Self-Reported Psychological Problems and Coping Strategies: A Web-Based Study in Peruvian Population During the COVID-19 Pandemic.

BACKGROUND: The Coronavirus pandemic has disrupted health systems across the world and led to major shifts in individual behavior by forcing people into isolation in home settings. Its rapid spread has overwhelmed populations in all corners of Latin-American countries resulting in individual psychological reactions that may aggravate the health crisis. OBJECTIVE: this study reports on demographics, self-reported psychological morbidities and associated coping styles during the COVID-19 pandemic for the Peruvian population. Methods: This cross-sectional study uses an online survey with snowball sampling that was conducted after the state of emergency was declared in Perú (on April 2 nd ). The General Health Questionnaire (GHQ -28) was used to identify somatic symptoms, incidence of anxiety/ insomnia, social dysfunction and depression and the Coping Strategy Questionnaire (COPE-28) mapped personal strategies to address recent stress. RESULTS: 434 self-selected participants ranging in age from 18 to 68 years old (ME =33.87) completed the survey. The majority of participants were women (61.3%), aged between 18 and 28 (41.7%), well-educated (>=85.0 %), Peruvian (94.2%), employed (57.4%) and single (71.20 %). 40.8% reported psychological problems, expressing fear of coronavirus infection (71.43%). Regression analysis shows that women developed more somatic symptoms (p<0.001*, C.I: -2.75 to -.99) and greater anxiety/insomnia (p=0.00*, C.I: -2.98 to 0.84) than men. Depression and social dysfunction were equally likely at any age. Educational status was protective against developing psychological disorders (p<0.05). While active responses (acceptance and social support) are scarcely used by individuals with psychological problems; passive strategies (such as denial, self-distraction, self-blame, disconnection, and emotional discharge) are more commonly reported. CONCLUSION: This study provides a better understanding of psychological disorders occurring during the COVID-19 pandemic in the Peruvian population. About half of the respondents reported psychological morbidity and poor coping responses. This evidence informs the need for broader promotional health policies focused on strengthening individual’s active strategies to improve mental health, especially in underprivileged groups during and after the Covid-19 pandemic.


Introduction
To date (June 10th, 2020), more than 400,000 deaths worldwide have been attributed to the coronavirus (1). Despite the deployment of several public health strategies to prevent continued transmission of the virus at the global level (1)(2)(3), the subjective perception of risk within the population represents a latent threat that may potentially trigger a wide variety of individual behavioral and emotional responses. Therefore, during this pandemic complex morbidities are highly likely to occur (4)(5)(6) and recent research has found a signi cant association between the current COVI-19 pandemic and the emergence of mental Particularly, Peru has been signi cantly affected by the COVID-19 pandemic, causing signi cant national alarm (29). Although exposure to the virus outbreak has already been shown to be related to adverse effects, the role of coping strategies that regulate emotional responses to stressing situations is discussed (17). Therefore, this study aims at investigating psychological health and how it is linked to the deployment of active or passive coping strategies in the general population exposed to the COVID-19 pandemic.

Study Design And Methods
A cross-sectional survey was administered in March-April, during the Covid-19 pandemic and through anonymous online questionnaires. Exclusively individuals (≥ 18 years) able to provide informed consent were recruited using a convenient snowball sampling process. Respondents were required to reside in any department in Peru. No monetary compensation was given for completing the questionnaire. The study protocol was approved by the ethics committee of "Catolica de Santa Maria" University (ref. no. 167-2020). The instruments were considered valid when fully completed; participants under 18 years old and those whose responses were biased by acquiescence or social desirability were excluded, based on the questionnaire's protocol.

General Health Questionnaire-Goldberg (GHQ-28)
The survey comprised the (GHQ-28) Questionnaire, a population-based, self-administered tool for screening and determining mental disorders. Participants were asked about symptoms and/or discomfort they had experienced recently (in recent weeks) during the coronavirus pandemic. Each item is scored based on a 4-point scale containing 4 subscales of depression, anxiety, social dysfunction, and physical symptoms, ranging from "better/healthier than normal" option, through a "same as usual" and a "worse/more than usual" to a "much worse/more than usual" option (30). For this study, Cronbach's alpha coe cient was calculated as a high reliability estimator, corresponding to α = 0.934 (IC95%, 0.925-0.943).

