Abstract
Background:
Coronavirus disease (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was declared a global pandemic in March 2020, affecting certain health measures. Precautionary hygiene measures of hand washing, mask-wearing, and social distancing were advocated and disseminated to the public through different government machinery.
Aim:
The current study explored if government messaging had an impact on the knowledge of COVID-19 and the necessary precautionary behaviors in three groups: persons with past suicide attempts (PSA), persons with schizophrenia (SZ), and the general population during the first lockdown (March to May 2020).
Materials and Methods:
A cross-sectional 22-item questionnaire was designed to assess “precautionary knowledge,” “precautionary behaviors,” “living circumstances,” and “tobacco and alcohol consumption” before and during the first Indian lockdown. PSA and SZ were contacted telephonically, while for the general population, the survey was adapted into Google Forms and circulated as a WhatsApp link. Inclusion criteria were both genders, 18-65 years, and Indians residing in India.
Results:
No differences among PSA, SZ, and the general population were reported in the knowledge for the lockdown and behavior for “hand washing,” “mask-wearing,” and “frequency of going outdoors.” Almost 15% of the general population moved back home during the lockdown. A significantly higher frequency of alcohol consumption was reported by the general population both before and during the lockdown compared with PSA and SZ.
Conclusion:
Appropriate COVID-19 knowledge and behavior were seen in PSA, SZ, and the general population. Thus, government-mandated behaviors for COVID-19 were adhered to by all three groups. The study demonstrates the effectiveness of the government’s health messaging among people with severe mental illnesses in times of a novel worldwide health crisis.
Keywords: COVID-19, public health, schizophrenia, suicide attempt
COVID-19 was declared a global pandemic by the World Health Organization on March 11, 2020,[1] when countries were recommended to effectively communicate ways to protect the public. The first confirmed case of COVID-19 in India was reported on January 30, 2020. In Kerala.[2] To arrest the rapid spread of the virus, the Indian Prime Minister announced a nationwide lockdown effective March 25, 2020. Precautionary measures of hand washing, mask-wearing, social distancing, quarantines, and self-isolation were repeatedly advocated by the government to mitigate human-to-human transmission.[3,4,5] These messages were repeated in multiple languages via caller tunes, media advertisements, and newspapers. Additionally, the Government of India launched the Arogya Setu mobile application on April 2, 2020.[6]
While much attention has been focused on COVID-19 morbidity and mortality rates in India, few studies have explored the impact of the pandemic on those with mental health disorders.[7] Specifically, the knowledge and attitudes of people with mental illnesses regarding the government’s precautionary measures have received little attention. This information is critical, as those with severe mental illnesses (SMIs) like schizophrenia, schizoaffective disorders, bipolar affective disorder, and major depressive disorder have impaired cognition that may impede information processing due to information overload from the media about the lethality of the pandemic.[8] Cognitive difficulties interfere with the ability to use technology like mobile applications for knowledge acquisition, further resulting in reduced awareness of the risks, reduced efforts at maintaining safety protocols, and an under-reporting of physical symptoms during crisis.[9] Inpatients are at further risk because of closed surroundings. Impaired judgment and poor self-care characteristics of SMIs further impede compliance with overall health guidance and put patients, their families, and professionals at risk.[10]
In China, 300 psychiatric inpatients tested COVID-19 positive due to noncompliance with precautionary measures.[11] A Romanian study found that male psychiatric patients diagnosed with either SMIs or substance and alcohol use disorders had significantly lower general knowledge of COVID-19 preventive measures as well as a lower ability to identify misinformation about the virus and the pandemic compared to controls.[12] A telephonic survey of Indian patients with SMIs conducted within a month of the first lockdown found that 8% of the patients lacked any awareness of COVID-19, and more than half lacked substantial knowledge of the physical symptoms of COVID-19 and safety precautions to be undertaken.[7] However, this study did not compare patients’ awareness about COVID-19 with that of the general population.
