The impact of psychosocial factors on depression among individuals Quarantined during COVID-19:  Analysis of the 2020 korean community health survey

doi:10.21203/rs.3.rs-3568079/v1

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Research Article

The impact of psychosocial factors on depression among individuals Quarantined during COVID-19: Analysis of the 2020 korean community health survey

https://doi.org/10.21203/rs.3.rs-3568079/v1

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Purpose

The experience of quarantine due to COVID-19 has significantly affected people's mental health. This study aims to explore the relationship between psychosocial factors associated with COVID-19 and depression among adults who have experienced quarantine.

Methods

This study used the data from the 2020 Community Health Survey, and examined 780 individuals who experienced quarantine owing to COVID-19. This study investigated the impact of subjective health status, life changes owing to COVID-19, fear of COVID-19, institutional trust, and interpersonal trust on the depressive symptoms.

Results

According to multilevel regression analysis, age, subjective health status, life changes owing to COVID-19, fear of COVID-19, and interpersonal trust are significant predictors of depressive symptoms among isolated individuals.

Conclusions

The findings provide insights on various psychosocial variables significantly affecting depression among individuals who were quarantined owing to COVID-19. The results of this study contribute to establishing an effective support system for managing and preventing depression among isolated individuals in similar infectious disease outbreak situations in the future.

COVID-19

Quarantine

Depression

Big data

The COVID-19 pandemic has brought several changes and has negatively impacted the mental health of individuals, including the development of depression [1]. According to the National Mental Health Survey for the first quarter of 2021 [2], 22.8% of the population was at risk of developing depression. Research on depression, through meta-analysis, during the COVID-19 outbreak reported a prevalence rate of 25%, which was significantly higher than the global prevalence rate of depression of 3.44% before the spread of COVID-19 in 2017 [3].

COVID-19 primarily spreads through respiratory droplets of infected individuals. Given its potent transmissibility, South Korea initially isolated COVID-19 patients in self-quarantine in medical facilities or separate spaces during the early stages of the pandemic [4]. Patients and individuals in quarantine are defined as those who are experiencing isolation in accordance with national policy to treat symptoms of infectious diseases and prevent further spread. The experience of quarantine causes feelings of isolation, shock, exclusion and discrimination owing to being infected, guilt toward family and acquaintances, symptoms after recovery, and financial difficulties owing to leave of absence and loss of income [5–8]. Individuals in self-quarantine also experience changes in daily life, disruption of personal and social relationships, worries about their own and family’s health, and feelings of guilt [9]. According to a meta-analysis study, 38.8% of quarantined patients in China reported symptoms of depression during the COVID-19 period [10]. A longitudinal study, conducted in the UK after isolation, reported that 25.1% of individuals experienced moderate to severe depression [11]. In South Korea, 8.5% of individuals in self-quarantine reported experiencing symptoms of depression [12].

The experience of infection and quarantine owing to acute infectious diseases have a long-term impact on depression, even after quarantine is lifted. This long-term effect was observed by depression either gradually decreasing or remaining stable after the quarantine had ended [11, 13]. According to meta-analysis studies, 10.5% of individuals reported symptoms of depression in the post-disease phase of Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) [14].

In previous studies, subjective health status has been identified as a variable closely related to mental health states, such as depression and anxiety [15]. Subjective health status, in the context of COVID-19 is also significantly associated with depression [16, 17]. Research in China on COVID-19 has shown that groups with lower perceived health levels have higher levels of depression [18].

Owing to COVID-19, the public has experienced changes in daily lives, including social distancing to curb the spread of COVID-19, mandatory mask-wearing, cancellation of personal and public schedules, and difficulties in accessing hospitals. According to previous studies, changes in daily life, caused by emerging infectious diseases, can induce stress, depression, and anxiety in individuals [19–21]. The economic downturn resulting from measures against the COVID-19 pandemic, also significantly impacted depression. According to a study in Spain, economic recessions are associated with high levels of depressive symptoms [22], and several studies revealed a positive correlation between financial difficulties owing to acute infectious diseases and depression [23, 24].

