Quality of life and anxiety in an underdeveloped city in IRAN during the COVID-19 pandemic: a cross-sectional study

doi:10.21203/rs.3.rs-2214514/v2

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Quality of life and anxiety in an underdeveloped city in IRAN during the COVID-19 pandemic: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-2214514/v2

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Purpose: Studies have widely explored the quality of life in wealthy communities during the COVID-19 pandemic; the present study selected the earthquake-prone and underdeveloped city, of Zarand (Iran) to examine the quality of life and anxiety.

Methods: 291 patients who were infected with COVID-19 in the last 14 days were included in the study. They were selected using systematic non-random sampling. The quality of life and anxiety of the participants were evaluated using the online WHO-Quality of Life-BREF and Beck Anxiety Inventory (BAI) respectively. The analysis was not limited to the significance and also included the effect size. Data were analyzed by SPSS software version 26 using Spearman's correlation, T-test, and Kruskal-Wallis.

Results: The quality of life scores were less than 50 out of 100 on average. 58% of patients reported moderate to severe anxiety and there was a negative correlation between all of the four physical(P value<0.001), psychological(P value<0.001), social(P value<0.007), and environmental(P value<0.001) domains of quality of life and anxiety, respectively. Education and quality of life were positively correlated in all domains except for the environmental domain. Participants' age ranged from 18 to 58 and the correlation between age and the physical and psychological domain was significant. No significant correlation was found between the quality of life, sex, and marital status.

Conclusions: The current study provides evidence of low Quality of life and high levels of anxiety in patients who experienced COVID-19. This implicates immediate considerations to be taken into account by policymakers and officials.

Quality of life

COVID-19

Underdeveloped

Beck Anxiety Inventory (BAI)

WHOQOL-BREF

Quality of life can be considered a subjective and multidimensional concept that emphasizes the individual's perception of his current situation. Although it is not possible to provide a specific definition of quality of life, many studies believe that this definition includes the social, psychological, and health status of people[1]. WHO defines Quality of Life as an individual's perception of their position in life in the context of the culture and value systems in which they live and concerning their goals, expectations, standards, and concerns[2]. The covid-19 pandemic, which first started in December 2019 has since then been a health emergency with dramatic consequences worldwide[3-6]; Its first confirmed cases were in Feb 2020 in Iran[7]. The covid-19 pandemic not only affects physical health but also well-being and other aspects of life[8]; it led to psychological distress (anxiety, depression)[9-10], social distancing, lockdown of non-essential services and schools, quarantine, and economic challenges (due to lockdown)[11]. Various studies in different settings have shown that the COVID-19 pandemic has impacted the quality of life[12-16].

Quality of life is related to mental health so anxiety and depression directly have a negative effect on the quality of life[17]. Anxiety appears as a future-oriented mood state, which includes a complex cognitive, emotional, physiological, and behavioral reaction system formed by preparation for anticipated events or situations perceived as threats. Pathological anxiety occurs when there is an overestimation of the perceived threat or a misappraisal of the danger of a situation, leading to excessive and inappropriate responses[18]. Recent studies have shown that the Covid-19 outbreak has caused mental health problems for people[19]. One recent study has shown that during the strict quarantine measurements by the Chinese government, people experienced mental health distresses such as depression and anxiety, and more than half of the people reported a moderate to a high level of anxiety[20].

In the growing trend of multidimensional problems related to the covid-19 pandemic, causing six outbreaks – and probably causing more outbreaks – the quality of life is now closely related to covid-19[21]. Zarand city is considered one of the relatively underprivileged areas in terms of infrastructure, recreation, economy, and health facilities; which receives government allocations to improve inequality. Being located in the Alpine-Himalayan orogenic belt, Zarand has suffered earthquakes (most devastating: 2005), so far, no studies have been conducted in the field of quality of life and its indicators in times of crisis in this city. Such studies may facilitate policymakers in terms of planning and providing to improve the quality of life of people in crisis.

The purpose of the present study was to measure the quality of life and anxiety in Zarand city during the covid-19 outbreak and probe the relationship between the quality of life and anxiety. The results of this study facilitate the designing and planning of better local policies. Also, this study will provide a basis for further studies in this area.