These studies suggest the difficulty experienced by psychiatric patients in fully following government guidelines during a crisis due to information overload and frequent changes in healthcare directives and recommendations about the pandemic.[13] Moreover, persons with SMIs have physical comorbidities like anemia (12%), diabetes (15%), and hypertension (21%) that may put them at additional risk for COVID-19 infection.[14] Thus, assessing their knowledge and behavior during the pandemic becomes necessary.
The current online/telephone-based study aimed to assess the difference if any, in the COVID-19 compliance knowledge and behaviors by government-mandated safety protocols among persons with a history of suicide attempts (PSA, excluding psychosis), persons with schizophrenia (SZ) and the general population residing in India.
MATERIALS AND METHODS
Participants
The study was a purposive sampling cross-sectional study conducted as online and telephone-based survey at two tertiary care teaching hospitals in New Delhi and Bengaluru, India. Participants were drawn from three different samples: (a) patients with a diagnosis of schizophrenia as per DSM-IV TR from the authors’ earlier research studies on Yoga or Mindfulness in schizophrenia,[15,16] (b) persons participating in a funded research study with a history of suicide attempt in the past month at the time of recruitment,[17,18] and (c) participants from the general population with access to smartphone and WhatsApp application. Inclusion criteria were all genders, ages 18-65 years, Indians residing in India, and the ability to provide oral/written consent to participate. There were no exclusion criteria. Participants who reported active suicidality during the interview were redirected to the research personnel who had administered them a 20 min brief telephonic manual-based intervention for suicidal thoughts at the time of the conduct of the original study in New Delhi and Bengaluru centers.[17,18]
Procedure
The study was approved by the Institutional Ethics Committee at both New Delhi and Bengaluru centers. The survey was conducted in two formats between June and September 2020: a telephone-based survey for SZ and PSA and an online survey developed using Google Forms and shared through WhatsApp for the general population (available on request from the corresponding author). For SZ and PSA, research staff at both centers contacted previously recruited study participants who had provided consent to be re-contacted. Those who answered the call and provided consent for the current survey were enrolled. Each call lasted 45 minutes.
The general population was recruited online through a Google Forms link via WhatsApp messaging. The survey was self-administered and took approximately 20-25 minutes to complete. Using the “validation” feature for “age,” we ensured that only Indians between 18 and 65 years could complete the survey. The data collected was entered into Excel sheets, and double-checked for any discrepancies. Duplicate entries from the same email addresses were identified, and the first response entry was retained.
Instrument
The online and telephonic data collection methods utilized the same survey. The survey was designed as a 22-item questionnaire divided into four sections assessing knowledge and impact of the pandemic on the following domains: “precautionary knowledge,” “precautionary behaviors,” “circumstances of living,” and “tobacco and alcohol use.” Questions were administered in one of the three formats: (a) multiple choice, (b) multiple selection, (c) short text entry or numeric entry, and administered in the format of “before lockdown” (before March 25, 2020) and “during lockdown” (March 25, 2020, to May 17, 2020). The 22 questions were preceded by a sociodemographic section that was based on the Diagnostic Interview for Genetic Studies.[19] The final survey was adapted into Google Forms for online data collection.
The questionnaire was developed via detailed discussion among a team of psychiatrists, psychologists, and social workers over two months. The content was reviewed and approved by an independent team of research psychologists and social workers, then piloted on five members of the research staff (not involved in the survey design and development) and five members of the general population to ensure comprehension and relevance.
Statistical analysis
Descriptive statistics were used to compare differences in findings by each of the three groups. Chi-square tests and analysis of variance were used to compare categorical and continuous variables respectively, and significant differences were further explored via post hoc Bonferroni comparisons to pinpoint differences among groups.
RESULTS
A total of 443 responses were collected: telephonically (n = 151) and online (n = 292). Duplicate entries and online entries from Indians residing abroad were removed (n = 32). A total of 411 responses were included in the final analysis: telephonic (n = 151) and online (n = 260) [see Figure 1]. Those from the past suicide attempt study (PSA) from Delhi and Bengaluru centers were combined to create the first cohort. Persons with schizophrenia (SZ) were from the Delhi study only and formed the second cohort. The third cohort was the general population contacted via WhatsApp.
