go working if telework was not possible. People who lived in a house with a garden or in an apartment with a balcony, could go outside and perform some physical or psychological activities in the garden or on the balcony. It is already proven that (physical) activities in outdoor space protect against mental health problems and restricted access is likely to have negative implications for mental health [87–95]. People who had not the possibility to go outside their house (e.g. no garden or balcony) might have experienced deprivation and this could cause the lower mental health we found in this study. Similar results were found in an epidemiological study where the type of housing children inhabit alters mental health correlates . High-rise, multiple dwelling units are inimical to the mental health of mothers with young children because of the social isolation and restricted play opportunities for children . A London study in low-income housing areas showed that having less access to private gardens is associated with a higher prevalence of depression .
Even though we found a statistically significant bivariate association between living area (rural living versus urban living) and mental health in our study sample of adults, living area was not a significant contributor for mental health in the multivariate analysis. This suggests that its explanatory power with regard to one’s mental health is limited compared to the other included predictors. Living in a rural area gave better mental health during COVID-19 lockdown than living in an urban area according to the study results. Living in a rural area gives opportunities to take long walks outdoors, being in nature, which positively promotes mental health [87–95]. However, this is contradicted in the study of Summer-Gabr  in the United States, where living in urban areas appeared to show better mental health than people living in rural areas due to better access to health care and mental health services. We speculate that the meaning and potential impact of a variable such as living area on one’s mental health might be weakened in our study as Belgium is a very small country in which the difference between rural and urban areas is less manifest. This implies that other factors, such as resilience and one's engagement in meaningful activities, might influence one's mental health stronger.
Finally, participants without children had lower mental health than adults with children. This is contrary to what the current literature stated. A national COVID-19 study in de US explained the low mental health in parents by the fact that parents reported worsening behavioural health for their children . Unstable financial circumstances, school closure, suspended educational services for children may underlie low mental health in parents . Our contrary results could be due to the fact that most of the participants who did not have children in our study, were students.
An unexpected result is that work status was not significantly associated with mental health in the multivariate analysis, despite their bivariate association. COVID-19 studies showed already that unemployed adults and students have more chance to be exposed to mental health problems [18, 66]. Similarly, in our study students reported lower mental health compared to employed and non-employed adults and the latter two groups did not differ substantially regarding their mental health. These results might reflect that students are a vulnerable subgroup during COVID-19 lockdown. Alternatively, employment, like we measured in our study, might be a too generic variable that neglects the type of job one performs or its job characteristics. It might be that one's mental health is more influenced by the extent of remote working and its interference with one's daily functioning at home.
Remarkably, educational level was not significantly related to mental health in our study. This contradicts previous studies that showed that people with higher degrees (above bachelor’s level) experienced an increase in mental health problems at the time of the pandemic [25, 67]. Probably our result might be due to range restriction, as indeed the majority (76.6%) of our participants held a higher educational degree (High school or University).
Nevertheless, our study demonstrated that maintaining or reconstructing meaningful activities in people during the COVID-19 pandemic seems to be an important pathway to reconstruct a meaningful life in the context of profound disruption . Improving awareness among people and authorities of the importance of meaningful activities in daily lives might lead to more widespread recognition of the potentially detrimental effects of activity disruption and deprivation when these occur  and the appreciation of people’s participation in meaningful activities.
The impact that isolation and lockdown due to COVID-19 have on people’s ability to achieve a sense of occupational balance, defined as a balance of engagement in occupations that leads to well-being , is alarming. Consequently, occupational therapists have a critical role to play in helping people respond to the COVID-19 pandemic . Profession leaders have articulated the relevance of our profession in supporting mental health and wellbeing in populations worldwide [100, 104, 105]. Occupational therapists already learned a lot from their clients about how everyday lives might be rebuilt within constraining parameters out of the control of the clients. Our unique occupational focus can be central in identifying new and creative solutions in response to the unprecedented and challenging COVID-19 crisis. Occupational therapists have the right knowledge and the creativity to respond to the massive impact of the COVID-19 pandemic on our clients and the general population including mental health . Providing meaningful activities during social lockdown is an important point of attention that, in addition to health and economic aspects, should be taken into account when deciding on measures concerning COVID-19.
To our knowledge, this is one of the first national sample studies that considered a comprehensive set of factors that might contribute to adults’ mental health, and in particular, identified meaningful activities as a plausible key predictor of one’s mental health.