Perceived stress among older adults during COVID‐19 outbreak: A cross‐sectional study in Southern Iran

Abstract

Background and Aims

The stress associated with the coronavirus disease 2019 (COVID‐19) pandemic significantly affects people's lives, especially older adults. The present study aimed to identify risk factors leading to the perceived stress associated with COVID‐19 among the adults over 60 years old of Southern Iran.

Methods

This cross‐sectional study was conducted in December 2021 in Bandar Abbas among older adults. The COVID‐PSS‐10 (Perceived Stress Scale) questionnaire was distributed among the older adults receiving healthcare services from health centers in Bandar Abbas selected through a convenient sampling method. Then, answers to the questions resulted in the score (without units).

Results

A total number of 456 participants between 60 and 90 years with an average age of 64 ± 5.12 years took part in this study. The mean ± SD score of total perceived stress was 16.45 ± 8.36 (the mean score of stress was 10.30 ± 6.16 and coping was 6.15 ± 3.83). Of the total, 129 participants (28.28%) were grouped as the high‐stress group. Results showed that the 70–79 years age group had higher odds of belonging to the stressed group than the 60–69 years age group (odds ratio = 2.336). Moreover, participants with a diploma were 57% more stressed than illiterate participants. The latter perceived less stress and had lower odds of belonging to the high‐stress group. The employed were 61% less likely to be categorized in the stressed group than the unemployed. Among women, 43% were less likely than men to be in the high‐stress group.

Conclusion

As the present findings showed, the risk factors of perceived stress induced by COVID‐19 are old age, low education, unemployment, and masculinity. Therefore, planning to improve stress‐coping skills such as entertainment, strengthening social relationships, physical activity, and the peace of mind of this population are suggested under the supervision of geriatric specialists and psychiatrists.

1. INTRODUCTION

The coronavirus disease 2019 (COVID‐19) crisis has been a significant issue since the beginning of the pandemic. ¹ The pandemic has created a lot of stress, such as a fear of infection, the threat of losing family and friends, and social isolation. It has changed the daily routines in people's lives and has had adverse effects on the mental health of society. ² , ³ As the existing studies show, these effects have increased mental health problems, especially stress in different populations of society around the world. ⁴ , ⁵ The stressful experiences associated with the COVID‐19 pandemic have a great effect on people's mood, well‐being, behavior, and health. The response to such a condition varies inter‐individually, especially among the older adults. The long‐term effects of stressors can further damage older adults' health ⁶ and this turns stress management into a major public health issue. ⁷ The severe cases of COVID‐19 infection have a different effect on the older adults than children and adolescents. It can cause severe infections, including pneumonia and acute respiratory distress syndrome in this vulnerable population. ⁸ In addition, with reduced cognitive ability, poor physiological function and physical fitness, and low immune function, ⁹ older adults with comorbidities are significantly more susceptible than other populations. ¹⁰ , ¹¹ Due to their reduced cognitive ability, the older adults are prone to anxiety, ⁹ which results in psychological instability.

Studies that have investigated perceived stress during COVID‐19 have often been conducted on the general public, ¹² students, ¹³ , ¹⁴ , ¹⁵ and employees. ¹⁶ , ¹⁷ Fewer international studies have focused on older adults. ¹⁸ , ¹⁹ In Iran, no study has been done previously on the stress induced by COVID‐19 among older adults. Due to the emergence of new variants of COVID‐19, the unknown time the pandemic ends, and also the vulnerability of older adults, there is a need for more studies in different areas. The present study aimed to identify risk factors leading to the perceived stress associated with COVID‐19 among the adults over 60 years old of Southern Iran. The present findings can contribute to providing solutions to policy makers and decision‐makers in the healthcare system.

2. METHODOLOGY

2.1. Study design and population

We conducted this cross‐sectional study in December 2021 in Bandar Abbas, Southern Iran. Bandar Abbas is the largest city in Hormozgan Province. The study population included older adults over 60 years old in Bandar Abbas. We used the COVID‐PSS‐10 (Perceived Stress Scale) questionnaire to determine the perceived stress caused by the prevalence of COVID‐19. The purpose of study and request for providing informed consent were included in the first page of the questionnaire. Participating in this study was completely voluntary.

The inclusion criteria were as follows: having an active medical record in the health centers, the least age of 60 years, no history of Alzheimer's and mental illness in the medical record (as probably these patients' perceived stress was different from others'), and residence in Bandar Abbas.