If perceived stress, changes in daily life, and COVID-19 fear among individuals who experienced quarantine owing to COVID-19 are major risk factors for depression related to COVID-19, then institutional trust and interpersonal trust can serve as protective factors against depression. The uncertainty of situations owing to acute infectious diseases can negatively affect mental health as the personal, economic, and social consequences of physical health, quarantine, and infection are unclear [25, 26]. The reaction to COVID-19 takes place not just on a personal level, but also at the level of institutions, government included. Trust in the institutions responsible for managing COVID-19 can help reduce the stress arising from situations related to COVID-19. Institutional trust is defined as the belief that governments and public institutions have the ability, expertise, and knowledge to make the best decisions for the welfare of the public [27]. while interpersonal trust refers to the positive expectation that others do not harm them and contribute to overall welfare [28]. Public trust in institutions dealing with COVID-19 is negatively correlated with psychological distress, and reliable communication of COVID-19 infections and changing policies by the media can reduce individual depression [29]. Proper adherence to social distancing policies reduces contact between individuals, thereby reducing COVID-19 infection rates [30]. Therefore, if there is trust that those around are responding appropriately to COVID-19, the stress arising from COVID-19 decreases [31].

In the context of COVID-19, demographic variables related to depression can include sex, age, and home income. Several studies, examining the relationship between sex and depression in the context of COVID-19, have shown that women exhibit higher symptoms of depression than men [32–35]. Regarding the relationship between age and depression, younger individuals have shown higher symptoms of depression [29, 32, 36]. Additionally, previous studies have shown that lower income levels are associated with higher symptoms of depression [29, 32].

Most studies, validating the relationship between COVID-19 and depression, have been conducted on the general public [1]. While there exist studies on depression in individuals quarantined owing to COVID-19 [11, 37], there is limited literature reviewing depression persisting after experiencing quarantine owing to COVID-19, and these studies have not sufficiently considered the psychosocial factors. Considering that there is a higher risk of depression in the long-term after infectious diseases, such as SARS and MERS [14], it is important to identify the impact of psychosocial variables on depression in individuals who have been quarantined owing to COVID-19 and to explore protective factors that can reduce depression in these situations.

The objective of this study is to explore the influence of subjective health status, fear of COVID-19, and changes in daily life experienced by individuals after hospitalization and self-isolation owing to COVID-19 diagnosis on their depression levels during the pandemic. Furthermore, this study verifies the impact of institutional and interpersonal trust on depression in the context of the COVID-19 pandemic.

Survey and Participants

This study is a secondary analysis research, conducted after receiving approval for data request and writing a pledge regarding the use of raw data from the 2020 Community Health Survey (CHS), conducted by the Korea Disease Control and Prevention Agency. The CHS is an annual survey that is conducted nationwide by public health centers. The 2020 CHS was conducted from August 16 to October 31, 2020, targeting adults aged 19 and older, residing nationwide [38]. The survey was conducted through individual face-to-face interviews by trained investigators who visited households while adhering to pandemic prevention guidelines, and data were obtained through Computer Assisted Personal Interview. In this study, from a total of 229,269 data points from the 2020 CHS, only those with a diagnosis and who had been quarantined owing to COVID-19 were extracted for analysis, in line with the purpose of this study. After excluding missing and outlier values, a final total of 780 participants were analyzed (Table 1).

Table 1

Sociodemographic characteristics (N = 780)
Variable		N	%
Sex	Male	376	48.2
Sex	Female	404	51.8
Age(Year)	≤ 20	236	30.3
	30–39	155	19.9
	40–49	135	17.3
	50–59	115	14.7
	60–69	84	10.8
	≥ 70	55	7.1
Home income (monthly)	< 200	133	17.1
	≥ 200 to < 400	217	27.8
	≥ 400 to < 600	202	52.9
	≥ 600 to < 800	116	14.9
	≥ 800 to < 1000	51	6.5
	≥ 1000	61	7.5
Region	Urban	511	65.5
Region	Rural	269	34.5

Measures

Depression

Depression was measured using the Patient Health Questionnaire-9 (PHQ-9) [39]. This tool consists of nine items that measure how often respondents have experienced each problem over the past two weeks. The PHQ-9, a depression screening tool, was also used in the 2020 CHS. Respondents answered on a 4-point likert scale, ranging from 0 to 3 (where 0 = not at all, and 3 = nearly every day). The sum of the responses to the nine items ranges from 0 to 27 points, with scores of 9 or above indicating that individuals are experiencing symptoms of depression, with higher scores indicating higher levels of depression [40]. The Cronbach's alpha for the depression scale in this study was .810.

Subjective Health Status

Subjective health status was measured using an item from the 2020 CHS that asks respondents how they perceive their health. Respondents answered on a 5-point likert scale, ranging from 1 to 5 (where 1 = very good and 5 = very poor. Higher scores indicate a more negative perception of one’s health status.