Methods :

This study was conducted between February 23, 2022, and March 15, 2022, in Zarand city. The inclusion criteria for this study included the age of 18 years or older, the ability to self-report by completing an online questionnaire, being a resident of Zarand city, and having contracted covid-19 infection approved with laboratory testing in the last 14 days; the exclusion criteria included age less than 18 years, missing data, covid-19 infection not approved by laboratory tests and/or covid-19 test reported more than 14 days before participation. Participants were selected using systematic non-random sampling and filled out the questionnaire. The questionnaire link was created in “Google Forms” and spread on social media platforms (Telegram groups, Telegram channels, WhatsApp groups, and Instagram accounts).

Measurements:

Study participants were examined by WHOQOL-BREF[22], Beck anxiety inventory (BAI) [23], and demographic (Age, sex, educational level, and marital status) standard structured online questionnaires in Zarand. The WHOQOL-BREF is a 26-item instrument consisting of four domains: Physical (7 items), psychological domain (6 items), social domain (3 items), and environmental domain (8 items); it also contains QoL and general health items which are not in the scope of our study. WHOQOL-BREF is based on the Likert scale. The raw scores are then transformed linearly to a 0–100-scale. The structural factors of this tool have acceptable validity and reliability in Iran[22]. The level of anxiety was measured using valid translations of the Beck anxiety inventory (BAI). The Beck Anxiety Inventory is a self-reporting instrument used in the general and diseased population. The total score of the questionnaire (containing 21 statements, each scored by a value ranging from 0 to 3) ranged from 0 to 63. In Iran, the validity and reliability of BAI are 72% and 83%, respectively. The score ranges for different levels of anxiety were normal (0 to 7), mild (8 to 15), moderate (16 to 25), and severe (26 to 63)[23].

Statistical Analysis:

IBM SPSS ver. 26 was used for statistical analysis.
Spearman's correlation was performed to measure the correlation between the WHO-Qol-BREF and BAI, age, and educational level. Spearman's correlation shows the significance of correlation (p-value) and correlation coefficient (ρ; the degree two variables are dependent).
The independent T-test for the mean difference was implemented for the sex group. The independent T-test shows the significance of the mean difference (p-value) between the two sex groups (male and female) but does not measure the effect size; Therefore, Cohen's d is measured in case of a significant mean difference. The independent T-test has the assumption of normality of distribution, which is a large sample size (n > 30) and is considered normally distributed even if the quantitative Kolmogorov-Smirnov normality test is violated.
Kruskal-Wallis (Also known as, one-way ANOVA on ranks) was used to measure the mean difference in WHO-QoL-BREF score between the three groups of marital status. In case of small sample size (n < 30) and violation of the Kolmogorov-Smirnov normality test, the ANOVA test is not appropriate and the Kruskal-Wallis test should be used.

Ethical consideration:

This study is approved by the ethical committee of the Shahid Beheshti University of Medical Sciences (IR.SBMU.RETECH.REC.1400.939). The purpose of the research was explained to all participants before opening the link and Their willingness to participate in the study was asked at the beginning of the questionnaire. They were assured about the confidentiality of their information would and the anonymous publication of results. They were also assured that their refusal to participate in the study would not affect their treatment.

Out of 304 participants, we excluded four missing data and nine participants under eighteen years old; Finally, a sample of 291 was analyzed. The age of participants ranged from 18-58 with a mean (SD) of 36.48 (9.96). Participants’ sex was dominated by females 227 (78.0%). The marital status included 246 (84.5%) married, 42 (14.4%) single, and 3 (1.0%) divorced/widowed participants. 174 (59.8%) had an educational level higher than a Bachelor's degree. (Table 1)

QoL and BAI scores:

58.8% of our sample reported moderate and severe anxiety levels. Only 17.5% reported a minimal anxiety level. In the QoL questionnaire, on average the scores in all QoL domains were lower than 50 out of 100; the lowest mean was for the social domain of QoL. (Table 1)

