key: cord-0869469-pr7i2bln
authors: Ashraf, Muhammad Umair; Raza, Saqlain; Ashraf, Asfa; Mehmood, Waqas; Patwary, Ataul Karim
title: Silent cries behind closed doors: An online empirical assessment of fear of COVID‐19, situational depression, and quality of life among Pakistani citizens
date: 2021-07-04
journal: J Public Aff
DOI: 10.1002/pa.2716
sha: fb54c32df3daff438900093f9fb3985621a20043
doc_id: 869469
cord_uid: pr7i2bln

The present study aimed to investigate the effects of fear of COVID‐19 and situational depression on the quality of life (QOL) of Pakistani citizens. An online cross‐sectional survey was conducted on Pakistani citizens via the snowball sampling technique. A total of 377 respondents (256 males and 121 females) participated in this study from August to October 2020. Adapted scales were validated using confirmatory factor analysis, and partial least squares structural equation modelling (PLS‐SEM) was applied to the data to test the hypothesised model. The study's findings showed a negative relationship between fear of COVID‐19 and QOL. Likewise, a reciprocal relationship was found between situational depression and quality of life. The results indicate that fear of COVID‐19 and situational depression during the pandemic have affected the lives of Pakistani citizens. The findings are particularly relevant for improving the QOL by limiting the information received from media and social networks. There is a need to control these mediums and promote community‐based interventions to provide accurate knowledge regarding COVID‐19. Fear of COVID‐19 and situational depression may be reduced in this way. Based on the current findings, psychotherapy and counselling programmes must be planned to minimise the adverse effects of fear of COVID‐19 and depression on the QOL of citizens due to the ongoing progression of the pandemic.

The present study aimed to investigate the effects of fear of COVID-19 and situational depression on the quality of life (QOL) of Pakistani citizens. An online cross-sectional survey was conducted on Pakistani citizens via the snowball sampling technique. A total of 377 respondents (256 males and 121 females) participated in this study from August to October 2020. Adapted scales were validated using confirmatory factor analysis, and partial least squares structural equation modelling (PLS-SEM) was applied to the data to test the hypothesised model. The study's findings showed a negative relationship between fear of COVID-19 and QOL. Likewise, a reciprocal relationship was found between situational depression and quality of life.

The results indicate that fear of COVID-19 and situational depression during the pandemic have affected the lives of Pakistani citizens. The findings are particularly relevant for improving the QOL by limiting the information received from media and social networks. There is a need to control these mediums and promote communitybased interventions to provide accurate knowledge regarding COVID-19. Fear of COVID-19 and situational depression may be reduced in this way. Based on the current findings, psychotherapy and counselling programmes must be planned to minimise the adverse effects of fear of COVID-19 and depression on the QOL of citizens due to the ongoing progression of the pandemic. (Dogan et al., 2020; Fareed et al., 2020; Iqbal et al., 2020; Shakoor et al., 2020) . The disease spread rapidly that within 3 months of identification, a total number of 81,846 cases were reported; of these 81,846 cases, 3287 people were dead by 25 March 2020. Globally, the disease spread from Wuhan to 193 countries (Huang & Zhao, 2020; Wang et al., 2020) . According to the World Health Organization (WHO) (2020) identified 69,176 incidents in Italy, 42,058 instances in Spain, 53,588 instances in the United States, and 4,541,392 cases in Pakistan till date. The most common indications are fever, myalgia, dry cough, and dyspnea, which usually appear within 2-14 days after the COVID-19 exposure. However, with the high infection statistics and comparatively high death rates, many people have been disquieted by the disease Zhao et al., 2020) . Vast literature and Health Care Practitioners (HCPs) have indicated that COVID-19 can be transmitted through social interactions and transferred from human to human. This invisible virus has caused many negative feelings and fear, which can lead to psychological problems such as depressed feelings comprising sadness, a lack of concentration, appetite change, disturbed sleep, and thoughts of death . (2020) stated that in addition to the severity and life-threatening nature of COVID-19, the fear of COVID-19 itself can be harmful. The onset of COVID-19 and the pandemic's natural surroundings creates fears throughout the world, leading to social stigmatisation in some cases. Contagious diseases are associated with several phenomena, such as fear of becoming a victim of the disease. The high death statistics being broadcasted on news channels and other mass media sources lead to psychological complications, including stigmatisation and a loss of stability and well-being (Ahorsu et al., 2020) . While many countries are endeavouring to produce vaccines for COVID-19, little consideration is being paid to the socio-psychological impacts of COVID-19 on the general population (Hamza Shuja, Aqeel, Jaffar, & Ahmed, 2020). Kang et al. (2020) and Jones et al. (2017) associated high rates of infection, poor protection against contagion, being overworked and uncomfortable, social isolation, and social distancing with mental health problems, that is, stress and situational depression, insomnia, disowning, aggression, and fear of COVID-19.

