|Ahead of print
|Psychological effects of the COVID-19 pandemic on parents in an urban setting in Andhra Pradesh
Shvetha Chilukuri1, Srinivas Singisetti1, Srikrishna Nukala2, Archana Vinnakota1, Abhilash Garapati3, Vidya Sanapala3, Laxman Rao Nambaru4
1 Associate Professor, Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
2 Professor, HOD, Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
3 Senior Resident, Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
4 Department of Community Medicine, Maharaja Institute of medical sciences, Vizianagaram, Andhra Pradesh, India
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|Date of Submission||15-Jan-2021|
|Date of Acceptance||25-Aug-2021|
|Date of Web Publication||11-Oct-2021|
Background: Existing literature around pandemics suggests that preventive measures during lockdown have an adverse impact on psychological well-being across different demographic groups. In particular, parents' stress is somewhat complex and influenced by the demands of looking after children, homeschooling, and an increase in domestic chores and needs exploration and timely attention.
Aims: The aim is to study the psychological impact of the COVID-19 pandemic and various associated factors on parents.
Settings and Design: This was a cross-sectional study done online using Google Forms sent to WhatsApp groups in an urban setting in Andhra Pradesh, on a purposive sampling basis.
Materials and Methods: A purposive sampling approach using a survey questionnaire through WhatsApp produced data from 159 parents who completed the Depression, Anxiety and Stress Scale (DASS-21) short version and the Parental Stress Scale (PSS).
Results and Conclusions: Criteria for severe stress on the DASS-21 were met in 47% of parents. Severe anxiety and depression were noted in 39% and 40% of the sampled parents, respectively. Mean parental stress scale score significantly correlated with the depression, anxiety, and stress subscales of the DASS-21. These findings indicate that pandemics and subsequent disease-containment responses such as lockdown may create a condition that parents may find overwhelming and one that could have a negative impact on parents and children. Pandemic planning must address these needs within the disease-containment measures.
Keywords: Anxiety, corona, depression, lockdown, parental stress
|How to cite this URL:|
Chilukuri S, Singisetti S, Nukala S, Vinnakota A, Garapati A, Sanapala V, Nambaru LR. Psychological effects of the COVID-19 pandemic on parents in an urban setting in Andhra Pradesh. Arch Ment Health [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.amhonline.org/preprintarticle.asp?id=328059
| Introduction|| |
Humanity is not new to the experience of epidemics and pandemics through the course of history. Only in the last century, the Spanish flu (1918–1920), the Asiatic flu (1956–1957) and in this century, the severe acute respiratory syndrome (SARS, 2002–2003), the “Swine”s; flu (2009), the Ebola (2013–2014), and others significantly affected people worldwide. Several psychological impact studies of these calamities on the general population suggest adverse emotional outcomes. These studies showed elevated levels of stress, depression, anxiety, and posttraumatic symptoms both during the pandemic and up to 1 year later.,,
At the end of 2019, the novel coronavirus disease (COVID-19) that originated from Wuhan, China, spreads rapidly around the globe. The outbreak was then declared a public health emergency of international concern on January 30, 2020, by the World Health Organization. Since then, life around the world has been deeply influenced by the pattern of the disease spread.
In an effort toward disease containment, we observed different countries “shutting down;” India also declared a “national lockdown” on March 25, 2020. “Lockdown” is an emergency procedure enforcing the prevention of movement by the public from one area to another. Consequently, all educational institutions, malls, factories, offices, local markets, public transport, airports, etc., were closed down entirely with exceptions for emergency services such as hospitals, groceries, fire stations, and petrol pumps.,
While lockdown and the enforced social distancing can be effective disease containment strategies, it is not without its own set of adverse psychological sequelae. Negative effects in response to lockdown: fear, nervousness, sadness, guilt, confusion, anger, numbness, and anxiety-induced insomnia were noted within the general population after the SARS epidemic in 2003., There were similar effects noted within the outbreaks of H1N1 in 2009 and the Middle East Respiratory Syndrome outbreak of 2012.,, The existing literature suggests that preventive measures such as quarantine, isolation, and social distancing also impact people's psychological well-being and emotive reactions to the pandemic itself.,,,
Despite the lockdown in India, confirmed COVID-19 cases had steadily risen, the resultant confinement, social, and economic restrictions had also posed a likelihood of persisting at the time of the study. While this predicament can be viewed positively in certain instances, for example, opportunities for personal growth and family bonding, the negative impact may be more distinct than these apparent benefits. Stress, depression, anxiety, lack of social contact, economic restraints, and reduced opportunities to mitigate stress have been the main trepidations across different age groups., Children may feel impatient as they may run out of the options to keep themselves engaged; the elderly may feel that their movement has been restricted, and adults may feel burdened with increased parental responsibilities and household chores in the absence of housemaids.
