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| BRIEF RESEARCH ARTICLE |
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| Ahead of print publication |
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Perceived stress, anxiety, stigma, and coping strategies during the COVID-19 pandemic: A cross-sectional study among physicians in the Mumbai Metropolitan Region
Shruti V Tilak1, Kranti S Kadam2
1 Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
2 Department Psychiatry, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| Date of Submission | 24-Jan-2022 |
| Date of Decision | 21-Feb-2022 |
| Date of Acceptance | 21-Feb-2022 |
| Date of Web Publication | 12-Sep-2022 |
Correspondence Address:
Shruti V Tilak,
Ground Floor, Seth GS Medical College and King Edward Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/aip.aip_10_22
Context: Health-care workers (HCWs) are facing stigma during the COVID-19 pandemic. Stigma is associated with poor mental health. Aims: This study aimed to assess the prevalence and psychological impact of COVID-19-related stigma and different coping mechanisms among physicians in Mumbai. Settings and Design: An online cross-sectional survey was conducted. Subjects and Methods: One hundred and seventy physicians from Mumbai were administered questionnaires on perceived stress, anxiety, COVID-19-related stigma, and coping strategies. Statistical Analysis Used: Data were analyzed using descriptive statistics, correlation tests, and binary logistic regression in the SPSS, version 20.0. Results: The prevalence of stress and anxiety was 57.6% and 20.0%, respectively. 34.7% of physicians felt stigmatized due to COVID-19. Stress was significantly associated with COVID-19-related stigma (P = 0.009), and emotion-oriented coping (P = 0.000), as was anxiety (P = 0.000, P = 0.000, respectively). Conclusions: COVID-19-related stigma is a major issue among physicians. Stigma and emotion-oriented coping mechanisms are predictive of mental distress in this population.
Keywords: Anxiety, coping mechanisms, COVID-19, health-care workers, perceived stress, stigma
How to cite this URL:
Tilak SV, Kadam KS. Perceived stress, anxiety, stigma, and coping strategies during the COVID-19 pandemic: A cross-sectional study among physicians in the Mumbai Metropolitan Region. Ann Indian Psychiatry [Epub ahead of print] [cited 2022 Sep 25]. Available from: https://www.anip.co.in/preprintarticle.asp?id=355942 |
| Introduction | |  |
Health-care workers (HCWs) around the world are facing a high mental burden during the COVID-19 pandemic, with increased levels of anxiety, depression, burnout, and psychological stress.[1] One reason for increased psychological burden among HCWs may be COVID-19-related stigma and discrimination.[2],[3] In a study from three Sub-Saharan African countries, 73.7% of health-care providers experienced social stigma associated with COVID-19.[4] The presence of stigma and discrimination among HCWs is linked with adverse work and mental health outcomes such as fatigue, burnout, decreased work satisfaction, anxiety, and depression.[5],[6] Social stigma was reported in HCWs during the severe acute respiratory syndrome, Middle Eastern Respiratory Syndrome, and Ebola outbreaks and seems to persist in the long-term, even after the containment of the disease and the passing of the threat.[5],[7]
Coping is defined as cognitive or behavioral measures taken by a person in response to a situation that is appraised as stressful.[8] Coping strategies are important predictors of mental health during stressful situations and therefore carry significance during the present pandemic. In a study on nurses in Spain, the use of negative coping strategies in response to COVID-19-related work stress was found to be significantly related to anxiety, depression, and somatic symptoms.
Understanding COVID-19-related stigma and its bearing on the mental health of physicians is important from the psychosocial perspective. Knowledge of the coping strategies being utilized by doctors can help identify individuals vulnerable to mental health deterioration.