*Table 1.*; Frequency, percentage, the mean and standard deviation of demographics and questionnaire results.
		N	N%	Mean	SD
Sex	Male	64	22.0%
	Female	227	78.0%
	Other	0	0.0%
Educational level	No highschool diploma	5	1.7%
	Highschool diploma	70	24.1%
	Associate degree	42	14.4%
	Bachelor's degree	139	47.8%
	Master's degree	31	10.7%
	Doctorate or higher	4	1.4%
Marital Status	Single	42	14.4%
	Married	246	84.5%
	Divorced/Widowed	3	1.0%
Beck Anxiety Inventory	Minimal	51	17.5%
	Mild	69	23.7%
	Moderate	77	26.5%
	Severe	94	32.3%
Age (years)				36.48	9.96
The physical domain of QoL Score				40.66	19.56
The psychological domain of QoL Score				38.47	18.04
The social domain of QoL Score				38.03	21.97
The environmental domain of QoL Score				48.39	17.55
N: Number of cases; N%: Number of cases by percentage; SD: Standard deviation; QoL: Quality of life.

QoL descriptive by demographics and BAI:

Men reported lower mean scores in physical and psychological domains and higher scores in social and environmental domains. We observed an upward trend between QoL and educational level; although participants in the “no high school diploma” opposite this trend, the group size are only 5 (Table 1). In marital status, the divorced/widowed group scored lower in all domains except for the environmental domain. A consistently downward trend was reported between all of the QoL domains and BAI with the minimal anxiety group showing the best QoL score on average. Table 2 and Figure 1 summarize the results of WHOQOL-BREF grouped by BAI, education, status, and sex.
Figure 2 shows a scatter plot of WHOQOL-BREF and age with an upward trend between the two.

*Table 2.*; WHOQOL-BREF QoL domains results grouped by demographics and BAI results.
		Physical		Psychological		Social		Environmental
		Mean	SD	Mean	SD	Mean	SD	Mean	SD
Sex	Male	44.75	19.15	41.80	19.29	36.98	24.93	44.63	19.65
Sex	Female	39.51	19.56	37.54	17.60	38.33	21.11	49.45	16.80
Educational level	No highschool diploma	52.86	26.77	56.67	23.68	51.67	35.06	58.13	21.72
	Highschool diploma	39.03	19.36	33.75	17.91	32.50	23.58	45.89	17.37
	Associate degree	37.24	16.98	36.11	16.19	35.32	18.66	46.13	17.11
	Bachelor's degree	40.29	20.27	39.72	18.53	39.15	21.41	49.89	17.55
	Master's degree	46.43	18.28	42.47	14.69	45.16	19.81	48.29	18.47
	Doctorate or higher	58.04	4.49	48.96	16.09	52.08	21.92	52.34	10.33
Marital Status	Single	42.09	15.79	36.61	16.53	39.48	22.55	47.25	18.11
	Married	40.48	20.26	38.89	18.37	37.87	21.96	48.59	17.52
	Divorced/Widowed	35.71	6.19	30.56	8.67	30.56	19.25	47.92	17.21
Beck Anxiety Inventory	Minimal	57.42	19.59	48.28	21.49	46.57	28.19	53.62	19.46
	Mild	42.39	17.52	40.76	16.06	36.71	20.97	49.37	16.04
	Moderate	41.23	15.02	40.21	13.50	39.39	18.96	49.31	16.04
	Severe	29.83	17.41	30.05	17.27	33.24	19.91	44.08	17.97
QoL: Quality of life; SD: Standard deviation.

Statistical tests, effect size, and correlations:

T-tests for gender showed no significant mean difference in physical (p=0.058), psychological (p=0.095), social (p=0.666), and environmental (p=0.077).

Kruskal-Wallis for QoL domains and marital status (p values were 0.858, 0.476, 0.798, 0.978 for physical, psychological, social, and environmental domains respectively) showed no significant mean difference between single, married, and divorced participants in quality of life in all domains.

The spearman's test showed a significant and moderate correlation between physical and psychological domains and beck anxiety inventory score but a weak between physical and psychological domain and age; a Significant but weak correlation between social and environmental domains and anxiety; a Significant but weak correlation between physical, psychological and social domain and education level.
Spearman's results are summarized in Table 3.