Among the South Asian countries, Pakistan is one of the affected countries that are experiencing many serious societal and economic concerns. Mamun and Ullah (2020) found that psychological problems associated with fear of COVID-19 lead to suicidal intentions, which have been reported in Pakistan and neighbouring countries such as India and Bangladesh. These cases could be caused by financial recession, fear of being infected with COVID-19, and high reported death statistics (Goyal et al., 2020; Kumar & Pinky, 2020; Mamun & Griffiths, 2020) . Furthermore, Mowbray (2020) found that the frequency of depression among the general population has increased by 7% and identified some determinants that increase the risk that a citizen will suffer from situational depression. These determinants include a poor socioeconomic background, being female, interpersonal conflict, family violence, overwhelming usage of social media, and inadequate social support (Torales et al., 2020; Usher et al., 2020) .

Many governments decided to follow the lockdown strategy to control the spread of COVID-19 (Dogan et al., 2020; Minai et al., 2021; Shakoor et al., 2020) . During a lockdown, many people from the low-income group such as daily earning labourers and drifting labourers get infected because they work far from their homes and family in overcrowded territories to afford essential life conveniences. Fighting against COVID-19 and thoughts of fulfilling basic needs can sometimes lead to contradictory outcomes, leading to severe depression and anxiety among the people whose quality of life (QOL) is severely affected (Pennycook et al., 2020) . WHO (2020) defines 'quality of life' as a person's self-perception regarding their locus in the environment of beliefs and value structure in which they live and in association with their vision, aspirations, standards, and apprehensions. It is a wide-ranging construct affected in a complicated way by the person's physical well-being, psychological stability, liberation level, social companionships, and their association with the prominent aspects of the environment in which they live (Vahedi, 2010 ). describe the protection model QOL in the light of COVID-19 as the interaction between protective moral support, social support, and a stable socioeconomic status (SES) and upsetting determiners, that is, disease or mental health problems. Clinically, the hopelessness, insomnia, and cognitive impairment result from these problems are influencing the overall QOL among citizens (Voruganti et al., 1998) .

Based on the above arguments, this work attempts to fill the gap in the QOL literature by;

• investigate the effects of fear of COVID-19 and situational depression on the quality of life of Pakistani citizens.

As such, there is a dearth of literature on the empirical examination of fear of death due to COVID-19. The severity and alarming consequences of COVID-19 have developed high fear among the population worldwide, and lockdown experiences have led to psychological problems, that is, depression among the population. These two constructs are invisible but prevalent; therefore, researchers have described fear of COVID-19 and situational depression as influencing people's lives behind closed doors. Since the sufferers rarely discuss these issues with others, researchers have coined the situation as silent cries behind closed doors. These issues have directly influenced the QOL of the general Pakistani population. The present study is among the pioneer to focus on fear of COVID-19, situational depression, and their impacts on the QOL of Pakistani citizens because this issue has not been adequately addressed in the existing literature.

Therefore, this study seeks to examine the QOL of Pakistanis during the COVID-19 pandemic outbreak in order to provide sociopsychological support to Pakistani citizens and promote their psychological well-being and mental health. Pakistan. Citizens living below the poverty line and the middle class groups who earn daily wages do not follow the standard operating procedures (SOPs) recommended by the health department because they claim that if they remain at home, they would have died of hunger. Previous studies in the same context were conducted to investigate Pakistan's preparation for Coronavirus as well the mental health and psychological aspects of COVID-19 (Mukhtar, 2020) . Meanwhile, the media has provided an overwhelming amount of information such that everyone already knows about the COVID-19 symptoms. Preventive measures like wearing a mask, using hand sanitiser, wearing gloves, and maintaining social distance can protect people from getting infected with COVID-19. Figure 1 depicts the COVID-19 statistics in Pakistan from April 2020 to October 2020 (Government of Pakistan, 2020). The highest death statistics were reported in June, followed by a declined from July onwards leading to the lowest statistics in October.

