Psychological Distress, Fear, and Coping Strategies among Citizens and Residents in Saudi Arabia During the COVID-19 Pandemic

Background: COVID-19 caused the worst international public health crisis, accompanied by major global economic downturns, mass-scale job losses, which impacted on the psychosocial wellbeing of the worldwide population. This study examined factors associated with psychosocial distress, fear of COVID-19 and coping strategies amongst the general population in Saudi Arabia. Methods: A cross-sectional study was conducted using an anonymous online questionnaire. Multivariate logistic regressions were used; Adjusted Odds Ratio (AOR) with 95% Condence Intervals (CIs) was reported. Results: Among 803 participants, 70 %(n=556), were females and the median age was 27 years; 35% (n=278), were frontline or essential service workers; 24% (n=195), reported comorbid conditions including mental health illness. Factors associated with moderate to high levels of psychological distress were: youth (18 - 29 years) (AOR 3.35, 95% CIs 2.06 - 5.44), females (2.59, 1.60 - 4.19), non-Saudi nationals (2.17, 1.11 - 4.26), change in employment (2.9, 1.73 - 4.87), negative nancial impact (2.14, 1.29-3.56), having comorbidities (2.67, 1.47 - 4.87), and current smoking (2.87, 1.55 - 5.33). Being ex-smokers (3.72, 1.14 - 12.14) and change in employment (3.42, 1.91 - 6.11) were associated with higher levels of fear of COVID-19. People whose nancial situation was impacted and who had contact with known/suspected cases (1.63, 1.12-2.38) had low medium to high resilient coping. Conclusions: People Saudi Arabia were at higher risk of psychosocial distress and fear along with low resilience from and avoid

Depoux, Martin [15] warned of the possibilities of adverse psychosomatic outcomes among people due to the pandemic, which is likely to be compounded by the constant ow of information (sometimes, misinformation) via online and various forms of social media. It is feared that the rapidly expanding mass hysteria and panic regarding COVID-19 may lead to long-term psychological problems among people, regardless of their socioeconomic status [15]. The limited studies on the impact of pandemics on society concerning previous experiences such as SARS, have pointed to many stressors linked to disease outbreaks and pandemics [16,17]. Few studies have examined the factors associated with mental wellbeing within Saudi Arabia and a study focused on the psychological impact of COVID-19 in Bahrain [7] and the United Arab Emirates [18]. A Saudi survey reports that 19.6% of 3017 respondents had moderate to severe anxiety levels during the pandemic [19]. Another study reported the occurrence of moderate or severe psychological impact among 23.6% of respondents [20]. Regarding residents in Saudi Arabia, most of them are temporary workers, mainly from low-income and middle-income countries. It is well documented that COVID-19 related deaths and infections had been disproportionately high among them compared to a high-income country like Saudi Arabia [2]. Previous research from Saudi Arabia examined the psychological impact among healthcare workers [21,22]. However, the present study aimed at examining the factors associated with psychosocial distress, fear of COVID-19 and coping strategies amongst the general population of Saudi Arabia.

Aim of the study
This study aimed to examine the factors associated with psychosocial distress, fear of COVID-19 and coping strategies amongst the general population in Saudi Arabia.

Study design and settings
This cross-sectional study was conducted among the general population Saudi Arabia. The study was conducted over 30 days, from 15th December 2020 to 15th January 2021. The participants were aged between 18 and 65 years old. The questionnaire was designed in accordance with the previously published literature and the survey was pre-tested for validation amongst migrants and non-migrants [14,23]. The present study used same methods and tools that used The survey was conducted in Arabic and English and took about 15 minutes to be completed. The present study used same methods and tools that used for the previous studies [14,24].

Study population and sample size
The study population included people residing in Saudi Arabia (irrespective of nationality), ≥18 years old and could respond to either Arabic or English questionnaires on an online platform. This included including patients, frontline health and other essential service workers, and general community members.
Snowball sampling was used to select study participants, so that the respondents could forward the survey link to their personal and professional networks. OpenEpi software was used to calculate the sample size. Considering 35.3 million populations in Saudi Arabia [25] assuming 50% prevalence of stress among the people, at 95% con dence intervals and 80% power, the estimated minimum sample size was 385.

Data Collection
An online link in Arabic and English was created with a structured survey questionnaire using the Google form. The plain language information statement and the informed consent form appeared on the rst screen. Only the participants, who provided informed consent and agreed to participate in the study, could move to the next screen containing the single eligibility criteria of being an adult. The subsequent screens had the complete study questionnaire. The anonymous questionnaire was introduced, and the invitation, which included an internet link and a QR code, was distributed via social media platforms, online community networks, staff and student email databases of participating universities/hospitals. Participants had the freedom to complete the questionnaire in their free time at home or while waiting to see a doctor. The online survey did not capture any personally identi able information from them.