There were significant differences by gender, with PSA having more females and the general population and SZ having more males. PSA was younger than the other two groups. Post hoc comparison showed that more respondents in the general population were married when compared to PSA (χ2 (2, n = 352) =5.18, P = .027) and SZ (χ2 (2, n = 319) =21.15, P < .0001). Additionally, there was a significant difference in the level of education among the three groups (χ2 (3, N = 411) 21.34, P < 0.0001). The SZ group reported the lowest level of education while those in the general population reported the highest. The majority of the general population had an undergraduate degree or higher, while the majority of PSA and SZ had a high school education or lower. There was significantly more unemployment in SZ as compared to the other two (χ2 (3, N = 411) 67.32, P < .0001). Post hoc analysis showed PSA had significantly more unemployed persons when compared with the general population (χ2 (2, n = 352) 16.21, P < .0001) [Table 1].
Table 1.
Demographic Variables | Past Suicide Attempt (n=92) | Persons with Schizophrenia (n=59) | General Population (n=260) | Χ2/F | P | |
---|---|---|---|---|---|---|
Gender | Male | 30.43% | 62.71% | 70.38% | 45.48 | <0.0001 |
Female | 69.57% | 37.29% | 29.62% | |||
Age | Age Mean±SD | 30.63±9.41 | 38.13±9.45 | 39.73±12.43 | 21.66 | <0.0001 |
Marital Status | Married | 34.78% | 52.54% | 77.31% | 22 | <0.0001 |
Unmarried | 65.22% | 47.48% | 22.70% | |||
Employment | Employed | 84.27%% | 59.32% | 96.54% | 67.3 | <0.0001 |
Unemployed | 15.73%% | 40.68%% | 3.46% | |||
Education | Illiterate | 3.30% | 1.70% | 0 | 21.34 | <0.0001 |
Upto primary school | 4.40% | 1.70% | 0 | |||
Upto middle school | 13.19% | 23.73% | 0 | |||
Upto high school | 43.96% | 38.98% | 2.70% | |||
Undergraduate | 25.27% | 25.42% | 40.38% | |||
Postgraduate and above | 9.90% | 8.47% | 56.92% |
No significant difference was seen among PSA, SZ, and the general population for “Why was there a lockdown?” More than 80% of all three groups attributed the reason for the lockdown to the “virus.” Chi-square analysis showed statistically significant differences among the three groups regarding the reason for regular hand washing (χ2 (3, N = 411) =17.62, P = .002), mask-wearing (χ2 (3, N = 411) =4.2, P = .005), and quarantine (χ2 (3, N = 411) =55.74; P < .0001). Among those who stated government order (12% PSA, 10.2% SZ, and 18% general population), SZ had significantly lower awareness regarding hand washing, mask-wearing, and “knowledge of quarantine” than both PSA and the general population after post hoc comparison. More participants in the SZ group attributed regular washing of hands (χ2 (2, n = 319) =16.06, P = .002) and wearing of the mask (χ2 (2, n = 319) =11.31, P = .006) to “government order,” than those from the general population. Similarly, more in SZ attributed the reason for hand washing (χ2 (2, n = 151) =6.37, P = .029) and mask-wearing (χ2 (2, n = 151) 9.81, P = .005) to “government order” when compared with PSA. Concerning the knowledge of being quarantined, significantly more persons in SZ reported “did not know” as compared to PSA (χ2 (2, n = 151) =13.21, P < .0001) as well as the general population (χ2 (2, n = 319) =38.45, P < .0001) [see Figure 2].
No significant difference was found among the three groups in the “frequency of going outdoors,” “washing hands on returning home,” or “wearing masks while going out” during the lockdown. On average, all three groups went outside “once or twice a week,” and “usually” (four to six times) washed their hands and wore masks when outdoors [see Table 2].
Table 2.