Parental stress is a cross-cultural concept and is a steadily growing area of research. It is well established that parental emotional status plays a prominent role in children's emotional well-being through daily parent–child interactions. Parental stress can be intensified by many challenging life situations around the pandemic. Containment processes such as lockdown and isolation can be traumatizing to parents and children., The COVID-19 pandemic has confronted parents across the globe with complex choices. Social and economic constraints, the threat of potential contamination when they do get back to work, and increasing demands of homeschooling and domestic chores are some of the challenges parents face today. Although there are recognized mental health threats associated with pandemics and the restrictive processes, very few studies examined these effects on parental stress. Hence, it is imperative to identify stress and resilience factors early on and prevent long-term mental health consequences in families. This study is among the few studies looking at the psychological impact of restrictions posed by the COVID-19 pandemic on parents, 6 weeks into the lockdown.
Aim of the study
To study the levels of stress, anxiety, and depression in parents during the COVID-19 pandemic, to look into the various factors associated with parental stress.
| Materials And Methods|| |
The study was designed and conducted as an online survey using Google Forms. The link was sent to relevant WhatsApp groups across Visakhapatnam, Andhra Pradesh, on a purposive sampling basis. The advantage of anonymity offered by Google Forms was utilized and explicitly explained in the forms. The link was first circulated on May 20, 2020, and kept open for responses till May 27, 2020. A reminder was sent a day before the study was closed. The survey invitation clearly defined the option of participation and the participant's right to decline and explicitly stated that participation implied the provision of informed consent. The instructions given in the beginning of the form were that they should proceed to fill in the form only if they are the parent of a child. Furthermore, it was stated that the study was unsuitable for the respondent if there was preexisting mental illness in the parent or child (including learning disability in the child). The questionnaire sent on WhatsApp clarified and asked only the parent who had the main caring role to respond and specified that only one among the two parents is required to respond. Completion of the survey questionnaire would usually take around 7–12 min. A total of 159 responses were received by the stipulated time, all of which were deemed suitable for the study.
A pilot study was initially done on 30 patients to estimate the required sample size for the study. 11 respondents had significant stress scores, giving a prevalence of 36.66%. The calculation for sample size was done, keeping power of 80%, with a result of 158 required as the minimum sample. The pilot sample was not included in the above study. The response rate per SE for the main study was not possible to detect, as a snowballing (chain-referral) method was used to collect sample. The Google form used excluded duplicate responses. Ethical Committee clearance was obtained from the institute on a fast-track basis.
- Parent of child/children below 18 years of age and being the main caregiver (to avoid duplication of response by both mother and father)
- Parent age between 18–60
- Any gender
- Ability to read English
- An Internet connection and WhatsApp installed on their phone.
- Not providing informed consent for the study
- Preexisting mental illness in parent/children.
- Sociodemographic profile
- The Depression, Anxiety, and Stress Scale (DASS)-21 (short version): The DASS-21 (short version) is a quantitative measure of distress along the three axes of depression, anxiety, and stress using Likert responses from 0 to 4. It is not a categorical measure for clinical diagnoses. The DASS scale can lead to a useful evaluation of disturbance; for example, individuals who fall short of a clinical cut-off for a specific diagnosis can be correctly recognized as experiencing considerable symptoms and at high risk of further problems. The severity labels (as mentioned by the authors of the scale) are used to describe a range of scores in the population. “Mild” for example may mean the person is above the population mean but probably still way below the typical severity of someone seeking help (i.e., it does not imply a mild level of disorder).