Study tool
The structured survey questionnaire was adapted from a previous Australian study conducted for the same objective of this study [14]. Psychological distress was measured using the Kessler Psychological Distress Scale (K-10) [26], fear was measured using the Fear of COVID-19 Scale (FCV-19S) [27], and coping was measured using Brief Resilient Coping Scale (BRCS) [28]. The tools have been recently examined for reliability and validity and it was found that these tools are valid and reliably amongst both migrant and non-migrant populations in Australia [23].

Ethical Considerations
All participants were requested to sign an informed consent form before lling the questionnaire to register their willingness to participate. All methods were performed in accordance with the relevant guidelines and regulations of the Declaration of Helsinki. Ethical approval was obtained from the Human Research Ethics Committee in King Fahad Medical City, Saudi Arabia (H-01-R-012).

Data Analyses
The database was downloaded from Google form and analyzed using SPSS v.25. Descriptive analyses had been undertaken to describe the study variables. Mean and standard deviations were computed for the continuous variable (age) and each scale (K10, FCV-19S and BRCS), while proportions were reported for categorical variables. To conduct inferential analysis K10 was de ned into low (score 10-15) and moderate to very high (score 16-50), FCV-19S scale was categorized into low (score 7-21) or high (score [22][23][24][25][26][27][28][29][30][31][32][33][34][35] and BRCS into low (score 4-13) and medium to high (score 14-20) resilient coping. Crosstabulation of the factors associated with psychological distress was done by comparing low and moderate to very high distress on the K10 scale. Factors associated with fear of COVID-19 were identi ed by comparing low and high fear on the FCV-19S scale, and factors associated with coping were identi ed by comparing low and medium to high resilient coping on the BRCS scale. Multivariable logistic regression analyses were performed to investigate the factors of moderate to very high distress on the K10 scale, high level of fear of COVID-19 on the FCV-19S scale, and medium to high resilient coping on the BRCS scale. Statistical signi cance was determined by p < 0.05. Odds Ratios (ORs) with a 95% con dence interval (CI) was used to assess the strength of the association. Adjusted ORs (AORs) indicated adjustment of potential confounding variables.

Results
A total of 803 individuals, aged ≥18 years, living in Saudi Arabia, participated in this study. Table 1 presents the characteristics of the participants. More than half of the participants (57.1%) were younger (18-29 years) and the majority (69.5%) were females, had a bachelor's degree or above (64.5%), and were living with family (85.8%). More than a third (34.6%) of the participants worked as frontline or essential service workers during the pandemic. Just over a third (33.7%) reported negative nancial impact due to COVID-19. Only 16.3% of the participants were current smokers, and more than half (56.5%) of them increased smoking during the pandemic. About a quarter (24.3%) reported pre-existing comorbid conditions including mental health issues (5.6%). About a tenth (8.2%) of the participants had tested positive for COVID-19, while over a tenth (12%) tested negative. More than a third (36.2%) had close contact with con rmed or suspected COVID-19 cases.