Past Suicide Attempt (n=92) | Schizophrenia (n=59) | General Population (n=260) | Χ2/F | P | |||
---|---|---|---|---|---|---|---|
| |||||||
Precautionary behaviour during the pandemic | |||||||
*How often did you go out of the house? | 2.65±1.57 | 2.42±1.42 | 2.39±1.41 | 1.14 | 0.319 | ||
*How often did you wash your hands after coming back from outside? | 4.85±0.55 | 4.61±1.08 | 4.84±0.63 | 2.867 | 0.058 | ||
*How often did you wear a mask when going out? | 4.91±0.47 | 4.76±0.9 | 4.87±0.63 | 1.004 | 0.367 | ||
Circumstances of living (Before vs During Lockdown) | |||||||
Where were you before/during the lockdown? | Before Lockdown | At Home | 93.50% | 94.90% | 79.60% | 15.57 | 0.001 |
Another Place | 6.50% | 5.10% | 20.40% | ||||
During Lockdown | At Home | 95.70% | 94.90% | 89.60% | 4.19 | 0.131 | |
Another Place | 4.30% | 5.10% | 10.40% | ||||
Change | No change/Back home/Away from home | 84/5/3 | 57/1/1 | 210/38/12 | 13.64 | 0.009 | |
How many rooms did that place have? | Before Lockdown | 2.23±1.75 | 2.71±1.63 | 3.05±1.29 | 10.984 | 0 | |
During Lockdown | 2.26±1.57 | 2.76±1.45 | 3.26±1.33 | 17.618 | 0 | ||
How many people lived there together? | Before Lockdown | 4.6±2.34 | 4.69±2.18 | 3.42±1.73 | 18.557 | 0 | |
During Lockdown | 4.61±1.97 | 4.8±2.24 | 3.71±1.79 | 12.525 | 0 | ||
Were you living with family members only? | Before Lockdown | Yes | 80.40% | 81.40% | 82.70% | 0.826 | 0.93 |
No | 13% | 13.60% | 13.80% | ||||
Others were there too | 5.40% | 5.10% | 3.50% | ||||
During Lockdown | Yes | 79.30% | 86.44% | 88.10% | 10.737 | 0.094 | |
No | 16.30% | 10.20% | 8.50% | ||||
Others were there too | 4.30% | 3.40% | 3.50% | ||||
Did you feel that you were staying in a crowded situation? | Before Lockdown | Yes | 12% | 13.60% | 10% | 0.705 | 0.702 |
No | 88% | 86.40% | 89.20% | ||||
After Lockdown | Yes | 12% | 8.50% | 5% | 5.127 | 0.073 | |
No | 88% | 91.50% | 94.20% | ||||
Did you lose your job during lockdown? | Yes | 7.37% | 5.10% | 6.20% | 1.49 | 0.86 | |
No | 90.24% | 94.90% | 91.90% | ||||
Don’t know | 2.44% | 0 | 1.90% | ||||
Tobacco and alcohol consumption (Before vs During Lockdown) | |||||||
**How often do you use tobacco? | Before lockdown | 0.36±1.12 | 0.79±1.57 | 0.63±1.62 | 4.26 | 0.12 | |
During lockdown | 0.25±0.91 | 0.71±1.52 | 0.54±1.56 | 4.14 | 0.13 | ||
Change (decrease) | 2 | 2 | 8 | 0.29 | 0.92 | ||
***How often do you have a drink containing alcohol? | Before lockdown | 0.21±0.64 | 0.19±0.66 | 0.49±0.86 | 6.32 | 0.002 | |
During lockdown | 0.09±0.35 | 0.10±0.55 | 0.35±0.81 | 6.37 | 0.002 | ||
Change in alcohol intake No change/increase/decrease | 86/0/6 | 56/0/3 | 225/5/29 | 6.37 | 0.15# |
*Answered on a 5 point Likert scale: 5 = Daily/Always, 4 = Usually (4-6 times a week), 3 = Often (2-3 times a week), 2 = Sometimes (Once a week), 1 = Never **Answered on a 5 point Likert scale: 4 = 4 or more times a week 3 = 2-3 times a week, 2 = 2-4 times a month, 1 = Once a month or less 0 = Never ***Answered on a 5 point Likert scale: 4 = Daily/Almost daily 3 = Weekly, 2 = Monthly, 1 = Less than monthly 0 = Never #There was no significant change in alcohol intake before and during
Our survey found a higher percentage of the general population living away from home before the lockdown than PSA and SZ; however, they largely stayed at home during the lockdown. Significantly more people in the general population moved back home during the lockdown. Post hoc analysis suggested that the general population was found to have better living conditions than PSA with a greater mean number of rooms in the house before lockdown (3.05 ± 1.29, P < .0001) and during lockdown (3.26 ± 1.33, P < .0001), while there was no significant difference between SZ and the general population, and PSA and SZ. The mean number of people living in the same house was less than four in the general population, while more than four in PSA and SZ. This situation did not change significantly from before to during lockdown in any of the groups.