The need for this study arose due to a paucity of medical literature on the mental health of doctors during the COVID-19 pandemic, with a focus on the effect of stigmatization and coping mechanisms. The aim of this study was to observe the prevalence of perceived stress and anxiety among doctors in the Mumbai Metropolitan Region and to explore their relationship with COVID-19-related stigma and coping strategies under stress. The study objectives were to record the prevalence of perceived stress, anxiety and COVID-19-related stigma, to observe the types of coping mechanisms used by doctors, and to analyze the relationship between these variables.
| Subjects and Methods | | |
A cross-sectional study on physicians in active practice in the Mumbai Metropolitan Region was carried out over 2 months. An anonymous, online google form survey was circulated by convenience sampling on the social media groups of the Indian Medical Association, Mumbai Branch, and 170 responses were gathered. This study was approved by the Institutional Ethics Committee with reference number EC/OA-158/2020 obtained on January 5, 2021. Informed consent of each participant was obtained electronically before filling the survey.
The survey included demographic details, COVID-19-related data such as COVID-19 exposure, and comorbidities. Perceived Stress Scale-10 (PSS-10) and General Anxiety Disorder-7 (GAD-7) were used to measure perceived stress and anxiety, respectively.[9],[10] The COVID-19 stigma scale was used to measure COVID-19-related stigma. It comprises 13 items scored on a 5-point Likert scale. The total score ranges from 0 to 52, with higher scores indicating higher stigma perception. The psychometric properties of the scale were established by a content validity index exceeding 0.78, with a Cronbach's alpha of 0.94.[11],[12] Coping Inventory for Stressful Situations-21 (CISS-21) was used to assess three types of coping behaviors: task-oriented, emotion-oriented, and avoidance-oriented coping. The CISS-21 contains 21 items divided into three subscales of 7 items each, rated on a 5-point Likert scale. Cronbach's alpha of the CISS-21 ranges from 0.75 to 0.88.[13]
Data were analyzed using the SPSS version 20.0 (IBM Corporation, Armonk, New York, U.S.A.), with a 95% confidence interval (CI) and statistical significance of P < 0.05. Variables were expressed as frequencies and percentages. Scores on the PSS-10 were interpreted as low stress (0–13), moderate stress (14–26), and high perceived stress (27–40). GAD-7 scores were categorized into low (0–10) and high anxiety (11–21). A cutoff of 26 or higher was used to define a high level of stigma perception on the COVID-19 stigma scale. The tests used to find significant associations in the data were Chi-square test for nominal data and Pearson's correlation tests for continuous variables. Binary logistic regression was used to determine significant predictors of stress and anxiety.
| Results | | |
Out of 170 total participants, 96 (56.5%) were male and 74 (43.5%) were female, with a mean age of 47.96 ± 9.44 years (age range of 25–74 years). 30.6% of doctors (52 out of 170) were general practitioners. The remaining 69.4% of specialists included 80 (47.1%) medicine-allied clinicians and 38 (22.4%) doctors in surgical fields. One hundred and twenty-five doctors (71.2%) reported being exposed to COVID-positive patients in their practice. 15.9% (23/170) of the sample had previously tested positive with the virus. Of these, 50% of doctors had been hospitalized due to COVID-19. 48.8% (83/170) of the total sample had at least one comorbidity, with hypertension emerging as the most common condition (30.6%). More than 10% (19/170) of doctors had multiple comorbidities.
The mean stress score was 14.99 ± 6.99. 57.6% (98/170) of doctors had at least moderate levels of stress; of these, 2.9% were severely stressed. The prevalence of anxiety was 20.0% (34/170). The mean level of stigma perception was 21.55 ± 10.03, with 59 out of 170 participants (34.7%) facing significant COVID-19 related stigma. Task-oriented coping strategies were the most frequently used by doctors (127/170, 74.7%), followed by emotion-oriented (32/170, 18.8%) and avoidance-oriented coping strategies (11/170, 6.5%).
Perceived stress was positively correlated with COVID-19-related stigma (r = 0.400, P < 0.000) and emotion-oriented coping (ρ = 0.699, P < 0.000), and negatively correlated with task-oriented coping (ρ = −0.425, P < 0.000). Anxiety had a positive association with stigma (ρ = 0.372, P < 0.000), emotion-oriented coping (ρ = 0.600, P < 0.00), and a negative association with task-oriented coping (ρ = −0.357, P < 0.000). No other variables such as age, gender, history of exposure, comorbidities, working hours, and avoidance-oriented coping strategies had any significant associations on the Chi-square or Correlation tests. On independent t-test analysis, participants who perceived COVID-19-related stigma had significantly higher stress scores (t = 3.29, P = 0.001).