2.2. Sampling

To select the eligible participants, the contact numbers registered in the healthcare centers in Bandar Abbas were used. One purpose of the present research was to estimate the proportion of people with high perceived stress. In similar studies, ²⁰ the reported percentage of people with high perceived stress was 14.3% (p). With an estimated α error of 5%, precision of 5%, and the following formula, the sample size was estimated at 188.

$$n=\frac{z_{1-\frac{\alpha }{2}}^{2}pq}{d^2}=\frac{{(1.96)}^2\times 0.143\times 0.857}{{(0.05)}^2}=188$$

The sampling was online and convenient in type. Considering the possibility of nonresponse and the sampling method, we finally increased the sample size to 2.5 times (design effect). Therefore, 470 people were selected as the final sample of the study.

2.3. Data collection and variable description

Data collection was conducted by sending the questionnaire hyperlink through social networks (WhatsApp, Instagram, and Telegram). The links were sent mostly after hours along with reminders. At first, the questionnaire was sent to the head of the family (with an older adults' member above 60 years of age). Then, the older adult's member him/herself completed the questionnaire. If the older adult was unable to do that, another family member helped with the procedure. To this aim, the required explanations were provided to the family members. They were asked to read the questions aloud to older adult and then mark the answer among the choices as the respondent replied.

The questionnaire used in this study was COVID‐PSS‐10, previously adapted by researchers in another study in Colombia. ²⁰

In the first part, the participants completed demographic information as the independent variables: age (year), sex (male, female), living place (urban, rural), marital status (living with spouse, single/widowed/divorced), education level (primary/secondary school degree, diploma, university degree), and employment (unemployed, employed, retired).

In the second part, there was the COVID‐PSS‐10 as the dependent variable with 10 Likert‐scale items (never, almost never, sometimes, fairly often, very often). COVID‐PSS‐10 presented a bidimensional construction: the first section named stress focused on the perceived lack of control over the situation (Question numbers 1, 2, 3, 6, 9, and 10) ranging from almost always with 4 points to never with 0 points. The second section named coping defined a set of cognitive and behavioral strategies needed to manage stressful situations (Question numbers 4, 5, 7, and 8) were inversely scored. ²¹ The total scores obtained ranged from a minimum of 0 to a maximum of 40. Scores at or above 25 were interpreted as the high perceived stress associated with COVID‐19. A sample item of the questionnaire is “I am confident about my ability to deal with personal problems related to COVID‐19.” The questionnaire was completed after informing the participants of the purpose of the study and completing an informed consent form to participate in the study. The questionnaire is available in the Supporting Information.

The design of the questionnaire required each question to be answered before moving on to the next question. Thus, in the end, there were no incomplete data in the study.

In previous studies, COVID‐PSS‐10 showed high internal consistency with a Cronbach's α of 0.86. ²⁰ The content validity of this questionnaire was substantiated by consulting with one expert in health education, two in gerontology, and three psychologists. We asked these experts to check the questionnaire for relevance, clarity, simplicity and necessity. Also, test–retest was done with the participation of 15 older adults who registered in a health center in Bandar Abbas. According to the test‐retest result, the reliability of the questionnaire was also determined by evaluating the internal correlation of questions and calculating the Cronbach's α coefficient (α = 0.792) and intraclass correlation coefficient (0.803).

2.4. Data analysis

The data were entered and analyzed using SPSS (Version 23.0, SPSS, Inc.) statistical software. Frequency, percentage, mean and SD indices were used as descriptive statistics. Logistic regression analysis was used to investigate the relationship between perceived stress levels and demographic variables.

2.5. Ethical considerations

All stages of the present study abided by the Declaration of the Helsinki Charter of Ethics. This study was approved by the ethics committee of Hormozgan University of Medical Sciences (#IR.HUMS.REC.1400.329). The ethics committee approved the online survey as well as the online letter of consent. All participants who consented to take part in the study were assured that their participation was voluntary and they could withdraw from the study at any time they wanted. In addition, the data were collected, saved, and analyzed anonymously.

3. RESULTS

This study was conducted with a response rate of 97% and 456 older adult participants residing in Bandar Abbas. The participants' age ranged from 60 to 90 years, with a mean ± SD of 64 ± 5.12 years. The majority of participants (57.2%) were male. Concerning the place of residence, 78.9% of the participants lived in urban areas. As for the marital status, 82.9% were married. Among the education levels, the diploma was the most frequent degree (35.5%). In terms of the employment type, 48% of the participants were retired. More demographic details are provided in Table 1. The mean score of total perceived stress was 16.45 ± 8.36. The mean ± SD score of stress and coping were 10.30 ± 6.16 and 6.15 ± 3.83, respectively.

Table 1.

The research participants' demographic variables

Demographic characteristics	Category	Frequency N = 456	%
Age (years)	60–69	360	78.9
	70–90	96	21.1
Sex	Male	261	57.2
	Female	195	42.8
Living place	Urban	360	78.9
	Rural	96	21.1
Marital status	Living with spouse	378	82.9
	Single/widowed/divorced	78	17.1
Education level	Primary/secondary school degree	144	31.6
	Diploma	162	35.5
	University degree	150	32.9
Employment	Unemployed	150	32.9
	Employed	87	19.1
	Retired	219	48.0

Figure 1 shows participants' responses to the questionnaire.

