Decline of Psychological Health Following the Designation of COVID-19 as a Pandemic: Descriptive Study

Background: COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020, and as of this writing, Texas, United States, has reported >675,000 cases with over 14,000 deaths. Many of the preventive measures implemented during the pandemic can increase sedentary lifestyles, which can lead to the development of chronic diseases, including obesity, among the general population and cause serious threats to people’s physical health and overall quality of life. Individuals with pre-existing comorbidities are at an increased risk of COVID-19 and may hence have higher levels of stress. Objective: This study aimed to investigate the relationship between physical activity levels and mental health status on an individual level and to compare them between those with and those without comorbidities in a cohort of Texas residents, before and after COVID-19 was declared a pandemic. Methods: An electronic survey was disseminated throughout various regions of Texas. In total, 160 individuals were asked questions about their demographic characteristics, time spent on daily physical activities, and daily mental health status before and after COVID-19 was declared a pandemic. Frequency distributions and descriptive statistics were analyzed. Results: Overall, 94 (58%) participants reported having ≥1 medical condition, and 31 (13.1%) had >3 medical conditions. Physical activity levels among participants with ≥1 pre-existing comorbidity drastically—but not significantly—decreased, as evident from a 10% increase in sedentary lifestyles after COVID-19 was declared a pandemic. On the contrary, we observed a 9% increase in the number of individuals without a pre-existing comorbidity who reported 30-60 min of physical activity per week. There was a 2-fold increase in the number of participants reporting more frequent feelings of nervousness, too much worry, trouble relaxing, and the fear of something awful happening after the pandemic. More specifically, individuals with pre-existing medical conditions reported, on average, a 10% higher incidence of feelings of stress, anxiety, and sadness compared to their healthy counterparts after COVID-19 was declared a pandemic. Conclusions: Stressful life conditions and chronic comorbidities are risk factors that can affect mental health and reduce the ability to perform activities of daily life. Therefore, when implementing pandemic protocols, municipalities should consider providing mental health support to their citizens to protect them from this rather inconspicuous adverse effect. (J Med Internet Res 2021;23(4):e24964) doi: 10.2196/24964


Introduction
COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020 [1], and Texas has reported >675,000 cases and 14,000 deaths as of this writing. The routines of individuals have been impacted since the beginning of the pandemic owing to the implementation of restrictions and preventative measures such as social distancing, self-isolation, stay-at-home orders, and closure of businesses and recreational facilities. Many of these protocols can have a negative effect, promoting a sedentary lifestyle and decreasing physical activity levels, which can lead to the development or exacerbation of chronic diseases and mental health issues [2][3][4][5]. This study aimed to explore the relationship between physical activity levels and mental health status at an individual level in a cohort of Texas residents before and after COVID-19 was declared a pandemic. We hypothesize that the declaration of COVID-19 as a pandemic, which led to the implementation of social distancing and self-isolation protocols, would negatively impact mental health, increase stress and anxiety, and decrease physical activity levels among all study participants.

Recruitment
Texas residents aged ≥18 years were recruited through social media and email, using convenience and snowball sampling over a 2-week period in July 2020. Respondent identities were anonymized, and the study was exempt from ethics review for the use of human subjects by the institutional review board of the University of Texas Health Science Center at San Antonio.

Survey Instrument
A shortened survey instrument initially developed by Flanagan et al [6] was used to capture respondent demographics, medical history, and physical and mental health status. Questions related to physical and mental health were constructed in a manner to determine health status before and after the implementation of COVID-19 quarantine protocols. Study data were collected and managed using Research Electronic Data Capture (REDCap) [7] tools hosted at the University of Texas Health Science Center at San Antonio. REDCap is a secure web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for data integration and interoperability with external sources.

Demographics and Medical History
Data on the participants' gender (male, female, or no response), age, marital status, employment status, household number, ethnicity, and race were collected. Participants were asked to indicate whether they have been diagnosed with any chronic medical conditions, including cardiovascular, respiratory, gastrointestinal, genitourinary, kidney, hematologic, infectious, dermatological, ophthalmologic, endocrine, musculoskeletal, oncologic, or neurologic disease. The demographic characteristics of the survey participants are presented in Table  1. Table 1. Demographic characteristics of the survey participants (N=160).

Questions on Physical Activity
Participants were asked to provide details regarding their physical activity levels before and after COVID-19 was declared a pandemic. Specifically, they were asked to provide details regarding their physical activity or exercise minutes per day. Participants were provided the following categorical variables as choices: 0-30 minutes, 30-60 minutes, 60-90 minutes, 90-120 minutes, or >120 minutes of daily physical activity.

