The COVID-19 pandemic invariably leads to lockdown in many countries all over the world. During the first MCO for the COVID-19 pandemic in Malaysia, nearly one-third of the respondents in this study experienced anxiety, the majority of whom were mildly to moderately anxious. Anxiety was significantly more common among respondents who were in the red zone and used avoidant coping strategies. Anxiety was also more common among those who were younger and did not have a partner. The overall QOL, as well as physical and mental health, social relationships, and environmental satisfaction were significantly worse among respondents who had anxiety.
The proportion of respondents with anxiety in our study was higher than the prevalence of anxiety symptoms (6–8%) in the general Malaysian population.(32) The prevalence and severity of anxiety in our respondents were similar to those in China, Japan, and Spain during the lockdown for the COVID-19 pandemic, ranging from 23.8 to 37.4%.(33–36) However, the prevalence of anxiety was higher in Iran (50.9%),(37) but lower in United Kingdom (21.6%),(38) and Italy (18.7%)(39) during the COVID-19 pandemic lockdown. The heterogeneous epidemiological distribution of anxiety in these countries during the lockdown could be attributed to several factors,(40) including the characteristics of the study population, and the burden of the disease in the region at the time of the study.(41) Compared to Malaysia, the incidence and mortality of COVID-19 were remarkably higher in the Iranian population during the study period, explaining the higher prevalence of anxiety among them.(37) The lower prevalence of anxiety in the population of United Kingdom and Italy may be due to the fact that the former study only included individuals with high and very high anxiety level,(38) while the latter study used a different instruments, the General Anxiety Disorder 7-items scale.(39)
Our study showed that anxiety was significantly more prevalent among respondents who resided in the area with a higher incidence of COVID-19 in recent weeks. A nationwide study among Chinese in China, Hong Kong, Macau, and Taiwan during the lockdown reported that respondents from the area with a more severe epidemic of COVID-19 such as Hubei province had significantly more psychological distress (p < 0.001).(42) Lai et al reported that healthcare workers in Wuhan were significantly vulnerable to adverse mental health outcomes such as anxiety (p < 0.001), depression (p < 0.001), and insomnia (p = 0.001) when compared to those working in other parts of China.(43) Liu et al reported that medical personnel in the Hubei province of China had significantly higher anxiety scores (p = 0.001) compared to their counterparts in other parts of China.(44) The higher prevalence of psychological distress such as anxiety among people staying in the area with a high incidence of COVID-19 during the lockdown may be due to their intensified thoughts about the virus. A study conducted among people in India during the COVID-19 pandemic highlighted more than 80% were preoccupied with the thought of COVID-19, 72% reported the need to use gloves and sanitizers, 37.8% were paranoid about contracting COVID-19, and 36.4% had distress related to social media.(45) Another study in China concluded that people who spent more time engaging in COVID-19 (≥ 3 hours per day) were more likely to suffer from general anxiety disorders (p < 0.001).(20)
During the MCO for the COVID-19 pandemic, anxiety was significantly more common among Malaysians who used avoidant coping strategies compared to other coping strategies. A study in the United Kingdom reported that avoidant behaviors during the COVID-19 pandemic lockdown was positively associated with all indices of distress including anxiety, and negatively associated with well-being.(46) A similar result was also reported during the COVID-19 pandemic lockdown in Italy, whereby healthy individuals’ anxiety scores were positively correlated with the avoidant coping strategies (r = 0.35, p = 0.016).(47) In Japan, three-quarters of healthcare workers used the escape-avoidance strategies to cope with stress during the COVID-19 pandemic. Two-thirds of them reported poor mental health with anxiety being the predominant symptom.(48) Carver and Pozo had highlighted that distress and coping were interdependent, with distress leading to dysfunctional coping, and causing a higher levels of distress.(49) Coping associated with distress was often passive and avoidant, such as mental and behavioral disengagement, denial, and alcohol use.
Several studies have highlighted younger age as an independent predictor of anxiety during the COVID-19 pandemic lockdown.(20, 33, 37–39) Even in the general population, epidemiological surveys consistently reported that current, as well as lifetime anxiety disorders, were more common in younger adults.(50, 51) The age-related psychological, social changes or a cohort effect could be the explanation.(52) Besides, the tendency of young people to receive a large amount of information via social platforms can easily cause stress and anxiety in them.(53) Information about COVID-19 during the pandemic and lockdown is frequently distressing and sometimes associated with rumors.(37) The age factor did not emerge as a significant predictor of anxiety in the current study, which may be confounded by the higher prevalence of staying in the red zone and adopting avoidant coping strategies among the younger respondents.
A local study showed that generalized anxiety disorder was significantly more common among singles, widows, widowers, and divorcees.(54) Similarly, another study showed that being with others reduced anxiety more effectively than being alone .(55) During the COVID-19 pandemic lockdown, loneliness was a strong predictor of anxiety, depression, and post-traumatic stress disorder among Spaniards.(56) In the current study, marital status did not emerge as a significant predictor of anxiety, which is consistent with reports from China and Turkey during the COVID-19 pandemic lockdown.(57, 58) This could be explained by the possibility of different sources of social support that could have varying degrees of influence on an individual, apart from a partner or spouse.(36) Therefore, future studies could examine different types of social support that could also contribute to coping strategies.
A web-based global multicenter study by Ammar et al. reported lower satisfaction with QOL among people from Europe, North Africa, Western Asia, and America during the lockdown for the COVID-19 pandemic.(59) People in Portugal who were quarantined at home because of the COVID-19 pandemic also reported a significant decline in their QOL.(60) On the other hand, 65% of respondents from China were satisfied with their QOL during the COVID-19 pandemic lockdown.(61) The mixed results from the different studies limit the generalizability of the findings, and therefore justify the need to investigate the QOL during the COVID-19 pandemic in our local setting. The current study showed a significant negative correlation between anxiety scores and each domain of the WHOQOL-BREF. This result was similar to a study conducted in Spain before the COVID-19 pandemic that involved 1,241 individuals who were receiving psychological treatment for emotional problems such as depression, anxiety, or somatic symptoms.(62) The reported negative correlation between anxiety and WHOQOL-BREF domains was psychological (b, -0.11), physical (b, -0.11), and environmental (b, -0.14), all p < 0.001. This finding is alarming because anxiety symptoms in the general population during the COVID-19 pandemic lockdown had a similar impact on QOL as in a population receiving psychological treatment. It raised a question of whether we had conducted adequate psychological screening in the at-risk population during the COVID-19 pandemic before they developed long-term sequelae.
Our study has several advantages that worth highlighting. First, an adequate sample size facilitated the generalizability of our study results. Our study was initiated during the initial phase of the first MCO, which allowed us to examine the immediate psychological and coping responses in the Malaysian population. Furthermore, our study was conducted via an online platform, which facilitated respondents’ participation, and reduced drop-out rates. The online questionnaires were available in English and validated the Malay version, which is also the local language of the country.
There were also some limitations that needed to be addressed. Since our study questionnaires were online basis, we were unable to reach communities that did not have access to internet, such as those living in rural areas. It was also possible that the respondents were limited to only those who were well-educated to answer these questions, as it required literacy in one of the two languages offered. This could explain why the majority of our respondents were of tertiary-level education. Our study also did not ask about respondents’ specific fears and concerns during the COVID-19 pandemic MCO. Due to the nature of this cross-sectional study, no true causality can be established between respondents’ psychological and coping responses and the impact on their QOL. The use of convenience sampling makes this study vulnerable to selection bias and influences that were beyond the control of the researchers. There was also the possibility of response and recall error among respondents, as some questionnaires required them to recall events that occurred two weeks ago.