This cross-sectional study was one of the earliest carried out among residents of Australia with a view to assess the extent of and identify factors associated with psychological distress, level of fear and coping strategies during the COVID-19 pandemic. Being female and increased alcohol drinking in the past four weeks were associated with higher psychological distress and higher levels of fear of COVID-19 in this study. In addition, higher psychological distress was associated with pre-existing mental health conditions, increased smoking in the last four weeks and higher levels of fear of COVID-19 while lower psychological distress was associated with being older (60+ years) and being a frontline or essential service worker. A higher level of fear was associated with being 30-59 years old, perceived distress due to change of employment status, providing care to known or suspected case of COVID-19 and having higher level of psychological distress. On the other hand, a lower level of fear was associated with being born in Australia, having a source of income and alcohol drinking in the last four weeks. Visiting healthcare providers in person in the last four weeks was also found to be associated with coping during the COVID-19 pandemic.
Previous research has revealed a profound and wide range of psychosocial impacts on people at the individual and community level during outbreaks of infection . However, it will be somewhat early to predict similar results emanating during the peak of the COVID-19 epidemic, with the uncertainty surrounding an outbreak of such unparalleled magnitude. A recent study carried out in 194 cities in China showed 53.8% respondents rating psychological impact as moderate to severe . This finding coincides with our study as it raised almost similar levels (moderate to very high level) of psychological distress (62.6%) among the study participants. A study from the UK showed that the prevalence of poor mental health was 37% amongst participants who were in isolation or maintaining social distancing, where poor mental health was defined as having moderate to severe depressive symptoms and anxiety . Similarly, the Australian Bureau of Statistics had been collecting COVID-19 impact survey data fortnightly involving a representative sample of over 1,000 adults across Australia, and findings indicated twice as many adults experiencing anxiety, nervousness and restlessness compared to pre-COVID surveillance data .
Evidence suggests that pre-existing anxiety disorders, existing health anxiety (those who worry excessively about having or contracting illnesses), and other mental health disorders (e.g., depression and post-traumatic stress) are at risk of experiencing higher anxiety levels during the COVID-19 outbreak . Similarly, our study showed a significantly higher level of psychological distress among participants having pre-existing co-morbidities such as psychiatric or mental health issues. Individuals who were self-isolating prior to receiving negative results for COVID-19 also showed heightened psychological stress and this was corroborated by another study, which identified anxiousness and feelings of guilt by the quarantined persons . In addition, a sense of stigma from other family members or friends might have contributed to such high levels of distress . Findings related to self-identification as a frontline or essential service worker exhibiting a lower level of stress in the present study was somewhat incongruous with other initial studies, which showed a significant mental health burden on frontline healthcare workers during pandemics . A recent systematic review of 59 studies with 54,707 participants showed that one or two of every five healthcare professionals reported anxiety, depression, distress and/or sleep problems during the current COVID-19 pandemic, which were primarily associated with increased workload . Due to the small number of participants, our study could not conduct subgroup analyses focusing on frontline healthcare providers and our findings of lower levels of distress among these groups could be due to the prolonged exposure of the pandemic period, being accustomed with service provision as frontline workers and/or availability of personal protective equipment.
The COVID-19 pandemic also led to maladaptive behaviours, including increased smoking and alcohol intake due to stress and social isolation . Previous studies also found that patients with a history of smoking are at higher risk of severe COVID disease, and those admitted to intensive care, may require ventilation . Our study has found significant association between increased smoking as well as alcohol drinking and higher psychological distress. Evidence from previous studies indicated community-wide disasters being associated with a number of behavioural health outcomes including increased mental health concerns and escalations in the use of alcohol [33, 34].
Social distancing, stay at home orders and quarantine measures may lead to boredom, uncertainty and disruption to routines and distress resulting in elevated psychological distress as found in our present study. Increased alcohol consumption might also be explained as a coping mechanism for the perceived distress as many self-medication hypotheses posit use of substances like alcohol for relieving distress . Our study results are also consistent with the findings from a literature review which documented an increase in alcohol consumption for some populations, particularly men, because of added mental stress due to uncertainty about the future due to COVID-19, and economic and employment concerns experienced as a result of the pandemic . The same can be stated regarding increased smoking, as most nicotine consumers reported using nicotine products as their main stress and anxiety coping mechanism. A multi-country study conducted in Italy, India, South Africa, the United Kingdom and the United States have revealed that during the COVID-19 pandemic, cigarette smokers have been buying more cigarettes than usual triggered by the fear that stores might run out of stock or be closed during lock down . Another study from the USA reported that one-third of the participants increased their tobacco use during the COVID-19 pandemic and subsequent ‘stay-at-home’ orders; that negative behaviour was associated with sociodemographic variables and depression .