Changes in Life Owing to COVID-19

The changes in daily life owing to COVID-19 were assessed using a question from the 2020 CHS. This question was designed to measure the extent of change in their lives the participants felt owing to the COVID-19 pandemic. The question was as follows: “If you consider your daily life status before the COVID-19 outbreak as 100 points and a complete halt of daily life as 0 points, how many points would you assign to your current status? Please mark a score between 0 and 100.” Participants responded on a 10-point likert scale ranging from 0 to 100. The scores were reverse-scored, meaning that a higher score indicated a greater change from life before the COVID-19 outbreak.

Fear of COVID-19

Fear of COVID-19 was measured using items from the 2020 CHS. Respondents were asked how worried they were about various aspects of the COVID-19 pandemic, including infection, death, blame from others, infection of vulnerable people, and economic damage. Each item was scored on a 5-point likert scale, with higher scores indicating greater fear levels. The Cronbach's alpha for the fear of COVID-19 in this study was .733.

Trust

Trust was measured using items from the 2020 CHS assessing trust in institutions and interpersonal trust during the COVID-19 pandemic. Institutional trust included trust in government agencies, provincial agencies, municipal agencies, the media, and healthcare institutions. Interpersonal trust was measured as trust in neighbors and coworkers. Each item was scored on a 5-point likert scale, with higher scores indicating higher trust. The Cronbach's alpha for institutional trust in this study was .859.

Statistical Analysis

First, Pearson correlation analysis was conducted using the SPSS 23.0 program to understand the correlations between variables. Then, hierarchical multiple regression analysis was conducted to verify the effects of each independent variable on depression. In the first step, sex, age, and income level were entered. In the second step, subjective health status, changes in life owing to COVID-19, and fear of COVID-19 were entered. In the third step, institutional trust and interpersonal trust were entered.

Descriptive Statistics and Correlation Analysis

Table 2

Mean, standard deviation, and correlation between variables (N = 780)
	1	2	3	4	5	6	7	8	9
1	1
2	.004	1
3	− .031	− .205^***	1
4	.099^**	.219^***	− .142^***	1
5	.077^*	− .083^*	− .003	.056	1
6	.126^***	.116^**	− .066	.114^**	.157^***	1
7	.003	.151^***	− .040	− .043	− .078^*	.109^**	1
8	.015	.110^**	− .035	− .031	− .042	.036	.492^***	1
9	.110^**	− .064	− .063	.286^***	.157^***	.122^**	− .023	− .105^**	1
M	.52	42.14	473.26	2.31	4.90	18.68	18.81	3.78	2.34
SD	.05	16.60	348.76	.86	2.18	3.62	3.66	.81	3.28
W	− .07	.55	2.14	.24	.10	− .71	− .49	− .58	2.79
K	-2.0	− .59	7.67	− .26	− .23	.60	.50	.62	12.27
^{*p<.001, p<.01, *p<.05}
^{note: 1=sex, 2=age, 3=home Income, 4=subjective health status, 5=changes in daily life due to the COVID-19, 6=COVID-19 fear, 7=institutional trust, 8=interpersonal trust, 9=depression}

Descriptive statistics and the results of correlation analysis are summarized in Table 2. Findings from the Pearson correlation analysis revealed the following: Sex was positively correlated with subjective health status, changes in daily life owing to COVID-19, COVID-19 fear and depression. Age was positively correlated with subjective health status, COVID-19 fear, institutional trust, and interpersonal trust, whereas it negatively correlated with home income and changes in daily life owing to COVID-19. Home income was negatively correlated with subjective health status. Subjective health status was positively correlated with COVID-19 fear and depression. Changes in daily life owing to COVID-19 were positively correlated with COVID-19 fear and depression, whereas negatively correlated with institutional trust. COVID-19 fear was positively correlated with institutional trust and depression. Institutional trust was positively correlated with interpersonal trust, and interpersonal trust was negatively correlated with depression.

