This quasi-experimental study was performed with a non-equivalent control group pretest-post-test design. The participants were 50 consecutive patients who were hospitalized in 2 hospitals in Shiraz, Iran, after being diagnosed with COVID-19. Patients were included in the study, if they met the following criteria: age over 18 years, willingness to take part in the study, being literate, having internet access and ability to work with the media. The following exclusion criteria were applied: previous experience of quarantine, unwillingness or inability to continue contributing to the study, having a history of psychiatric disorders or taking psychiatric medications, and death or transfer to the ICU.
Online multimedia psychoeducational intervention
We used WhatsApp as a tool to deliver multimedia psychoeducational contents (videos, podcasts, texts and pictures) to patients. Psychoeducational interventions mainly included cognitive–behavioural techniques, mindfulness-based stress reduction and positive psychotherapy.
Cognitive–behavioural techniques were used to teach patients how to recognize and mitigate their cognitive biases, especially in relation to disease and the likelihood of adverse events due to disease . In addition, various types of relaxation techniques including progressive muscle relaxation, imagination exercises, and diaphragmatic breathing were taught to the patients via video clips and audio files. Mindfulness techniques were incorporated to help patients recognize their negative thoughts and emotions about the disease and reduce the intensity and impact of those thoughts and emotions on their level of stress . In this technique, the patients were trained to allow their negative emotions just be, without attempting to alter them or trying to push them away Patients were encouraged every day to practice these techniques and provide feedback on which techniques work best for them as well as adapt to their condition. The patients were informed that they were not required to do all the techniques every day. Instead, they were advised to choose the most effective technique for themselves and practice it daily. In order to increase positive emotions and optimism in patients, positive psychotherapy exercises such as “Positive Reminiscence”, “Hope, Optimism, and Posttraumatic Growth” and “Finding Meaning”, were taught to the patients. For example, during the “Positive Reminiscence Exercise”, patients were encouraged to think about events from their past that evoke positive emotions, visualize the events in detail, and focus on the pleasant feelings arising during the exercise . During “Hope, Optimism, and Posttraumatic Growth” exercise, patients were encouraged to think about times when important things were lost, but other opportunities transpired .
Data were collected using online questionnaires and forms. Socio-demographic and clinical assessment form developed by the researchers was used to assess sociodemographic characteristics (age, gender, marital status and educational level) and clinical features (dyspnoea, fever, cough, tiredness, anorexia, nausea, diarrhea and hemoptysis) of the patients. Other measures were as follows:
Connor-Davidson resilience scale: The resilience of the patients was evaluated by the Connor-Davidson resilience scale (CD-RISC) . It consists of 25-items rated on a 5-point Likert scale, ranging from 0 (not true at all) to 4 (true nearly all the time). The CD-RISC score can range from 0 to 100, with higher scores reflecting greater resilience. Internal consistency (Cronbach’s alpha) for the full scale is 0.89 . The scale demonstrated good convergent validity, and factor analysis yielded five factors . The Persian version also showed high internal consistency (Cronbach’s alpha=0.89) and sufficient validity [21, 22].
Perceived Stress Scale (PSS): Perceived stress was estimated employing the Perceived Stress Scale. The PSS was designed to measure the degree as to which situations in one's life are appraised as stressful . It is a self-report 14-items questionnaire rated on a 5-point Likert scale, ranging from 0 (never) to 4 (very often). The total score of the scale can range from 0 to 56, with higher scores indicating higher levels of perceived stress. This measure has exhibited sufficient reliability (Cronbach’s alpha =0.84-0.86) and validity . The Persian version also showed excellent internal consistency (Cronbach’s alpha=0.90) and convergent validity .
Ethical approval was obtained from the local Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1399.011). Eligible participants were informed about the study objective, and the voluntary nature of their participation. Electronic informed consent form was filled out by all the patients. The data were collected anonymously without name lists.
Before the start of intervention, four inpatient wards of two hospitals were randomly assigned to either intervention or control condition so that one ward in each hospital was assigned to intervention and the other to control condition. All eligible participants in wards allocated to the intervention condition received online multimedia psychoeducational interventions during 2 weeks, whilst patients in wards allocated to the control condition received face-to-face or telephone-based psychological counseling in case of need. Random assignment of wards was performed by an independent observer not involved in this study, using a coin toss. Patients were blinded to patient group assignment. Evaluators were not informed of patient's treatment assignment. The risk of contamination was minimized by the fact that the hospitalized patients in the intervention and control hospital wards were not in contact with each other.
Patients were requested to complete the baseline questionnaires within 48 h of admission to the ward. Immediately at the end of the second week, the online instruments of the perceived stress and resilience were reapplied and the posttreatment scores were obtained (Figure 1).
Compliance test for normal distribution with Kolmogorov–Smirnov test was applied. Levene's test was used to examine the heterogeneity of the variances. Chi-square tests were performed to compare the groups concerning demographic and clinical variables. Since there was no interaction between dependent variables with socio-demographic and clinical variables (p value >0.05), the assumptions of Analysis of covariance (ANCOVA) were not established to control the effects of these variables as covariates . Therefore, Student’s t-tests were carried out to evaluate the differences between the two groups with regard to dependent variables (perceived stress and resilience). Between group effect size for mean differences of groups with unequal sample size within a pre-post-control design (dppc2) was calculated according to Morris’s recommendations . A p value <0.05 was considered to be statistically significant. The analyses were conducted with SPSS® for Windows® version 22.0 (SPSS Inc, Chicago, IL, USA).