Figure 1.

Participants' responses to the questionnaire

Using a cutoff of 25 points or more to define high stress, there were 129 participants (28.3%) in this group. Table 2 shows the result of regression analysis for demographic variables. A statistically significant relationship was found between perceived stress and age, education and employment.

Table 2.

The relationship between perceived stress and demographic variables N = 456

Demographic variable	Category	Normal N = 327	High stress N = 129	OR	95% CI	p
Age (years)	60–69	273 (83%)	87 (67%)	Reference
	70–90	54 (17%)	42 (33%)	2.336	1.386–3.935	0.001
Sex	Male	186 (57%)	75 (58%)	Reference
	Female	141 (43%)	54 (42%)	0.573	0.338–0.973	0.039
Place of residence	Urban	264 (81%)	96 (74%)	Reference
	Rural	63 (19%)	33 (26%)	1.055	0.571–1.953	0.863
Marital status	Living with spouse	273 (83%)	105 (81%)	Reference
	Single/widowed/divorced	54 (17%)	24 (19%)	1.017	0.545–1.899	0.958
Education level	Primary/secondary school degree	87 (27%)	57 (44%)	Reference
	Diploma	132 (40%)	30 (23%)	0.434	0.232–0.812	0.009
	University degree	108 (33%)	42 (33%)	1.117	0.568–2.196	0.749
Employment	Unemployed	96 (29%)	54 (42%)	Reference
	Employed	69 (21%)	18 (14%)	0.307	0.140–0.673	0.003
	Retired	162 (50%)	57 (44%)	0.612	0.318–1.180	0.143

Abbreviations: 95% CI, 95% confidence interval; OR, odds ratio for high stress compared with low stress.

Adults aged 70–90 years had higher odds of being in the high stress group than those aged 60–69 years (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.39–3.93). Women were less likely than men to be in the high‐stress group (OR 0.57, 95% CI 0.34–0.97). Moreover, participants with a diploma were 57% more stressed than participants with primary or secondary education (OR 0.43, 95% CI 0.23–0.81). Employed participants were less likely to have high perceived stress compared with those who were unemployed (OR 0.31, 95% CI 0.14–0.67). The place of residence and marriage were factors that were not significantly related to the perceived stress.

4. DISCUSSION

The present study aimed to evaluate the perceived stress induced by the prevalence of COVID‐19 in the older adults of Bandar Abbas. The findings showed that older adults had a high level of perceived stress.

The findings showed that about one‐third of the participants had high perceived stress associated with COVID‐19. The intensity of stress during the COVID‐19 pandemic was reported in several studies. A study of Colombian adults showed that 14.3% of the population experienced high stress. ²⁰ An international study investigated the effect of COVID‐19 psychological distress and the results showed that more than 70% of respondents had above‐average levels of stress. ²² In her study, Jeanblanc et al. ²³ described the predictors of COVID‐19 stressors among the older adults: demographic variables, depressive symptoms, perceived stress, and stress management strategies. Narimani et al. ²⁴ in Iran also stated that perceived stress, perceived social integration and support play an important role in the older adults' COVID‐19‐related anxiety. The stress induced by the COVID‐19 emergent conditions and the concomitant quarantine have persuaded more stress for the older adults with their more social communication problems. Health protocols such as the need to wear masks, gloves, and use antiseptics have further limited the older adults' social communication, because they are naturally less physically ready to take such protective measures and might not even feel like doing so. In these conditions, the presence of supportive services such as family, friends and other acquaintances in dealing with problems causes a feeling of greater control over negative psychological conditions.

The present findings showed a statistically significant relationship between participants' stress and age. An increase in age was associated with more perceived stress. Contrary to this finding, Jiang's ²⁵ study of perceived stress during the COVID‐19 pandemic in China showed that older adults had lower levels of perceived stress than young individuals. Studies in Spain and China have also shown lower levels of stress in the older adults compared to the young population. ²⁶ , ²⁷ The difference between our findings and these studies could be due to the fact that our study sample consisted only of the older adults. Furthermore, old age is a major risk factor of morbidity and mortality due to the COVID‐19. ²⁸ , ²⁹ Therefore, the older adults are considered as one of the most vulnerable populations during COVID‐19. Nikolich‐Zugich, ³⁰ in a systematic review, stated that COVID‐19 put some pressure on older adults and there was a need for managing social distance in this age group. In studies on the severe acute respiratory syndrome pandemic, the age over 60 years has been identified as a risk factor. ³¹ Younger people showed to have more occupational, financial, and social concerns ²² , ³² and, in contrast, the older adults with less of these obsessions stay more at home and, thus, face other problems such as reduced mobility, reduced sleep quality, loneliness and stress. ³³ With increasing age, comorbidities also affect the older adults. Thus, careful planning to meet the movement requirements of this age group under the supervision of geriatricians, psychiatrists and physiotherapists can be helpful.