Table 3

Hierarchical regression analysis (N = 780)
Independent variables		Final Model (Model 3)
Independent variables	B	SD	β	t
(constant)	− .539	.926		− .582
Sex	.423	.222	.064	1.901
Age	− .026	.007	− .133	-3.732^***
Home income	.000	.000	− .044	-1.279
subjective health status	1.097	.134	.287	8.212^***
changes in daily life due to the COVID-19	.171	.052	.114	3.318^**
COVID-19 fear	.066	.031	.073	2.100^*
Institutional trust	.058	.035	.065	1.661
Interpersonal trust	− .461	.156	− .114	-2.953^**
R²	.138^***
Adjusted R²	.129^***
^{*p<.001, p<.01, *p<.05}

The analysis results indicated that age, subjective health status, changes in daily life owing to COVID-19, COVID-19 fear, and interpersonal trust had a significant impact on depression among quarantined individuals (Table 3). Conversely, sex, home income, and institutional trust did not influence depression. Specific results indicate that, depression levels decreased as age increased (β=-.133, p < .001). The relationship between subjective health status and depression showed that depression increased as the perception of subjective health status became more negative (β = .287, p < .001). In addition, depression increased as the perceptions of changes in daily life because of COVID-19 became more negative (β = .114, p = .001), and as the fear of COVID-19 increased (β = .073, p = .036). However, depression decreased as interpersonal trust increased (β=-.114, p = .003). The total explanatory power of depression by the independent variables was 13.8%. After examining the stepwise R2 change, the explanatory power was significant at 2.2% in the first step (p = .001), and the R2 change of subjective health status, changes in daily life owing to COVID-19, and COVID-19 fear were significant at 10.6%, after controlling for sociodemographic variables (p < .001). Furthermore, the R2 change of institutional and interpersonal trust was significant at 1.0% after controlling for sociodemographic variables, subjective health status, changes in daily life owing to COVID-19, and COVID-19 fear (p = .013).

This study examined the depression and psychosocial experiences of the general public who had been quarantined because of the COVID-19 pandemic by analyzing the influence of subjective health status, changes in daily life owing to COVID-19, COVID-19 fear, and both institutional and interpersonal trust on depression in the context of COVID-19.

First, when examining the experience of depression among individuals who had been quarantined after the outbreak of COVID-19, it was found that 9.1% of all study participants experienced feelings of depression that were significant enough to interfere with their daily lives for a continuous period of at least two weeks within a year. Among the respondents in this study, 4.9% experienced symptoms of depression.

Among the sociodemographic variables, only age was significantly related to depression. Conversely, sex and home income were not related to depression. This study showed that depression levels decreased as age increased, thereby supporting existing research that the increase in depression levels among younger individuals during the COVID-19 period [29, 32]. Economically active younger individuals were more vulnerable to depression in situations where the impact of the COVID-19 pandemic had led to unemployment or economic loss. However, previous studies also suggest that individuals over the age of 60 years were vulnerable to depression during the COVID-19 pandemic [41]. Older individuals may become more vulnerable to mental health issues as their lack of proficiency with electronic devices can lead to isolation from external resources due to COVID-19. Although several previous studies have revealed that women are more vulnerable to depression than men, this study did not find a significant correlation. While home income did not show a significant effect on depression in this study, previous research has shown that unemployment and economic loss during the COVID-19 pandemic increased levels of depression [29, 32]. The discrepancy in results may be because of this study measuring average income over a year, not economic loss.

Subjective health status was a significant predictor of depression among individuals who had been quarantined owing to COVID-19. This aligns with existing research, which suggests that negative perceptions of one's health status increased depression during the COVID-19 period [16, 17]. Subjective health status also influences COVID-19 fear, with increased fear noted among those perceiving their health negatively [42]. Particularly, individuals, including older adults who find it difficult to manage their health during isolation may be more vulnerable to depression because of low subjective health status [43, 44]. The difficulty in managing existing chronic diseases and fear of complications owing to COVID-19 may have made individuals more susceptible to depression.

Furthermore, the results indicate that depression levels increase as negative perceptions of changes in daily life because of COVID-19 increase. These results align with previous studies, showing a rise in depression levels when life changes occur because of infectious diseases [1, 20, 45]. During the COVID-19 period, external activities were limited, and it became difficult to maintain social relationships owing to public health measures such as social distancing [6]. Reduced physical activity owing to these limitations could also have made individuals more susceptible to depression [21]. These restrictions on social contact could have led to a decline in physical functioning and contributed to depression, potentially leading to suicidal tendencies [46, 47]. Maintaining non-face-to-face contact through social media can be helpful when it is difficult to have face-to-face social relationships.

