This is nationwide survey of psychological distress in the general population of Nepal during the COVID-19 pandemic. The COVID-19 Peritraumatic Distress Index (CPDI) questionnaire (survey questionnaire attached as Supplementary file) adapted from the Shanghai Mental Health Centre [8]. The CPDI questionnaire incorporated relevant diagnostic guidelines for specific phobias and stress disorders specified in the International Classification of Diseases, 11th Revision. The survey data is collected through online Google Form with informed consent. The structured Google Form with CPDI question is published in social media network and sent in personal mail requesting participants to share the survey form to wider audiences. The psychological distress score is made available to respondents upon completion of the questionnaire. The Google form was used to collect demographic data (age, gender, religion, education, employment status, monthly family income, nationality, ethnicity, and residence), and the response to CPDI questionnaire. The CPDI questionnaire registered details including anxiety, depression, specific phobias, cognitive change, avoidance, and compulsive behaviour, physical symptoms and loss of social functioning in the past week. The overall response was indexed and categorized in three different group (mild, moderate, severe) of psychological distress level with score ranging from 0 to 96. A score ≤ 28 is normal; 29 to 51 is mild to moderate distress, and ≥52 is severe distress. Psychiatrists and public health physicians from Nepal verified the content validity of the CPDI. The linguistic validation of the questionnaire was done with forward translation by two independent translators, reconciliation, and again backward translated by two independent translators who are blind to the original questionnaire format. The approved translation was put alongside the original language questionnaire. Data were collected from 11 April (3 weeks since enforcement of nationwide lockdown) till 17 May 2020.
Exposure variable
The survey questionnaire included socio-economic and demographic variables such as age (<30, 30-45, >45 ), gender (male, female), religion (Hinduism and non-Hinduism), education (less than secondary, post-secondary and tertiary education), employment status (employed, not-employed, students), monthly family income (<NRS100900, NRS 100901-309000and > NRS 309000), nationality (Nepali and non-Nepali), ethnicity (Brahmin & Chettri and Other), and residence (Province1; 2; 3;4;5;6;&7)
Outcome Variable
Modified version of the COVID-19 Peri-traumatic Distress Index (CPDI) with 24 items is used to measure outcome. The present study has used the e-questionnaire in Nepali version (supplemented with English version) of the CPDI, and internal consistency was assessed by using Cronbach’s α. The internal reliability of the present study found to be 0.896 (p<0.001). For each of the 24 items, participants were asked to self-rate psychological impact related to COVID-19 and frequency activities in the last week. The 5-point Likert scoring system was used (never-0, occasionally-1, sometimes-2, often-3, always-4) to rate the psychological impact. A score of 0-28 is normal or no distress. A total score between 29 and 51 indicates mild to moderate distress and a score of greater than and equal to 52 indicates severe distress.
Statistical Analysis
Collected data were extracted to Microsoft excel-13 and imported and analysed using SPSS (Statistical Package for Social Sciences) version-22). An initial univariate analysis was conducted for all variables to assess the distribution for each variable. Categorical variables were summarized using percentages. Logistic regression analyses were used to estimate the odds ratios of relevant predicting variables. This gives how a set predictor X (exposure variables) is related to the dichotomous response variable of Y (outcome variable). For convenience, we define the response to be Y=0 or 1, with Y=1 denoting the occurrence of the event of interest. The outcome variable is No distress=0 and distress=1. The exposure variable were continuous as well as categorical.
Research Ethics
All respondents gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the protocol and approved by the Ethics Committee of Nepalese Army Institute of Health Sciences (NAIHS).