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Orthodontics, 3Conservative Dentistry and Endodontics, Vishnu Dental College, Bhimavaram, 5Department of Prosthodontics
and Implantology, Sai Swaraj Dental Clinic, Guntur, Andhra Pradesh, India, 4Research Assistant, College of Dentistry,
University of Florida, Gainesville, USA
A bstract
Background: It is imperative to acknowledge that COVID‑19 poses significant burden on the psychological well‑being of people. With
implementation of lockdown and measures like quarantine, the mental health of people is affected, and the associated problems
may range from depression to suicidal ideation. With this background, the aim of this study was to assess COVID‑19 anxiety among
general population of the state of Andhra Pradesh. Materials and Methods: This cross‑sectional study assessed the COVID‑19 anxiety
among the population of Andhra Pradesh using COVID‑19 Anxiety Scale (CAS‑7), a seven‑item validated psychometric instrument
which assesses the cognitive, emotional, and physiological dimensions of COVID‑19 anxiety, using a semantic differential scale.
The final sample constituted 1,346 participants. Statistical analysis was done using SPSS version 20 software (IBM SPSS statistics for
Windows version 20, Armonk, NY, USA). Results: The mean age of the study participants was 36.13 ± 10.2 years, and 55.8% were
males. The mean CAS‑7 score in this study was found to be 18.9 ± 6.4. The item with highest mean scores was: “How concerned are
you when people cough or sneeze because of the fear that you may acquire COVID‑19?” No significant differences in CAS‑7 scores
were found based on gender, educational qualification of the participants, while significant differences were observed based on place
of residence, presence of COVID‑19 affected individuals in close surroundings, tobacco, and alcohol consumption. Conclusion: The
results of this study inform that it is imperative for authorities and health care professionals to focus on the mental health aspect
of COVID‑19 and arrange for necessary support mechanisms.
Received: 23-06-2020 Revised: 13-09-2020 This is an open access journal, and articles are distributed under the terms of the Creative
Accepted: 23-09-2020 Published: 30-11-2020 Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is
given and the new creations are licensed under the identical terms.
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How to cite this article: Meesala N, Harsha GV, Kandikatla P,
Karteekvarma PV, Nadakuditi SR, Kakaraparthi SK. Measuring the impact
DOI: of COVID-19 on mental health as a preliminary procedure in primary care
10.4103/jfmpc.jfmpc_1244_20 provision: A cross-sectional study using COVID-19 anxiety scale. J Family
Med Prim Care 2020;9:5554-8.
© 2020 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow 5554
Meesala, et al.: COVID‑19 on mental health
order to provide necessary care for the growing number of this study were the ability to read Telugu, more than 18 years
COVID‑19 cases with an infrastructure and manpower that of age, and no previously known mental health problems. The
is not prepared for the pandemic.[2] Although the physical scale was administered online viz. Google forms, first to the
implications of COVID‑19 are known and are being actively known contacts of the authors, and then these known contacts
shared among populations, mental health implications of were asked to share the form among their contacts. The focus
COVID‑19 are relatively less discussed. It is imperative to of the study was mainly limited to the districts of Srikakulam,
acknowledge that COVID‑19 poses significant burden on the Vizianagaram, Visakhapatnam, East Godavari, West Godavari,
psychological well‑being of people.[3‑5] With implementation of Krishna, and Guntur. The study period was determined apriori
lockdown and measures like quarantine, the mental health of as 1 week, from 11th June to 18th June 2020, and the responses
people is affected, and the associated problems may range from collected during this period were intended to be included in
depression to suicidal ideation.[6] There have been reports on the analysis. CAS‑7 is a brief 7 item instrument with good
completed suicides because of fear of COVID‑19, stigmatization psychometric properties which assesses the cognitive, emotional,
of COVID‑19 affected, etc.[7] In these circumstances, screening and physiological dimensions of anxiety using a semantic
the mental health of populations with regard to COVID‑19 differential scale. The minimum and maximum possible scores
may help in identification of psychological burden posed on CAS‑7 are 7 and 28, respectively. The following demographic
by COVID‑19 among people and facilitates preparation of data were collected along with the COVID‑19 anxiety scale:
necessary health care delivery systems, formulation of targeted age; gender; place of residence; educational background; any
behavioral interventions. Few countries have started online known contact with COVID‑19 affected individual in the past
mental health services to negotiate the growing mental health 2 weeks; any known COVID‑19 cases in the close surroundings
concerns among people.[8] Though structured clinical interviews of the participants (within 2 km); current tobacco and alcohol
are preferred with regard to mental health, it is not uncommon consumption status. All the participants were informed about the
to use psychometric tools in measuring various attributes of study details and expressed consent by voluntarily participating
mental health. There is vast scientific literature on psychometric in the study. Statistical analysis was done using SPSS version 20
instruments measuring depression, anxiety, resilience, fear, stress, software. Descriptive statistics, Independent samples t‑test,
phobia, etc.[9‑12] However, as these psychometric instruments one‑way analysis of variance (ANOVA) were employed in data
were not developed specifically in the context of COVID‑19 analysis.