Coping Estrategies Questionnaire (COPE-28)
The survey also included the (COPE-28) Brief version (28 items), which measures behaviors and cognitive responses to stressors related to Covid-19. We used the Spanish version (31), which has 14 subscales (asking about self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, relief, positive reframing, planning, humor, acceptance, religion, self-blame). The tool identi ed active and passive strategies asking 4-point values (1: "I haven't been doing this at all"; 4 "I've been doing this a lot") (32). For the present study the calculation of Cronbach's alpha coe cient as a reliability estimator was α = 0.858 (IC = 95%, 0.838-0.876).

Data analysis
Respondents were asked to identify categorically key demographic information, which is subsequently analyzed using Stata Statistical Software 15.0 for Windows (33) as proportions. Linear regression was used to calculate whether there were univariate associations between sociodemographic data, the GHQ scale and COPE-28 questionnaire.
To establish the relationship between psychological health and both active and passive coping strategies, structural equation models (SEM) were used. Path analysis (34) was done with comparative adjustment index (CFI), with values ≥ .90 (35) the root mean square error of approach (RMSEA), with values ≤ .80 (36) and the goodness-of-t Index (GFI > .8 or > .9) was used to evaluate how well the models t (37). From the correlations, the nal model was elaborated with path analysis, using the data on participants who presented with psychological problems to determine the active and passive coping strategies most frequently used within this group. The presence of psychological problems was identi ed using the GHQ scale with a cut-off point 23/24 (38). (Table 1)  3.2 General health status based on socio-economic pro le (Table 1) We standardized the sampling, adjusting it to ± 1.5 threshold (39) where 40.8% (n = 177) of respondents reported psychological disorders in contrast to noncases (59.2%), with a cut-off point of 23/24 (38).

Participant characteristics
Being female was associated with increased somatic symptoms (P = 0.001; 95% CI = -2.75 to -3.74) and indicators of anxiety and insomnia (P = 0.001; 95% CI = -2.98 to 0.84). Being within the age group between 59-68 years was negatively and signi cantly associated with somatic symptoms (P = 0.04; 95% CI = -4.06 to -0.13). While the 29 to 38-year-old group scored signi cantly higher on questions about anxiety/insomnia (P = 0.02; 95% CI = -2.73 to -0.19). The social dysfunction indicator is present at all ages except for the 39 to 48-year-old group. Negative association score is found for severe depression regardless of participants age. Concern about the absence of hygiene products (including personal protection, antibacterial gel, chinstraps and others) is negatively associated at a moderate level (P = 0.05; 95% CI = -1.77 to -0.001) with somatic symptoms.