- Parent Stress Scale (PSS): The questionnaire was developed by Judy Berry and Warren Jones in 1995 and has 18 items rated on a 5 point scale. It is completed by parents and evaluates both positive and negative aspects of parenthood, i.e., emotional benefits, self-enrichment, and personal development versus demands on resources, opportunity costs, and restrictions. Scores can range from 18 to 90. Higher scores indicated a higher level of parental stress. Despite the DASS-21 having a stress subscale, the PSS was additionally used, keeping in mind the study's aim, i.e., looking into stress specifically from the parenting role.
Both the above scales were used without any translations.
All statistical analyses were performed using the SPSS-16 trial version and in MS Excel 2007. Qualitative variables were expressed in frequencies and percentages, while quantitative variables were expressed in means and standard deviations. Chi-square test was used for examining the categorical data. Karl-Pearson correlation coefficient was used to explore the relationship between quantitative variables. Regression analysis was used for estimating the most influencing factors. Student t-test was used to compare between two group means. ANOVA was used for comparing two or more groups. For all statistical analyses, P < 0.05 was considered statistically significant.
| Results|| |
The total number of respondent participants (n) was 159. The typical participant was female (66.7% of the respondents), with a postgraduate or above education level. Most respondents were health-care professionals (37%) or homemakers (35%). Just under half of the parents (45.9%) from the sample stated that their employment was affected by the pandemic [Table 1].
The mean total DASS-21 score was 30.55 (standard deviation [SD]: 22.201). The mean score on the stress, anxiety, and depression subscales of the DASS-21 was 11.8 (SD 7.5), 8.62 (SD 7.99), and 10.13 (SD 7.66), respectively. 46.4% (n = 75) of the sample scored severe and above on the stress subscale. Correspondingly, 38.5% (n = 62) and 40.9% (n = 65) had severe scores on the depression and anxiety subscales.
[Table 2], [Table 3], [Table 4] show the associations between demographic/independent variables with the various subscales of the DASS-21. The results indicate that parents with higher educational status (undergraduate and postgraduate) had highly significant stress levels (P < 0.001). The levels of stress, anxiety and depression was also higher in health professionals and home makers (P = 0.003, 0.004, and 0.022 for stress, anxiety, and depression, respectively). The association with employment (i.e., employment having been affected by lockdown) was significant with the stress and depression subscales but not so with the anxiety subscale.
|Table 2: Depression anxiety and stress scale-21 stress subscale - association with demographic variables|
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|Table 3: Depression, anxiety, and stress scale-21 anxiety subscale association with demographic variables|
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|Table 4: Depression, anxiety, and stress scale-21 depression subscale - association with demographic variables|
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On the PSS, the sample minimum and maximum scores were 21 and 86, respectively; the mean score was 54.0 (SD: 17.314). [Table 5] depicts the means and associations of the variables on the PSS. Being a female, health professional, or a homemaker, an educational background at or above graduation, and having employment affected by the pandemic were significantly associated with higher parental stress levels.
|Table 5: Parental stress scale: Means comparison and association with demographic variables|
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The score on the PSS, total DASS-21 as well as scores on all the subscales of DASS positively correlated with each other with levels of significance < 0.001 (two-tailed). During regression analysis, the components of DASS: Stress, anxiety, and depression subscales had a significant influence on the PSS score (r = 0.912) (P < 0.001 for stress and < 0.001 for anxiety and depression, respectively). Furthermore, the regression analysis done inversely showed the PSS score having a significant influence on the total DASS score (r = 0.832, P < 0.001).
| Discussion|| |
This study is archetypal in probing into the psychological impact of an exceptional situation (the COVID-19 pandemic) on a specific group within the general population (parents) within a city of Andhra Pradesh, 6 weeks into the lockdown. The study hoped to gain valuable insights into the effects of the uncertainties and restrictions of the pandemic on parents' mental health.
The DASS scales have been shown to have high internal consistency and yield meaningful discriminations in various general settings. The short version of the DASS-21 has good reliability and strong internal consistency. The questions on the PSS, in contrast, address specifically to stress from parenting.