*Table 3.*; Correlations and T-tests for QoL results grouped by demographics and BAI results.
			Physical	Psychological	Social	Environmental
Spearman's rho	Age (years)	ρ (rho)	0.144^*	0.148^*	-0.003	0.095
	Age (years)	P value	0.014	0.012	0.957	0.108
	Educational level	ρ (rho)	0.124^*	0.141^*	0.177^*	0.077
	Educational level	P value	0.035	0.016	0.002	0.193
	BAI	ρ (rho)	- 0.439^*	- 0.322^*	- 0.157^*	- 0.194^*
	BAI	P value	< 0.001	< 0.001	0.007	0.001
Kruskal-Wallis	Marital Status	P value	0.858	0.476	0.798	0.978
T-Test	Sex	P value	0.058	0.095	0.666	0.077
*: Correlation is significant; QoL: Quality of life.

We discuss the results in five separate sections: COVID-19, Anxiety, Age, Education, and Sex.

COVID-19:

Our study does not aim to measure the impact of covid-19 infection and pandemics on the QoL, as it is an aiming to measure the QoL of residents of Zarand city infected with the disease. A city with an underprivileged background and a history of natural disasters. Yet, we can mention how the anxiety during covid-19 might have impaired the QoL when compared to previous findings before the pandemic.

The COVID-19 pandemic has led to the loss in Iran until the date of this study and many are infected by the disease[24]. We will discuss the effect of anxiety caused by the COVID-19 pandemic further. Studies have hypothesized the possibility of COVID-19 independently causing depression, anxiety, and sleep problems[25-26]_.

In the physical domain, COVID-19 is primarily an upper respiratory infection but lower respiratory infection, pneumonia, gastrointestinal infection, fatigability, pain, fever, decreased daily activity capacity, and other complaints are also reported[27]. These complaints can potentially affect the physical domain of QoL of our participants (our participants had COVID-19 infection - confirmed by the laboratory test - in two weeks when filling out the questionnaire).

People in Zarand are closely connected and social ties are valued in the culture. Iranian ministry of health defined a color map based on the COVID-19 outbreak and cities with red COVID-19 status were subject to lockdown and quarantine. Social distancing can impact the QoL in the social domain[28] especially since interpersonal dependability is valued in Zarand. COVID-19-infected patients were subject to two weeks of quarantine.

The WHOQOL-BREF covers questions on the environmental domain of QoL. Questions number eight (freedom, physical safety, and security) and fourteen (access to recreation and leisure activities) are likely to be affected by COVID-19. Lockdowns, losing jobs, bankruptcy, and inflation resulted in financial difficulties during COVID-19[29]. Access to transportation was also restricted by the government (question number twenty-five).

Anxiety:

We found that anxiety level is correlated with lowered quality of life in COVID-19 infected population. The higher anxiety led to a lower level of quality of life. The spearman's test proved the correlation significant in all domains with an effect size of moderate between anxiety and physical and psychological domains of QoL and a small effect size between anxiety and social and environmental domains. (See Fig1, Table3.) Lee et al.'s found anxiety is related to all dimensions of quality of life[30], although did not find Patrick J. Brown et al. the relationship between anxiety and QoL in the environmental domain[31].

58.8% of our participants reported moderate or severe levels of anxiety which we believe indicates a high prevalence of anxiety symptoms in the COVID-19-infected population of Zarand city.

Anxiety disorders are psychological diagnoses and disorders manifesting as excessive worries, irritability, fatigue, and sleep problems[32]. The fear of infection and death has led to reporting of worries and anxiety complaints. Being worried about themselves and their loved ones, COVID-19 might potentially downgrade the QoL scores. We proposed more explanations on how COVID-19 might have impacted the quality of life in the first paragraph of the discussion section.

Age:

We found a positive and significant correlation between the age variable and the physical and psychological domains of quality of life, but it is so weak that it can be ignored. Patrick J. Brown et al. found that increasing age does not always mean a decrease in the quality of life and this applies to the psychological, social, and environmental areas, but the physical quality of life decreases with increasing age[31]. The results of the study by Thadathil et al. on 220 adults over 60 years of age have also shown that physical quality of life decreases with age[33]. Probably, one of the reasons for the discrepancy of the results of other studies compared to our research is that our participants aged from 18 to 58 years, yet diseases are more prevalent in ages above 60, which further impairs QoL.

