This study shed light on the combined effects of the current economic crisis and COVID-19 pandemic on the MWB in the general population in Lebanon. It showed that during the pandemic, economic and other factors, directly or indirectly related to COVID-19, significantly affected MWB of the general population. However, fear of COVID-19 lost its significance in the workers’ group, who reported that the main factors negatively affecting their MWB were those directly related to their employment status and the already collapsing Lebanese economy. In all groups, individuals with a more favourable financial status seemed to be at lower risk of being affected by both the pandemic and the economic situation, since the IFDFW scores were positively correlated with a better MWB.
In the current context, fear of poverty is illustrated by the subjective economic assessment, showing a significant shift towards low and below poverty classes, thereby revealing the direct impact of difficult financial situations on their MWB. Prior to the COVID-19 outbreak, the World Bank had forecasted that by 2020, the proportion of Lebanese below the poverty line would increase from 30 to 50%.35
Regarding the workers’ group, individuals owning their businesses before the crisis, working from home since the beginning of the economic crisis, and worrying about the long-term effect of the crisis on their employment status experienced the worst MWB. The main impact was directly related to worrying about their work: those who worked remotely from home feared a wage cut-down or even dismissal if the situation persisted. Business owners feared a complete collapse in income, in the absence of governmental financial support, since budgetary policies are lacking in Lebanon.36
Although “economic damage” can only be assessed when the pandemic subsides,37 financial loss creates long-lasting socioeconomic distress with anger and anxiety that can last months after the pandemic. A recent report from the World Bank pointed out a substantial impact of COVID-19 on the Lebanese economy (11% decrease in GDP), especially with uncertainties about the duration of the pandemic and the drastic changes in the financial system.36 In such a vulnerable system, workers were highly preoccupied with the wilting economy and outcomes of lockdown on their employment rather than fearing the virus itself.
In contrast, unemployed respondents (retired, students, and housewives) worried about contracting the virus and not being able to afford the treatment. Our results are different from those reported in China, where the helplessness feeling of participants was low, although more than half of them declared feeling horrified and apprehensive because of the COVID-19 pandemic.38 A possible explanation is that China being the world’s second-largest economy, people can afford to stop working and rest during the lockdown, without their MWB being affected.38
Another significant aspect is the level of education. Our results showed that the higher the level of education, the lower the MWB. This outcome is not surprising since being unable to plan, face unforeseen expenses, and overcome any sudden deterioration in people's economic environment has an impact on their MWB.11 Therefore, in our study, participants holding university degrees might have felt deceived and worried about their future in Lebanon due to the current challenging context.
In addition to the economic factors, our results showed that some sociodemographic factors also affected the MWB of Lebanese people; lower MWB was associated with the female gender, having a chronic disease, and experiencing verbal violence at home, whereas a better family satisfaction was correlated with a better MWB. These associations can be explained by homeschooling led by mothers39 and forced confinement with a violent partner,40 while family support improves MWB.38 A recent systematic review evaluating the impact of the COVID-19 pandemic on mental health outcomes, including MWB, concluded that a lower psychological well-being was noted among females and those who self-reported a poor health.15 In fact, vulnerable people, particularly those with chronic diseases, require special attention. Around 20% of our respondents had a chronic disease and exhibited a lower MWB in the whole group and the workers’ subgroup. Lebanon has high percentages of vulnerable populations, such as elderly,41 and chronic diseases,42-44 considered at higher risk for COVID-19 and lower MWB.15,45 Reasons in this context could include panic due unreliable information for patients,46 especially in an era of massive misinformation in the media,47,48 added to the economic situation itself. Furthermore, the healthcare system in Lebanon is mainly private,49 while 10.5% of our population reported not having any health coverage. Consequently, patients with chronic diseases might fear not being able to afford medications and medical care, especially with the significant drop in the sizes of the rich and middle classes, in favour of a significant increase in poor and below poverty classes, as demonstrated by our results.