Association between sociodemographic variables and subscales of active and passive coping strategies in covid-19
Positive reassessment subscale is strongly associated with being females (p = 0.03*, CI: -0.63, -0.04) and older ages (the exception is for 29-38 years old).
Likewise, a signi cantly negative association exists with the Acceptance subscale (p = 0.06, CI: -0.53 a 0.01). Those with graduate (P = 0.01; 95% CI = -1.13 to -0.18) and doctoral degrees (P = 0.04; 95% CI = -1.04 to -0.03) are less likely to engage on planning activities as a coping strategy. People with higher education (P = 0.01; 95% CI = 0.18 to -1.05) are more likely to use positive reassessment as a coping strategy. Moreover, positive reassessment behaviors punctuated negatively lower among married respondents (P = 0.02; 95% CI =-1.63 to -0.12), and with concern, at moderate level, about shortage of personal toiletries, protection and other items (P = 0.01; 95% CI = -0.70 to -0.12) ( Table 2). are commonly used at any age. Senior group (59 to 68 years) is associated negatively with relief-seeking behaviors (P = 0.02; 95% CI = -1.23 to -0.09). Finally, while being a college student is strongly associated with higher rates of religion-based responses as a coping strategy (P = 0.03; 95% CI = 0.07 to 1.14), postgraduate respondents (P < 0.001) tend to use greater self-distraction, self-blame and emotional release strategies compared to high school students.  Emotional support strategy correlates signi cantly positive with somatic symptoms (r = 0.20**), anxiety/insomnia (r = 0.13**) and social dysfunction (r = 0.15**). The planning strategy correlates inversely with severe depression (r = -0.19**). It is clear that the greater the social support response, the lesser the anxiety/insomnia (r = 0.16**) and social dysfunction (r = 0.13**). The situation-acceptance strategy is a protective factor against indicators of somatic symptoms, anxiety/insomnia and severe depression (*p < 0.05). It is also evident that the active strategies of positive re-evaluation and humor do not correlate with any indicator measured with the general health scale (GHQ). On the contrary, passive coping styles (denial, self-distraction, self-blame, disconnection, withdrawal and substance use) correlate signi cantly with general health indicators.
3.5 Path analysis results related to active and passive coping strategies (Fig. 1) Social acceptance and support-seeking behaviors are active strategies more likely to be used by individuals who rated with psychological problems (this  Our ndings suggest that during the period of social isolation (April-May), respondents experienced psychosomatic symptoms, anxiety, social dysfunction and severe depression as assessed by GHQ-28. Gender, age, education level, and having moderate concerns about purchasing protective products in uenced the mental health of respondents; other variables, including nationality, employment and marital status, and being afraid of the coronavirus disease were not signi cantly associated with the presence of psychological symptoms. In our sample, educational status is a protective factor against mental health disturbances. In similar research, studies in China at the beginning of the pandemic found that education, employment and marital status are protective factors of mental health (12) (40).
Our data suggests that women experience higher levels of somatic symptoms and anxiety/insomnia. These ndings are consistent with previous studies reporting greater levels of anxiety (12), fear within women (13), and older adults exposed to public health messages in the context of European quarantined countries, such as Italy (41). Being female and a young adult (29)(30)(31)(32)(33)(34)(35)(36)(37)(38) increases risk of anxiety; while older are more likely to report depression, these ndings are similar to Newby's (14) who found that students were at greater risk for depression than older adults.
Regarding sources of concern, we found that participants reported little concern respect to some changes in circumstances, such a working without family (3.69%), doing domestic work (4.15%) and maintaining children and family care (10.14%). A higher percentage was worried because of social isolation (38.94%), and not being able to work (27.88%). Drawing from another studies we notice that people report higher rates of anxiety due to concern for themselves and their family (42). The distinctive distribution of work and responsibilities across Peruvian families seems to be driving varied behavioral responses (somatic symptoms, anxiety/insomnia, social dysfunction and severe depression) supported by the last national report. In here, a great number of families were classi ed as nuclear households (53.9%) made up of a couple with or without children or at least one, followed by extended families (20.6%) and single person households (16.8%) (43). The changes of working circumstances due to the current social distancing are perceived differently among single respondents (71.2%) who are less likely to report concern for others or to work without being with the family. Nearly half of respondent (47.70%) also reported signi cant higher somatic symptoms due to shortage of protective products (personal toiletries). The use of tonics and medicines to not get sick or prevent physical discomfort are also reported in similar studies regarding massive purchases of cleaning supplies and food upon higher alarm among the population (7).