Logistic regression showed that COVID-19-related stigma (B = 2.75, P = 0.009) and emotion-oriented coping (B = 9.82, P = 0.000) were significant predictors of stress, Nagelkerke's R2 value of the model being 32.7% [Table 1]. Anxiety was also significantly associated with stigma (B = 7.80, P = 0.000) and emotion-oriented coping strategies (B = 6.39, P = 0.000) (Nagelkerke's R2 = 32.8%). | Table 1: Binary logistic regression analyses for perceived stress and anxiety
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| Discussion | | |
The present study on doctors in the Mumbai Metropolitan Region reports a 57.4% and 20.0% prevalence of perceived stress and anxiety, respectively. In comparison, Chatterjee et al. found that 32.9% of doctors faced psychological stress, and 39.5% had anxiety.[14] These estimates are comparable with data reported in a meta-analysis of stress and anxiety in frontline workers during the COVID-19 pandemic, which observed that perceived stress was present in 45% (95% CI 24.3%–67.5%), and anxiety in 25.8% (95% CI 20.5%–31.9%) of workers, respectively.[15]
COVID-19-related stigma was perceived by more than one-third of doctors in the present sample. Previous reports from Kerala found a higher prevalence of stigma in doctors during the COVID-19 pandemic (62.1%–66.7%).[12],[16] The differences in prevalence could be due to regional variation. Stigma emerged as a significant predictor of stress and anxiety; for every point increase on the COVID-19-related stigma scale, the odds of feeling stressed and anxious increased by a factor of 2.75 and 7.80, respectively. There were no previous Indian studies that surveyed COVID 19 related stigma to predict its relationships with mental health parameters, although Chatterjee et al. found that “feeling ostracized in the workplace” significantly predicted stress, anxiety, and depression among doctors during the COVID 19 pandemic.[14] From these findings, it can be reasonably stated that stigmatization of HCWs is a major issue during the present pandemic which needs to be studied further and addressed at the community and policy level.[17]
Most of the present sample adopted task-oriented coping mechanisms, which are associated with better mental health outcomes.[18] Emotion-oriented coping was strongly predictive of stress and anxiety, which is consistent with previous reports.[18] A qualitative study among frontline physicians during the COVID-19 pandemic reported that knowledge of psychobehavioral aspects of mental health like resilience and coping strategies are a major unmet need of the health-care community.[19] Despite this, literature is sparse on coping strategies in Indian HCWs. This is a concerning lacuna, especially during a distressing situation like the present pandemic, and needs to be addressed to improve the overall mental well-being of HCWs.
Strengths and limitations
Since this survey was solely focused on doctors from a single urban area, with the recruitment carried out online through a convenience sampling method, the results may not be generalizable to all HCWs. Despite these limitations, the present study sheds light on two important domains that have a significant bearing on mental health; the problem of social stigma faced by doctors during the COVID-19 pandemic and the different coping methods being utilized to overcome stressors with a focus on the consequences of maladaptive coping.
Future research directions
The findings of this study indicate a need for preventive psychosocial research in the domain of stigmatization due to the contagion, as well as coping, resilience, and other mental wellness aspects. This could be done by undertaking larger observational studies as well as interventional research to raise knowledge and awareness among health-care community and the general public.
| Conclusions | | |
Our research finds that more than one-third of doctors felt stigmatized during the COVID-19 pandemic and identifies stigma and emotion-oriented coping as strong predictors of mental distress in this population. This indicates the need for further exploration of these domains with the intention of dispelling COVID-19-related stigma, encouraging healthy coping behaviors, and improving the overall mental health of HCWs.
Acknowledgment
The authors would like to acknowledge Dr. Nalakath A. Uvais for sharing with us, on request, the COVID-19 stigma scale.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1]
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