This cross-sectional survey was conducted among people in Saudi Arabia. Aspects of psychological distress, fear of COVID-19, and coping strategies were assessed using K10, FCV-19S and BRCS scales, respectively.
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  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 . Al-Hanawi, Mwale  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 . 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 significant increase in stress during the COVID-19 outbreak . 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 financial impact of COVID-19, and smoking were significantly 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 .
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 . The explanations of the result which could be a result of dependence on inauthentic information received from social media platforms. Marar, Al-Madaney  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 . 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 .
In this study, smoking was associated with increased psychological distress. According to previous evidence, smoking could cause symptoms such as depression and anxiety . In a study from England, there was a significant association between psychological distress and past smoking . 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 . Significantly, one research indicated that 25% reported increasing smoking more than usual, though 51% reported smoking the same amount during COVID-19 pandemic . It is important to note that a recent study from Saudi Arabia showed a prevalence of cigarette smoking of 21.4% in the population . 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 financial challenges were related to high level of fear from COVID-19 and psychological distress. The economic effect of COVID-19 was well described worldwide . In particular, research undertaken in Italy, India, South Africa, the UK and the USA identified 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 .
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 . Unlike other countries suffering from food insecurity and free treatment, unavailable beds at intensive care units, and insufficient doctors, the Saudi government made extraordinary efforts in economics, health, religion, social support, food, and quality of life .
Individuals in this research, who came in contact with confirmed 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 . In one study, religion was one of the most frequent coping strategies among nursing students in Saudi Arabia . The Ministry of Health in Saudi Arabia developed multiple methods to support the wellbeing and mental health of frontline and health care providers. This included mobile applications, hotlines and virtual meeting available for addressing concerns and worries of healthcare providers . It is also important to note that different health care professionals and age groups may use different coping strategies. In one study, nurses used avoiding coping style and positive reappraisal than doctors and those > 40 years of age used social support and those <40 years relied on avoidance of stress management techniques . The global cross-sectional studies that assessed associated factors 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 . Despite positive coping strategies in the health and medical field, 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.