Coping Strategies
Interestingly, sociodemographic such as gender, age, educational status and the likelihood of being married in uence a person's likelihood of using active coping style. In our study self-distraction and self-blame, both passive strategies, were signi cantly informed. Self-distraction was used by individuals of all ages except among those 18 to 28 years old. Analyzing religion -related coping beliefs, we found that university students and groups from 39 to 48 years old increases in praying as a strategy, which corresponds with the country culture according to national records (76.0% of Peruvians profess being Catholic) (43).
A great deal of women respondent (61.3%) reported using religion-based strategies probably to mitigate stress, those results are also supported by previous recent Chinese studies during the pandemic (74.77%) (9).
Psychological problems and use of coping strategies Coping strategies are mediated by cultural factors and gender differences. This study con rms that women tend to use more passive strategies, except for positive re-evaluation as an active strategy. Contrastingly, Asian-based studies reported the deployment of active styles focusing on problem solving (active, social support and planning) are analyzed and can signi cantly predict responses of anxiety (3.4%), anger (2.2.%) and sadness (0.9%). With that said, women may be more likely to use proactive, problem-centered coping in the face of the pandemic and less likely to use passive strategies than men. (13). This has some minor uctuations in North America, where women are more likely to report strategies that focus on passive behaviors such as distraction, religion, and less humor (44). We found that women with psychological problems use religion, self-distraction and venting possibly to alleviate the distress they feel about the pandemic, has not been reported in other studies.
People with psychological problems use adaptive strategies based on acceptance and the support-seeking behaviors to face the crisis. In contrast, the sample of participants without psychological problems had a predominance of cognitive coping with planning and disconnecting from activities, followed by less seeking social support, most likely due to the higher educational status of the respondents; self-distraction was the only passive or blocking coping strategy that ranked high in this group. Interestingly, in Singapore, in late 2002, in the face of severe acute respiratory syndrome (SARS) two coping strategies, denial and planning, were associated with post-traumatic morbidity. Both, lack of planning and denial are ways of reducing powerlessness in the face of stress but at the same time they are maladaptive strategies leading to psychological problems (5). We found that the use of passive responses (denial, self-distraction, selfblame, venting, and religion) may respond to the unprecedented impact of the COVID-19 pandemic on a country and global scale; metaphorically, it is understood as a chain of misadjusted responses that begins with rejecting the deadly consequences of the disease, not accepting reality, resorting to various activities to avoid thinking about the crisis, and avoiding confronting the problem.
Among the strengths, this study was one of the rst to investigate the impact of COVID-19 on mental health and coping strategies in the face of the crisis. It was conducted two weeks after the declaration of the state of emergency by the Peruvian government Future research could follow participants in the aftermath of the pandemic and examine the evolution of psychological problems after the state of emergency.
Other studies on low-income populations with educational and health needs and restricted access to the Internet provided insight into their coping strategies and the effects on their mental health.

Conclusions
Recognizing the compelling need to minimize the risk of transmission and the severity of the epidemic, mental health disorders need to be addressed early by strengthening active strategies within the population to prevent disease progression.
This study found moderate scores for psychological problems in response to the COVID-19 pandemic. The association of female gender, higher education and all age groups except the youngest (18 to 28 years) allows for detection of high-risk groups. The occurrence of psychological problems is better captured through the analysis of participants' coping mechanisms when confronted with critical situations. The ndings inform of timely intervention programs to minimize long-term problems, which may potentially arise after quarantine particularly in the vulnerable population.

Limitations
An Internet-based survey method was used to avoid possible coronavirus infection. We used a snowball sampling in a voluntary manner and conducted through an online system. Therefore, some selection bias is considered. Only people who had access to the Internet connection were able to participate in the study via computer or mobile phone, which limited the participation of people who did not have these technological devices. In the absence of low-income people, we will have constraints in understanding their psychological responses to the pandemic. The sample size was neutralized by extensive data analysis using linear regression and structural equation modeling Declarations Ethics approval and consent to participate This study involves human participants, whose written consent was retrieved at start of the study. The study protocol was approved by the ethics committee of "Catolica de Santa Maria" University (ref. no. 167-2020).

Consent for publication
The authors utilized a research form to ask the participants their consent to publish their clinical results.

Availability of data and materials
The datasets generated and/or analysed during the current study are available at the OFS repository, available at: https://osf.io/zs8um/? view_only=48a6dd4bb5be41c2a5050d093f6bcbc0

Competing interests
The authors declare that they have no competing interests Funding:

Not applicable
Author contribution RAG and ABP made considerable contributions to conception and drafting. RAG and JHC worked in the analysis and interpretation of data. JBH reviewed the concluding edition. All authors contributed writing, editing, and reviewing the nal manuscript.

Figure 2
Report of the path analysis. Standardized coe cients of active and passive coping strategies in participants without psychological problems (N = 257; *p < .05).