Our findings showed a more statistically significant difference between stress and employment status in older adults. Employed people had lower levels of stress than the unemployed. COVID‐19 stress has also been reported in different occupational groups with different effects. For example, a study in China found that the COVID‐19 pandemic created stress levels for healthcare workers, which led to a worrisome state of anxiety and depression in this occupational group. ³⁴ With the advent of COVID‐19 and the precautionary laws of governments, older people who were not employed at the time were required to remain home, and different studies have shown the negative psychological impact of being out of the community and staying home during COVID‐19. ³⁵ , ³⁶ Occupational engagement can have a positive effect on a person's lack of focus on COVID‐19. The retired and unemployed older adults are at a greater risk of stress due to the lack of social communication and entertainment.

The present study showed that people with a diploma perceived less stress than illiterate people. Similar results were reported in other studies concerning how education is related to stress. ³⁷ Zhong et al. ³⁸ concluded in his study that people with higher levels of education showed higher levels of information about and better attitudes toward COVID‐19. As the present findings showed, it can be concluded that higher education has changed people's perception of accepting any news and rumors so that they are less affected by false rumours and news that could in some way increase their stress.

In this study, sex showed a significant difference in the level of perceived stress. Women had less perceived stress and this was in contrast to the findings of other studies in which women were more seriously affected by stress and the consequent other psychological problems. ² , ³⁹ , ⁴⁰ A study in Turkey examined levels of depression, anxiety, and health anxiety during the COVID‐19 pandemic and found that women were more affected. ³⁹ A study in US older adults showed that although men may be more prone to the COVID‐19 adverse effects, women were more concerned about the COVID‐19 pandemic. ⁴¹ This difference may be due to differences in the participants' demographic variables. There is lower percentage of women than men and the percentage of employed and retired women compared to the employed or retired men.

The present findings did not reveal any significant relationship between perceived stress and marital status. In line with the results of the present study, no significant relationship was observed between these two variables in Pedrozo‐Pupo's study. ²⁰ Contrary to our findings, being single was associated with high perceived stress in a number of studies. ⁴ , ⁴² , ⁴³ Arguably, the cultural matters could have been involved. According to the culture of the studied region, it is not customary for the older adults to live alone, because even in the case of losing a life partner (divorce/death), these people live with other family members and, as a result, they get their support.

4.1. Strengths and limitations

One strength of the present study was that we used the medical records of households in the healthcare centers to contact the older adults. Thus, if it was needed, we asked a family member to complete the online survey for the older adults. Another limitation of this study was differentiating stress caused by COVID‐19 from the stress of other origins. We attempted to reduce the effect of this bias at least partly by using the specialized COVID‐PSS‐10. Another limitation was the possibility that the family members had shown their understanding of the older adults' stress level. Attempts were made to solve this issue by explaining the response process in the above‐mentioned conditions. In addition, considering that more than a year has passed since the beginning of the pandemic, at the time of conducting the study, the stress level caused by COVID‐19 gradually decreased, and if the study was conducted earlier, different results could have been obtained.

It is suggested to conduct studies with control groups and longitudinal studies over longer periods of time and with larger samples of older adults.

5. CONCLUSIONS

As the present findings showed, the risk factors of perceived stress induced by COVID‐19 include old age, low education, unemployment, and masculinity. Therefore, planning to improve stress‐coping skills including creating entertainment, strengthening social relationships and physical activity, and the peace of mind of this population is suggested under the supervision of geriatric specialists and psychiatrists. Further research is needed to identify the predictors of stress and anxiety by different demographic groups in conditions similar to the COVID‐19 pandemic to plan coping mechanisms.

AUTHOR CONTRIBUTIONS

Nahid Shahabi: Conceptualization; Methodology; Writing – original draft; Writing – review & editing. Shokrollah Mohseni: Formal analysis; Methodology; Validation. Sara Dadipoor: Methodology; Supervision. Roghayeh E. Rad: Data curation; Writing – review & editing. Laleh Hassani: Writing – original draft; Writing – review & editing.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

All methods conform to the Declaration of Helsinki. The study was approved by the ethics committee of Hormozgan University of Medical Sciences (ethical code IR.HUMS.REC.1400.329). All participants filled online consent form to participate in this study.

TRANSPARENCY STATEMENT

The lead author Laleh Hassani affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

Supporting information.

Shahabi N, Mohseni S, Dadipoor S, Rad RE, Hassani L. Perceived stress among older adults during COVID‐19 outbreak: a cross‐sectional study in Southern Iran. Health Sci Rep. 2022;6:e993. 10.1002/hsr2.993

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.