No difference was found in the groups regarding losing jobs in the lockdown. More than 90% of participants in all three groups stated that they did not lose their job.
No difference was found among the three groups in terms of frequency of tobacco consumption, and no significant change in tobacco consumption was reported from before lockdown to during lockdown in all three groups. The frequency of alcohol consumption was significantly higher in the general population both before and during lockdown. No significant change in alcohol intake in the three groups was reported from before lockdown to during lockdown [see Table 2].
DISCUSSION
Having access to current and understandable information about preventing COVID-19 infection is associated with following recommended practices of hand washing, mask-wearing, social distancing, and isolation.[20] Findings from previous studies have reported mental health disorders to be a risk factor for COVID-19 acquisition, as well as a poor predictor of prognosis after infection due to various factors including difficulty in processing health-related information, lack of adherence to preventive measures, poor living circumstances and greater medical comorbidities.[21,22,23] The current study compared “precautionary knowledge,” “precautionary behavior,” “living conditions,” and “tobacco and alcohol use” among persons with PSA, persons with schizophrenia (SZ), and the general population through a self-reported survey.
PSA and SZ study participants seeking psychiatric treatment at government hospitals in Delhi and Bengaluru had significantly different sociodemographic characteristics from the general population that was recruited through an online survey. SZ had the highest level of unemployment among the three groups, aligning with previous research on high unemployment in persons with SMIs when compared with the general population.[24,25] PSA and SZ were also less educated, with only a third of the participants in both groups completing an undergraduate degree. In the general population, almost all participants had an undergraduate degree or above. They had higher employment rates and were employed in better-paying professions than PSA and SZ. They also had better living conditions with a greater number of rooms in the house and fewer people living together in the same house.
Our results found more than 80% of participants in all three groups correctly attributed the reason for the lockdown to the virus. All three groups also followed the precautionary behaviors advocated by the government, like regular washing of hands, wearing of masks, and reduced frequency of going outdoors during the lockdown. The government’s constant messaging was effective in not only creating awareness about the pandemic but also in the practice of and adherence to government-mandated protocols. However, regarding precautionary knowledge about the pandemic, we found SZ were relatively less aware of the virus being the exact reason for hand washing and mask-wearing when compared with PSA and the general population (although they were a small minority in all three groups). Post hoc analysis revealed that among those who attributed the reasons for hand washing and mask-wearing to “government order,” the SZ group was the highest. It appears that while messages regarding the requisite measures to be undertaken reached the SZ group, the exact reasons for engaging in the precautionary behaviors may not have been well understood by them. SZ likely followed hygiene measures because the government said so, and not due to the COVID-19 outbreak. Their lack of comprehensive understanding could be attributed to relative impairment in cognitive ability for abstraction and inference, along with factors like lack of motivation and insight that may hinder persons with SZ from complete information processing.[26] Their lack of employment and education may have reduced “opportunities for social exchange of information,”[12] as well as reduced access to the internet, online media, etc., for the acquisition of health-related information.[7] This also explains why SZ demonstrated lower awareness when asked, “Were you in quarantine?” Cognitive difficulties in schizophrenia may prevent thorough grasping of a new term and its relative meaning during a crisis.[8] Nonetheless, the government directives regarding COVID-19 reached this vulnerable population, which adhered to these directives as well as the general population.