Education:

In addition, the results of our research showed that there is a positive, meaningful, and weak correlation between education level and the physical, psychological, and social domains of the QoL. Our findings are consistent with M. Gil-Lacruz et al. and F.Purba et al^. showed higher education, and higher quality of life[34-35].

The level of education is a determinant of QoL. Recent research shows that people with lower education suffer from a shortage of skills and face a greater risk of job loss, financial challenges, and troubled social life[36]. Furthermore, the evidence indicates that education is an important predictor of health status, employment, decision-making, problem-solving, and critical thinking[37]. All of these highlights the important role of education in QoL.

Sex:

Although the studies of M.Gil-Lacruz, F.Purba, Jinzhuo Hu, et al., reported that women have a lower quality of life than men[34-35,38], we found that there is no significant difference in the QoL between the sexes, In contrast to previous research. The reason might be that traditionally in Zarand men are more socially involved and women's roles and social activities are limited to the families. Men are also the main source of income in families. This means that covid-19 may have affected the life of men more than women because the role of men is further limited than that of women which were limited even before the pandemic. Yet, there is a limitation in the distribution of sexes in our study. Participants are dominated by women (78% vs 22%, table1) which even with the statistical correction may still bias the analysis.

Limitations:

Considering that in cross-sectional studies, specific results may be observed depending on the specific period in which the research is conducted, these types of studies cannot show the continuity of effects of the covid-19 epidemic on various aspects of people's quality of life. It is suggested that in the future, longitudinal studies should also investigate the relationship between anxiety and quality of life and compare the results with cross-sectional studies. Although online surveys were the best method of data collection during the covid-19 epidemic due to the lockdown, the findings may be biased due to restricted access to questionnaires. Participants were between 18 and 58 years old, and older people did not participate in this research which may be due to limitations in affording smartphones and internet plans, and general and digital illiteracy; so it is suggested that the research In the future, attention should be paid to the presence of older people in the research and investigation of the desired indicators. Regardless of age, our study missed populations in the lower social class who can afford smartphones and internet plans; there are no exact estimates on the number of the missed population but their non-attendance may affect the result, though not significantly.

Despite some limitations of online studies, the findings of our research can provide a perspective on the psychological effects of the covid-19 pandemic on the quality of life and related factors.

The other limitation is that the sex of our participants is dominated by females (Females 58% vs. Males 22%), Although statistical tests are designed to minimize bias still findings can skew as a result of unequal participation by the sexes.

Our study showed 58.8% of our participants reported moderate or severe levels of anxiety which we believe indicates a high prevalence of anxiety symptoms in a covid-19 infected population of Zarand city; we suggest further studies with bigger sample size and more diversity in Zarand. We also believe affordable psycho-social support interventions should be provided by policymakers and local officials.

QoL: Quality of Life

BAI: Beck Anxiety Inventory

SD: Standard Deviation

WHO: World Health Organization

Acknowledgment:

We thank Dr.Mahnaz Hejazi-Shirmard, assistant professor of occupational therapy at Shahid Beheshti University of Medical Sciences, and Erfan Arabpour Medical student at Shahid Beheshti University of Medical Sciences for supporting this research.

Funding

This study was supported by the Shahid Beheshti University of Medical Sciences.

Competing interests

The authors declare that they have no competing interests.

Authors contributions

The initial conceptualization and design of the research were done by AAD, MA, and NMA.AAD and MA participated in the design of the questionnaire. MA and AAD extracted patients’ contact information and completed questionnaires. MA collected the information and entered it into the statistical software. MA analyzed the data. All authors were involved in writing the article. The authors read and approved the final manuscript.

Ethics approval

This article was approved by the ethics committee of the Shahid Beheshti University of Medical Sciences, under number IR.SBMU.RETECH.REC.1400.939.

Consent to participate

Informed consent was obtained from all individual participants in the study.

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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Quality of life and anxiety in an underdeveloped city in IRAN during the COVID-19 pandemic: a cross-sectional study

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