47.2% of the respondents reported having severe or higher levels of stress on the DASS-21. Respondents with corresponding levels of anxiety and depression were slightly lower at approximately 39% each. A similar study on PTSD in parents following disease-containment measures such as quarantine and isolation found that the criteria for PTSD were met in 25% of the parents in isolation or quarantine. Another recent general population study in India early on during the COVID-19 pandemic also showed higher psychiatric comorbidity levels at around 36% for anxiety and lower for depression. Thus, this study's observed higher levels of psychological distress (stress, anxiety, and depression) would be predictable. In our research, while a significant number of respondents fell in the standard score range in all the DASS subscales, those who did experience higher levels of distress fell into the “extremely severe” category. This bimodal distribution of scores came as a surprise. As this is within a specific subgroup of the population (i.e., parents), we explain that perhaps parents coped well within a certain threshold beyond which the transition to pathological distress levels was quick and extreme. Several factors could be viewed as causal, including the lack of traditional means of stress relief and support systems during the pandemic. From [Table 2], [Table 3], [Table 4], [Table 5], it is evident that the brunt of care role and responsibility may have fallen on the homemakers. Parents working in IT and allied professions were the other group that experienced significantly higher levels of stress, anxiety, and depression. These groups also experienced higher levels of parenting stress (P = 0.001). Lesser levels of stress, anxiety and depression were noted in health professionals.
On the DASS-21, summative scores were distinctively high for individual items such as “I tended to overreact to situations” and “I found it hard to relax.” Likewise, on the PSS, questions like “I sometimes worry whether I am doing enough for my child(ren)” and “Caring for my child(ren) sometimes takes more time and energy than I have to give” had maximum summative scores. Perceived lack of flexibility (due to children/child care responsibilities) in balancing various aspects of one's own life was another aspect of the questionnaire that scored high with parents sampled in the study, where respondents gave free comments, lack of domestic help, and financial burden were highlighted. Despite high levels of stress reported by parents, we found low summative scores on the individual items indicative of positive parenting (these are some of the reverse-scored items on PSS), such as “My children are an important source of affection for me” and “Having a child(ren) gives me a more certain and optimistic view for the future” indicative of an overall positive outlook at the time. While it is known that marital disharmony rates increase during a lockdown, this did not feature in the open comment section of responses received. One would hypothesize that the stigma associated with marital disharmony would have made it difficult for the respondents to discuss it openly. It would be worth considering such statements as part of the questionnaire in future studies.
| Conclusion|| |
The COVID-19 pandemic has resulted in substantial change in our environment. The study findings correspondingly indicate that the pandemic and subsequent disease-containment measures evoke a higher level of parents' psychological distress. Pandemic disasters are unique as they do not include congregate sites for recovery but, conversely, require potentially prolonged containment measures. Thus, when placed in a situation where we are suddenly restricted, it is but easy to feel overwhelmed. This is indeed a challenge for everyone, but more so with parents and families. Therefore, mental health practitioners must adapt their practices to address this potential need for family interventions that cater to parents and children, especially during the containment process. Future directions in the field could include supportive, meaningful, and structured sessions through telepsychiatry while staying sensitive to this massive contextual shift. Further studies looking into the long-term impact of the COVID-19 pandemic and containment measures overtime on parents, children, and families could also be insightful.
Despite the questionnaire being sent to many parent groups in the city, the responses received were limited. Although this study was able to capture high levels of psychological distress in parents, it did not consider other potentially confounding variables. These include number of children, ages of children, or for example, many parents may also be cares to elderly parents or children with medical illnesses. Furthermore, inclusion of a comparison group who were not parents could have given strength to the conclusions (of stress resulting from parental role). While there was an open comment section, it might not have captured sensitive issues such as marital disharmony. Studies carried out through WhatsApp questionnaires have inherent limitations, though the same was justified due to the study's expedited nature. The limitations hence include a requirement that parents are tech-savvy and well versed in English. The survey distribution was limited to Visakhapatnam's city; results, therefore, could be generalized to urban populations only and perhaps less reflective of the rural parent population. At the time of the study survey (6 weeks into lockdown), the number of cases and therefore, people undergoing quarantine in Visakhapatnam was negligible and not considered in our study. This, however, can be a significant influencer during the height of any pandemic, and should be considered for future studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam - 530 045, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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