Psychological distress
Among the study participants, 72% experienced moderate to very high levels of psychological distress. One in four individuals (25.8%) experienced very high levels of psychological distress ( Table 2). After adjusting for the effects of potential confounders, evidence of signi cant association for moderate to very high psychological distress was observed with age, sex, nationality, perceived distress due to change of employment, the nancial impact of COVID-19, having co-morbidities and current smoking. (Table 3).  Fear of COVID-19 Among the participants, one in 10 (11.1%) demonstrated high levels of fear of COVID-19 (Table 4). In the multivariate analyses, it was found that a high level of fear of COVID-19 was signi cantly associated with perceived distress due to change of employment situation and smoking status. Individuals who perceived moderate to a great deal of distress due to change in employment were 3.42 (95% CI: 1.91 -6.11) times more likely to experience high levels of fear of COVID-19 compared to the individuals who perceived a little or no distress. Being an ex-smoker was associated with higher levels of anxiety of COVID-19 compared to those who never smoked (AOR .72, 95% CI: 1.14 -12.14) ( Table 5).  Coping strategies More than half (55.8%) of the participants had medium to high resilient coping (   This study indicated a high percentage (70%) of people who suffered from distress during the pandemic, the prevalence of which was more than double compared to other local research in Saudi Arabia.
Referring to Alkhamees, Alrashed [29] assessed psychological impact during an early stage of the pandemic and showed that a quarter of the participants suffered from a moderate to severe psychological impact [20]. Al-Hanawi, Mwale [30] also conducted a study in May 2020 and indicated that 40% of the general public in Saudi Arabia suffered from psychological distress caused by COVID-19 [30].
Thus, as COVID-19 lasted for a prolonged period, more people are expected to have a psychological impact, and more efforts are needed for psychological support. The same observation was noted in Canadian research showing a signi cant increase in stress during the COVID-19 outbreak [31]. In addition, other factors may play a role in contributing to the increased level of psychological distress in this study as the previous studies were conducted during the initial months of the pandemic. 'Infodemic' could potentially contribute to the heightened distress in this study, which requires further investigations.
In terms of associated factors, age, gender, nationality, perceived distress due to change of employment conditions, the nancial impact of COVID-19, and smoking were signi cantly associated with higher levels of psychological distress. Similar to this study, research conducted in the US during the pandemic showed that women, Hispanics, Asians, families with children under 18, and foreign-born respondents had higher subjective fear and worry levels than their counterparts [32].
Individuals aged 18-29 years had higher psychological distress this result coincides with A report from over 60 countries found that Younger age groups were more vulnerable to the mental health impact of the pandemic [10]. The explanations of the result which could be a result of dependence on inauthentic information received from social media platforms. Marar, Al-Madaney [33] reported that most of the Saudi population used social media platforms when they needed health information. Another study showed that social media had a positive impact on the knowledge of the Saudi population towards COVID-19 [34]. However, it was found that younger individuals were less likely to practice coping methods such as spirituality and mindfulness, which has proved to be a handy tool to control stress and depression [35].
In this study, smoking was associated with increased psychological distress. According to previous evidence, smoking could cause symptoms such as depression and anxiety [36]. In a study from England, there was a signi cant association between psychological distress and past smoking [37]. The study showed further deterioration in mental health among smokers during the COVID-19 pandemic. A systematic review also showed a bi-directional effect between psychological distress and smoking [36].
Signi cantly, one research indicated that 25% reported increasing smoking more than usual, though 51% reported smoking the same amount during COVID-19 pandemic [38]. It is important to note that a recent study from Saudi Arabia showed a prevalence of cigarette smoking of 21.4% in the population [39]. Thus, it is essential to further investigate to alleviate the risk of smoking and mental health in the population especially during the pandemic.
Additionally, changes in employment conditions and nancial challenges were related to high level of fear from COVID-19 and psychological distress. The economic effect of COVID-19 was well described worldwide [40]. In particular, research undertaken in Italy, India, South Africa, the UK and the USA identi ed that, cigarette smokers bought more cigarettes than usual triggered by the fear that stores might run out of stock or be closed because of lock down during the pandemic [11].
In terms of coping strategies, more than half of the study participants had medium to high resilient coping. The relationship between coping strategies and stress was assessed previously [41,42] According to previous literature; Saudis are reasonably resilient to COVID-19 stress compared to other countries experiencing this pandemic with high quality of life scores [43]. Unlike other countries suffering from food insecurity and free treatment, unavailable beds at intensive care units, and insu cient doctors, the Saudi government made extraordinary efforts in economics, health, religion, social support, food, and quality of life [3].
Individuals in this research, who came in contact with con rmed or suspected COVID-19 cases were more likely to have medium to high resilient coping, which could be due to accessing free treatment and an advanced healthcare system in Saudi. In addition, there is a clear relationship between coping strategy and stress outcome [44]. In one study, religion was one of the most frequent coping strategies among nursing students in Saudi Arabia [45]. with psychological distress, levels of fear, and coping strategies among community members, frontline workers, and patients across 17 countries found physicians had higher psychological distress, but low levels of fear of COVID-19; nurses had medium to high resilient coping [24]. Despite positive coping strategies in the health and medical eld, there were limited coping strategies for other essential service workers, and general community members who suffered from CVOID-19. Future studies should focus on intervention measuring and programs among the general population in Saudi to identify coping strategies.
This study had a large and representative sample from different categories of frontline workers and the general population and was conducted during the second wave of the pandemic. Findings will assist in having a clear vision for decision-makers to manage psychological distress and fear of COVID-19 with adaptable strategies for Saudi people. However, there are several limitations to this study. The use of an online self-administered questionnaire may have introduced response and recall bias. Additionally, the dissemination of questionnaires through social media platforms for recruitment resulted in having more participants from certain regions than others.

Conclusion
Identi cation of high-risk groups with increased psychological distress and fear during the current COVID-19 pandemic was critical. Factors identi ed in this study would strengthen illness prevention by guiding policymakers for such a vulnerable population. Healthcare authorities should monitor young people and smokers about their mental health, and considering a behavioural support program will be invaluable.
Those affected by changes in employment and negative nancial impacts, should be prioritised within the current support services available in Saudi Arabia. Living in a COVID-safe environment and adopting a lifestyle supporting both physical and mental well-being during the pandemic era is warranted in Saudi Arabia. Saudi Arabia (H-01-R-012). Each study participant read the informed consent form along with a plainlanguage summary and ticked their consent in the online form prior to accessing the study questionnaire.

Abbreviations
All methods were performed in accordance with the relevant guidelines and regulations of the Declaration of Helsinki.

Consent for publication
Data were collected anonymously; therefore, no identifying information was collected from the study participants.
Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Con ict of Interest
The authors have declared no con ict of interest.

Funding Sources
This research did not receive any speci c grant from funding agencies in the public, commercial, or notfor-pro t sectors. Authors