derived mental health issues, instruments directed at assessing the
mental health burden posed by COVID‑19 are required. A good Results
number of validated psychometric tools were made available
in the past few months to measure COVID‑19 related mental The mean age of the study participants was 36.13 ± 10.2 years,
health problems.[13‑19] Among these measures, COVID‑19 Anxiety and 55.8% were males. Table 1 shows the descriptive statistics
Scale (CAS) is a 7‑item psychometric instrument developed in of the background characteristics of the study population. The
the Indian context aimed at identifying the COVID‑19 anxiety mean CAS‑7 score in this study was found to be 18.9 ± 6.4.
among general population. Table 2 shows item wise mean scores for CAS‑7 based on age
group, place of residence, presence of known COVID‑19 cases
Andhra Pradesh is a South Indian state with a population of in surroundings, tobacco and alcohol consumption status. The
4.97 Crores according to 2011 census. The state is among the two items with highest mean scores were: “How concerned are
states with more number of COVID‑19 confirmed cases, with you when people cough or sneeze because of the fear that you
8,999 confirmed cases and 106 deaths as on 21st June, 2020.[20] may acquire COVID‑19?”; “How afraid are you of acquiring
Andhra Pradesh is also among the top five states/UTs in terms COVID‑19 when going into the public?” There was a statistically
of number of COVID‑19 tests done.[21] With COVID‑19 cases significant difference in the COVID‑19 anxiety scores based on
showing a consistent linear trend over the past few weeks and the place of residence, presence of known COVID‑19 cases in
with the lockdown lifted, it is expected that apprehension, anxiety, the surroundings, age group of the participants, and their current
fear among people will rise. With this background, the aim of this tobacco, alcohol consumption status. No significant differences
study was to assess COVID‑19 anxiety among general population in CAS‑7 scores were found based on gender and educational
of the state of Andhra Pradesh. qualification [Table 3]. Older participants showed significantly
higher CAS‑7 scores compared to younger individuals.
Materials and Methods Higher CAS‑7 scores were observed among participants who
reported identification of COVID‑19 affected individuals
This cross‑sectional study to assess the COVID‑19 anxiety among within their close surroundings. Current smokers and alcohol
the population of Andhra Pradesh was conducted in June, 2020. consumers demonstrated higher COVID‑19 anxiety compared
Ethical approval for the study was obtained from the Institutional to non‑users. CAS‑7 scores were observed to be the highest
Review Board [03‑20‑IRB‑GEMS] on 4/4/2020. COVID‑19 among the population from Guntur and Krishna districts of
anxiety scale (CAS‑7), developed in the Indian context by Chandu Andhra Pradesh, while the least anxiety scores were reported
VC et al., was used to assess the COVID‑19 specific anxiety among from the districts of Srikakulam and Vizianagaram [Figure 1].
general population.[18] The eligibility criteria for participation in Since there was no reported use of tobacco and alcohol among
Journal of Family Medicine and Primary Care 5555 Volume 9 : Issue 11 : November 2020
Meesala, et al.: COVID‑19 on mental health
Journal of Family Medicine and Primary Care 5556 Volume 9 : Issue 11 : November 2020
Meesala, et al.: COVID‑19 on mental health
0 5 10 15 20 25
Conclusion
Figure 2: Association between current tobacco, alcohol consumption It is thoroughly established that epidemics are associated with
status and CAS‑7 scores in the male stratum (n = 752) mental health problems. In the COVID‑19 context, the magnitude
of these problems would only be more severe given the rate of
Health Organization and the central, local governments on transmission of SARS‑CoV‑2. In these circumstances, it is
spreading awareness to refrain from tobacco and alcohol use imperative that authorities and health care professionals focus on
as these habits make the individual more prone for getting the mental health aspect of COVID‑19 and arrange for necessary
infected with SARS CoV‑2. Getting aware of the predisposition support mechanisms. It is also important to acknowledge that
and being unable to quit the habit may lead to dissonance health care professionals are vulnerable for COVID‑19 associated
among the individuals, and the conflict may by the reason for mental health concerns being a part of the frontline workers in
increased anxiety. Nevertheless, it is clear that the two pandemics combating COVID‑19. Hence, documentation of COVID‑19
“COVID‑19” and “addiction” are on a verge of collision which posed mental health burden using validated psychometric tools
only makes the situation more verse in terms of catering to the is the need of the hour.
needs of the population.[30] The understanding of differences in
COVID‑19 anxiety and fear across different categories of the Declaration of patient consent
sociodemographic variables goes a long way in identification
The authors certify that they have obtained all appropriate
of vulnerable populations and facilitation of the provision of
patient consent forms. In the form the patient(s) has/have
necessary mental health services. The findings of this study are
given his/her/their consent for his/her/their images and other
important from a primary care perspective as early identification
clinical information to be reported in the journal. The patients
of COVID‑19 impact on mental health among populations is
understand that their names and initials will not be published and
warranted both in reducing COVID‑19 transmission and in
due efforts will be made to conceal their identity, but anonymity
avoiding burden on the health care systems post COVID‑19.
cannot be guaranteed.
These findings also inform the preparation of psychoeducational
materials to alleviate COVID‑19 specific fear and anxiety among
Financial support and sponsorship
populations.
Nil.
The limitations of this study include collection of data through
Google forms online among an arguably convenient sample. Conflicts of interest
Further, all the study participants have completed secondary There are no conflicts of interest.
Journal of Family Medicine and Primary Care 5557 Volume 9 : Issue 11 : November 2020
Meesala, et al.: COVID‑19 on mental health
Journal of Family Medicine and Primary Care 5558 Volume 9 : Issue 11 : November 2020
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