Finally, only in the workers’ group, current smoking status was significantly associated with better MWB versus previous smokers. It is noteworthy that in Lebanon, behavioural/motivational factors for smoking cessation are mainly driven by health-related issues. Thus, this particular population of “previous smokers” might be at higher risk of vulnerability and chronic diseases (including pulmonary diseases), exposing them to lower MWB scores.50 The positive correlation among current waterpipe smokers (regular and occasional) might seem surprising since tobacco exposure is known to be a major risk factor for decreased MWB.51 However, smokers might have felt some relief reducing their stress and anxiety towards hardship, through the already known “self-medication” hypothesis of smoking, postulating that individuals turn towards smoking to cope with stress and alleviate their depression and anxiety symptoms;52-54 this is added to the specificities of waterpipe smoking (positive and negative reinforcement, social aspect and conviviality).50,54
Our study also revealed the beneficial effects of physical activity/exercise on overall MWB, particularly in the subgroup of workers, with almost 30% of them reporting an increase in the time allocated for exercise. Several reports have been published recently regarding the importance of physical exercise as a therapy to fight the mental and physical consequences of COVID-19 lockdown.55,56 Physical activity and exercise help also maintain immune system function in the current precarious environment and are particularly recommended in vulnerable populations such as those with chronic diseases57 who scored a lower MWB in our study.
Overall, these results are compatible with the Biopsychosocial model that we had used to generate the hypotheses and build the questionnaire, and Lebanese mental wellbeing was related to biological characteristics (chronic disease and family history of COVID-19), behavioural/psychological factors (health beliefs such as the fear of COVID-19), and social conditions (family relationships, education, economic status and social support).27
Limitations and strengths
Some limitations could be noted in our study. Although our sample was weighted for gender, age, and regions, it mainly consisted of people with a university level of education with high computer literacy; thus, our results might not be generalized to the whole population. This outcome was expected since the survey used was online, and only computer literate people with Internet access were able to participate. However, this selection bias is not expected to affect the associations found in the multivariable analysis since the education factor was taken into account as a potential confounder, and all results were adjusted over the education factor. Moreover, although the questionnaire was piloted to improve its clarity, there is a probability of information bias, since the questionnaire was self-administered online, with no possibility to explain confusing questions to respondents, if any; however, the use of an online questionnaire is expected to decrease the subjectivity related to interviews. Furthermore, recalling difficulty and subjectivity bias related to some questions are also plausible. In all cases, the non-differential information bias would drive the results towards the null hypothesis, thus underestimating the real associations. An additional potential bias would be the residual confounding since not all confounders could be measured.
Nevertheless, and despite these limitations, to the best of our knowledge, this is the largest (sample size large enough to account for statistical power of main comparisons) and the first study evaluating the combined effect of the COVID-19 pandemic and the economic crisis on the MWB in the general population. Moreover, a standardized questionnaire with validated scales was used to evaluate MWB, economy or COVID-19-related factors. Finally, our study pilot-tested the validity of the questionnaires, and all used scales have shown very good to excellent reliability.
Clinical implications
In light of all these challenges, the Lebanese government should implement a reliable crisis management strategy that outlines stabilization and recovery measures to help people navigate through this period with minimal impact on mental, physical, and overall quality of life 2,58.
Several useful tips could also be applied to manage COVID-19 parenting challenges. In that context, the United Nations Children’s Fund (UNICEF) published an article with a list of expert tips to help parents well interact with their children and families during this period 59. Some of these tips are of particular interest in our population since they help parents, and women, in particular, cope with the financial stress, and involve children and teens in organizing family budgets. Such an approach would alleviate the tension within the family and build a model of “peaceful and loving relationships” where children feel more secure and loved 59.
Moreover, it is of paramount importance to promote strategies aiming at improving mental well-being of patients with chronic diseases. Such strategies would include measures to protect them against the COVID-19, educate them on the importance of communicating with their healthcare providers and adhering to treatments, in addition to developing strategies for telemedicine and remote consultation if the lockdown persists 60. Specific recommendations have already been developed in Lebanon for the geriatric population 46 and cancer patients 61-63, even if their implementation could face obstacles due to the reluctance of patients to change 64.
Finally, this period could be the opportune moment to quit smoking 65,66, especially in a country reporting the highest smoking rates (waterpipe/cigarette) in the Middle East; people should be encouraged to overcome their boredom by choosing “healthier” options such as physical exercise. However, it is imperative to ensure that safety precautions are followed to reduce the risk of spreading the infection and preferably exercise at home 55,57.