Our study showed females had higher distress and fear of COVID-19, which was consistent with studies from China , Italy  and the USA  suggesting that female gender was a consistent predictor for psychological distress. A host of reasons can be postulated for this as females disproportionately share the larger percentage of caregiving roles, in both formal and informal sectors. They also serve as the primary caregivers more frequently, within a household, which may further accentuate their anxiety and stress in a pandemic situation . The abovementioned Chinese studies also showed that young adults (aged 18-30 years) exhibited the highest level of psychological distress, which was consistent with our study findings. Such distress could be correlated with an increased use of social media, as young participants may watch and listen to much more negative news, which would then intensify their feelings of anxiety and depression in times of crisis.
Higher levels of fear amongst middle-aged participants in our study were more likely due to being part of the workforce with possible financial uncertainly in the event of future job loss. This could also be a possible explanation of accentuation of psychological distress, and therefore, participants utilised more healthcare services (by physical visits or through telehealth) to overcome the COVID-19 related stress during the study period. Like previous studies, our study also found that fear of COVID-19 was a prominent risk factor for the onset and maintenance of increased alcohol consumption . This explains why participants used alcohol as part of their neuro-adaptations and coping response to the stress (induced by fear) because of the pandemic and social isolation .
The results of our study further illuminated additional aspects of the factors relating to fear of COVID-19. Level of education did not have any impact on the fear of COVID-19. Similarly, participants had no association between fear and having any existing comorbidities or increased healthcare utilisation. No association was also found between fear and providing care to family or patients with known or suspected COVID-19. There could be multiple possible explanations for this finding. First, a third of the participants, being frontline essential workers, somehow accepted the situation and their role as caregivers or service providers to the family and population they served, respectively. Second, the pandemic was not regarded as severe in intensity in Australia during the study period (June 2020). Third, it could have been that participants were less aware of the severity of the virus; and finally, trust in the initiatives taken by the Australian Government, including stage 3 restrictions with banning of non-essential travel between and within the states and social isolation to prevent the exponential spread of the virus. Participants born in Australia also experienced less fear compared to those not born in Australia, which might be related to better knowledge about the health system, support networks and stronger coping by the Australia born residents. Another study from Australia reported that self-perceived probability of losing jobs was greater amongst people who were born overseas in a non-English speaking country compared to those who were born in Australia, which could also explain the higher psychological distress in non-Australian born residents in our study . However, it was beyond the scope of this study to examine all the relevant factors. Our study demonstrated that frontline or essential workers were less fearful than their counterparts, which could be explained by the availability of increased testing and personal protective equipment for the health care and frontline workers.
More respondents in our study completed bachelor and above qualifications, possibly due to higher number of front line or essential service workers taking part in this survey, who would presumably had higher education than others. According to the International Labour Market (ILO), almost 25 million jobs could be lost worldwide due to COVID-19 . However, pervasive job loss was not evident among our study population as one-third of them were working as frontline or essential service workers who would not necessarily lose jobs during such a crisis, and other participants might have benefitted from the employment support initiative by the Australian Government like jobseeker or jobkeeper payment [46, 47]. Accordingly, employment status of our study participants might not reflect the true job loss situation in Australia due to the ongoing pandemic of COVID-19.
The survey responses in this study were predominantly from Victoria although the survey link was shared across all the states in Australia through various social media platforms and emails. This could be explained by the researchers’ use of snowball sampling technique as community acquaintances and their accessibility to GP clinics/ allied health service facilities in Victoria than in the other Australian states. Therefore, findings of this study might be more generalisable to the State of Victoria rather than across Australia, and it was also likely that distressed individuals had responded to our survey resulting in selection bias. A significant number of participants in the study were not born in Australia, which is a reflection of the country’s multiculturalism. According to the Australian Bureau of Statistics, almost 30% of Australians were born overseas, increasing the cultural diversity of Australia's population . More females than males participated in the survey, which could be due to more frequent visits to healthcare providers by females than males , and increased number of female workforce being employed in the frontline healthcare or essential service facilities/outlets . Findings of our study were limited to people who could access online platforms to participate; hence, generalizability was limited to internet-literate people. Considering the restrictions of movement and social distancing, an online survey was the only viable option during the pandemic to address our research objectives. However, the strength of the study was the achievement of the target sample size within the crisis period; hence the study had significant power to test the hypotheses.
Social distancing and self-isolation due to the current COVID-19 pandemic were likely to be stressful for people. Therefore, it was also important to understand responses from our study participants regarding their coping strategies, considering some groups could be more vulnerable than others to the psychosocial effects of the pandemic. Findings of our study were supported by prior research outlining coping activities like social connection with families and friends, limiting exposure to pandemic-related news, maintaining adequate sleep, nutrition, exercise, and practicing meditation (mindfulness) .