Questions Related to Psychological Status and Mental Health
Participants were asked if they were worried about their physical health with respect to the COVID-19 pandemic. They were also asked about generalized stress, anxiety, and sadness before and after the COVID-19 pandemic. Furthermore, 8 questions were related to the participants (1) feeling nervous, anxious, or on edge; (2) not being able to stop of control worry; (3) worrying too much about different things; (4) having trouble relaxing; (5) being restless and finding it difficult to sit still; (6) becoming easily annoyed or irritable; (7) feeling afraid that something awful might happen; and (8) having difficulty getting things done because of these mental health issues. Participants selected either (1) not at all, (2) several days, (3) over half the days, or (4) nearly every day. Each response was converted to a numerical score for analysis.

Statistical Analysis
Descriptive statistics were calculated to summarize the response frequency. Respondents who declined to answer a question were considered missing and excluded from the calculated proportions. We report all summary statistics. For paired testing of questions that asked for pre-and post-COVID-19 comparisons, we used a paired samples t test to analyze mean values. The significance level was set at Cronbach α=.05, and all tests were 2-sided. All data were processed using SPSS for Windows (version 23.0, SPSS Inc).

Participant Demographics
In total, 160 individuals responded to the social media posts. The vast majority of respondents were married, white, non-Hispanic or -Latino females. Overall, 65 (41%) respondents identified themselves as Hispanic or Latino (Table 1), which was more than the 31% estimated census of Hispanic or Latinos in Texas. More than half of the respondents (n=91, 57%) were aged <45 years and had full-time jobs (n=117, 73%), while 30 (19%) indicated that they were unemployed.

Slight Reduction in Physical Activity in Response to the Declaration of COVID-19 as a Pandemic
No significant differences in self-reported physical activity were observed for the entire cohort of respondents. Similarly, no significant differences were observed in the subgroups of individuals with (P=.81) or without (P=.91) pre-existing medical conditions. Physical activity was slightly-but not significantly (P=.81)-reduced among participants with ≥1 pre-existing condition, as evident from a 10% increase in sedentary lifestyles after COVID-19 was declared a pandemic. On the contrary, we observed a 9% increase in the number of individuals without a pre-existing conditions reporting 30-60 min of physical activity per week.

Negative Effect of the COVID-19 Pandemic on Psychological Health
Respondents were asked how the quarantine protocols in Texas impacted their psychological health (Table 3). We observed significant increases in feelings of fear, annoyance, restlessness, worry, nervousness, sadness, anxiety, and stress (P<.001) among the survey respondents. Specifically, participants reported more frequently feeling nervous, worrying too much, having trouble relaxing, and feeling afraid something awful might happen after the pandemic. This negative impact on psychological well-being interfered with their ability to accomplish their work, tasks, or interact with other people. Similar results were obtained among individuals with and those without pre-existing medical conditions. The only exception is that individuals without pre-existing medical conditions reported that the COVID-19 pandemic had no significant impact on their ability to relax (P=.08).

Principal Findings
After COVID-19 was declared a pandemic, quarantine and social distancing protocols were implemented to help mitigate disease spread in Texas. The implementation of these protocols was accompanied by several adverse effects on quality of life, which were independent of the SARS-CoV-2 infection. With the requirement for more individuals to stay at home and in isolation from friends, family, and colleagues, physical and mental health can depreciate. Mental health was drastically affected in our respondents owing to social isolation measures implemented by local municipalities in Texas. Overall, our survey respondents reported feeling more stress, anxiety, and sadness after COVID-19 was declared a pandemic. However, the long-term implications of quarantine protocols on mental health remain unknown. However, evidence from natural disasters suggest that mental health symptoms peak in the following months and can persist for years [8]. For example, 5% of the population of Texas affected by hurricane Ike met the criteria for major depressive disorder in the months following the storm [9]. Therefore, while a significant impact is demonstratable approximately 4 months into the quarantining protocol, there is potential for even greater impacts in the subsequent months.
Quarantine protocols can have a serious impact on physical health, leading to the development and progression of chronic diseases [10]. The American College of Sports Medicine recommends that most adults engage in moderate-intensity exercise training for more than 30 minutes for more than 5 days a week [11]. Contrary to Tinson et al [2], participants with no pre-existing medical conditions increased their physical activity after COVID-19 was declared a pandemic, with more individuals meeting or exceeding the recommended physical activity guidelines of the American College of Sports Medicine [11]. In this study, physical activity levels slightly-but not significantly-decreased among participants with pre-existing medical conditions, which indicates a potential risk of decreased overall health, potentially resulting in the exacerbation of medical conditions. Given that the risk of COVID-19 is significantly higher in subgroups of the population, which have pre-existing medical conditions, such subgroups are expected to decrease the time they spend outside of home in fear of unintended exposure to the virus.

Limitations
Our study is limited by the self-reported nature of our survey and the convenience and snowball sampling method used to recruit participants. Further, without the use of geocoding, including zip codes, we are limited in our ability to generalize our results to different regions in Texas. Finally, our survey was