The findings of this study also revealed that depression levels among those who had been quarantined during COVID-19 increased as COVID-19 fear rose. These findings are in line with several existing studies that have shown that fear of COVID-19 increases levels of depression during the pandemic [48, 49]. Fear is the most common emotion experienced during an outbreak of a novel infectious disease, and affecting various psychological and behavioral domains [42]. The concept of COVID-19 fear includes not only fear of infection and death, but also fear of being blamed by others, infecting vulnerable family members, and economic loss. Individuals with high COVID-19 fear, who had been quarantined, may have experienced a reduction in their social networks because of blame from others, which, in turn, may have led to self-blame and increased levels of depression. Infection of vulnerable individuals, such as older adults, those with underlying conditions, and weakened immune systems, could have led to severe COVID-19 symptoms and increased risk of death, which could also have increased levels of depression. Therefore, providing continuous and preventive health care services to vulnerable groups seems necessary by identifying the family and cohabitants of those isolated during outbreaks of acute infectious diseases. The fear of economic loss could have also increased depression, as confirmed by previous studies [22, 24]. Although the government had provided various financial support, including disaster relief funds, it seems necessary to continue supporting groups that continue to experience economic loss as COVID-19 persists.

Trust in institutions responding to COVID-19, such as the government, medical institutions, and the media, did not significantly affect the depression levels of quarantined individuals. This is different from previous studies that found that trust in the appropriate response capabilities of institutions reduces depression and anxiety [29, 49]. This study, unlike preceding studies conducted on the general public, focused on quarantined individuals, which may explain different results. Additional research on the relationship between institutional trust and depression among quarantined individuals may be necessary. However, interpersonal trust among individuals quarantined during COVID-19 reduced depression. This is similar to the results of previous studies conducted on the general public, where interpersonal trust reduced stress and anxiety during the COVID-19 period [31]. In situations where COVID-19, an acute infectious disease, is transmitted by close contacts, trust in acquaintances and colleagues to appropriately respond to preventive measures, such as wearing masks and practicing social distancing, seems to have a protective effect against depression during the COVID-19 period.

In summary, in the context of the existing COVID-19 pandemic, factors such as age, subjective health status, changes in daily life because of COVID-19, fear of COVID-19, and trust in others have been identified as significant variables influencing depression among individuals who had been quarantined owing to COVID-19, as confirmed in previous studies on depression among the general population. However, sex, income level, and trust in institutions did not influence depression, which is different compared to studies involving the general population.

This study is significant in that there is a lack of research on depression among the general public who had been quarantined during the initial pandemic situation of COVID-19. Previous studies have identified depression occurring during isolation and the factors affecting it in patients hospitalized and individuals in self-isolation. Conversely, this study can be used as baseline data to understand the characteristics of depression that persist, even after isolation. As the number of individuals with isolation experience rapidly increases because of the prolongation of COVID-19, it is expected to serve as reference material for planning psychological and social interventions for those experiencing depression.

This study has some limitations. Owing to the nature of the CHS, this study could not measure changes in daily life because of COVID-19 and interpersonal trust through multiple questions. In addition, owing to the nature of the original CHS data, it was impossible to distinguish between those hospitalized due to confirmation and those in self-isolation, therefore, the analysis was conducted together. As the impact of hospitalization experience owing to COVID-19 and self-isolation experience on depression may differ, future research should distinguish between those with COVID-19 confirmation experience and those in simple self-isolation to verify the effects of psychological and social factors on depression. Last, further research is needed to examine the effects according to the characteristics and course of isolation experience, as the duration of isolation experience and the period after release from isolation were not verified.

Acknowledgements

This research used data from the 2020 Community Health Survey. Thanks to the Korea Disease Control and Prevention Agency for providing the data. We would like to thank Editage (www.editage.co.kr) for English language editing.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data Availability This study analyzed data from ‘2020 Community Health Survey’ conducted by the Korea Disease Control and Prevention Agency.

Conflicts of Interest The authors declare they have no conflict of interest.

Informed Consent No approval was required because secondary data was used.

Compliance with Ethical Standards No approval was required because secondary data was used.

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The impact of psychosocial factors on depression among individuals Quarantined during COVID-19: Analysis of the 2020 korean community health survey

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Abstract

Introduction

Methods

Survey and Participants

Measures

Depression

Subjective Health Status

Changes in Life Owing to COVID-19

Fear of COVID-19

Trust

Statistical Analysis

Results

Descriptive Statistics and Correlation Analysis

Discussion

Declarations

References

Additional Declarations

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