A possible explanation for high rates of adherence to government directives could be the living circumstances of SZ, which had the highest mean number of people living together in the same house. This may have resulted in better compliance despite not fully grasping the reason for these behaviors. Living with more caregivers in the same house may have led to better supervision and the modeling of precautionary behaviors. In collectivistic cultures like India, interdependent living is a central feature of the family system, which in turn has been shown to contribute significantly to the recovery of those with mental illness when compared with the West.[27,28,29]
PSA demonstrated better knowledge than SZ of the pandemic. This could be due to younger age and higher employment in PSA than in SZ. In our study, the number of females with suicide attempts was more compared to males with suicide attempts. A study found that recent female suicide attempters have better cognition than recent male suicide attempters.[30] This could possibly explain the good knowledge of the pandemic and appropriate behaviors in the PSA population in our study. Suicide attempters, however, have poorer cognition as compared to healthy controls. Their lower awareness when compared with the general population is not surprising.[31,32] This puts PSA “in-between” SZ and the general population.
The general population in our survey was found to have a significantly higher frequency of alcohol consumption than PSA and SZ both before and during lockdown. This is surprising as the liquor shops were closed during the lockdown. Since the general population had higher employment and presumably higher income than PSA and SZ, they may have had a pre-existing inventory of alcohol at home. However, their frequency of intake was low (less than once a month) both before and during lockdown. In the case of tobacco, a low percentage of each group consumed tobacco, and there was no significant difference among the groups. There was also no change in tobacco consumption from before the lockdown to during the lockdown in the groups. This is possible because tobacco may have been available during the lockdown in small commodity shops selling essentials.
Limitations
The general population was recruited through a WhatsApp link that invited them to fill out the survey on Google Forms. This may have resulted in the general population in our study being highly educated and better employed than the ordinary general population of India. Given they were technologically savvy with access to smartphones and the Internet, they were presumably better informed about the pandemic and the preventive measures to be undertaken than others in India. PSA and SZ were drawn from patients presenting to government or charitable hospitals in Delhi and Bengaluru, indicating membership to the lower socioeconomic strata. Generally, lower socioeconomic status persons have limited access to technology-related health information, which was the major source of information during the lockdown. Different methods of participant recruitment and survey administration are another limitation. The survey was self-administered to the general population, who filled out the form on their smartphones or computers, while it was telephonically administered to PSA and SZ. Telephonic recruitment was a slower and more cumbersome process than online recruitment through self-administration due to the difficulty of communicating on the telephone. This may account for fewer responses from PSA and SZ.
CONCLUSION AND FUTURE IMPLICATIONS
Our findings provide promising evidence that government messages regarding COVID-19 containment measures were equally effective in reaching patients with mental health disorders when compared with the general population. Regardless of internet access differences and the substantial differences in demographics, the similarity in knowledge and behavior during the pandemic among the groups is striking. This has implication for policymaking as it illustrates that in times of health emergencies like epidemics and pandemics, repeated health messaging can reach vulnerable populations with impaired cognition.
Ethical approval
Ethical approval was sought from the Institutional Ethics Committee of the tertiary hospitals in New Delhi and Bengaluru where the study was conducted.
Financial support and sponsorship
We acknowledge the funding from various agencies. Salary of SS was supported by the Indian Council of Medical Research project “National Coordination Unit of Implementation Research” under Task Force for NMHP (File No. 514l-41151 lMl2017lNCD-1/31.07.2018), ICMR. Salary of TB was supported by the Fogarty International Center, NIH project “Cross Fertilized Research Training for new investigators in India and Egypt (D43 TW009114).” The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of NIH or ICMR. NIH and ICMR had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We would like to thank all our research participants for agreeing to participate in the survey. We would also like to acknowledge the efforts of our research staff, Ms. Nupur Kumari, Mr. Gyan Deepak Shah, Ms. Varsha Gupta, Mr. Nitin Antony, and Ms. Dhritishree Das, for agreeing to participate in the pilot survey and offering their valuable feedback.
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