According to Ferriss (2004) , there is no specific theoretical background to provide an assessment of QOL. However, the concept of neo-Malthusian theory provides some foundations regarding the factors influencing QOL as it states that demographic changes lead to dysfunction due to the deprivation of social needs, that is, food and jobs, which affect the dynamics of QOL. Furthermore, Goldschmidt's (2006) hypothetical model states that an increase in the size of economic activities reduces poverty. In view of other concerns regarding the development of the social system, Marx and by Durkheim laid the foundation of the structural function theory, which specifies the specific necessities such as involvement in the environment, biological necessities of humankind, the social system to survive, and the necessity of group life, while the absence of these necessities would have a significant influence on QOL (Ferriss, 2004) . Due to the dearth of studies employing Maslow's (1943) hierarchy of needs and theory of human motivation (1943), the current study becomes among the pioneer studies that use this theory to fill this gap. Maslow (1943) properly. The second stage is security needs, consisting of order, sureness, independence from fear, safety against grievance, health and well-being, and control of their life. These needs are fulfilled through family relations and society. Currently, many people are experiencing various socio-psychological issues due to the COVID-19 outbreaks, such as a lack of basic needs, fear of the disease, joblessness, depression, and other psychological disorders. These situations have changed the ability to fulfil basic needs from previously. Huang and Zhao (2020) stated that fear and compromised physical health significantly influence people's mental health. Fear of COVID-19 is transformed into depression and anxiety when one gets infected. Prior studies show that people's emotional reaction comprises fear and uncertainty in terms of negative social behaviour, which directly influence their QOL (Mowbray, 2020; Torales et al., 2020) . Fear of COVID-19 develops due to perceived threat to life, isolation, and fear of compromised physical health.

These progress into severe feelings of depression and stress among the people who have experienced or been exposed to COVID-19 cases (Dong & Zheng, 2020; Jeong et al., 2016; Liu, 2020) . These experiences and exposure seem to be more severe in developing countries like Pakistan. Based on this discussion, the following hypothesis is proposed:

H1. There is a significantly negative relationship between fear of COVID-19 and the quality of life of the citizens of Pakistan.

The third stage is love and a sense of belonging. People seek feelings of interconnectedness encompassing affection, dependence, and affiliation as part of particular groups, that is, family, peers, and work, while fourth stage is esteem needs that consist of two types, namely self-esteem or self-respect and social repercussion or status. After satisfying all the above discussed stages, a person will reach the last stage of self-actualisation, which is self-satisfaction, in search of particular growth. The preceding study of Lodhi et al. (2019) stated that QOL is an all-encompassing line of attack that can be explained in various manners but there is a considerable agreement that QOL is a multi-mechanism phenomena determined through the subjective and objective well-being of a human being. It is influenced by multiple factors such as age, gender, employability, and SES. According to Hunt and Mckenna (1992) , the prerequisites of QOL are eating, drinking, good sleep, sex, averting pain, warmth, security, absence of depression, steadiness, love, physical connection, closeness, interconnecting, shared experiences, working for collective targets, curiosity, exploration of the world, consent, respect, a sense of usefulness, self-esteem, skills, authority, freedom, and self-actualisation. Depression statistics were not well understood in Pakistan in the past, but WHO considers depression as the main factor in developing fear. It is the primary cause of incapacity; these statistics lie between 28% to 63% among the Pakistani population. One of the probable causes of depression is social adversity in semi-periphery countries like Pakistan (Figure 2 ).

Depression can affect the social and psychological well-being of a person, and hence, there is a need to investigate and address this critical issue to promote and develop initiatives to reduce depression (The Nation News, 2020).

H2. There is a significantly negative relationship between situational depression and quality of life among the citizens of Pakistan. et al. (2020) . All the scales were measured using a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree.

SPSS version 25.0 was used to obtain the descriptive statistics and detect multivariate outliers. As suggested Lynch's (2013) , Mahalanobis distance was employed to detect the outliers, and a significant level was considered in an acceptable range. Common Method Bias (CMB) was checked by performing Harman's single-factor test. No bias were found as a single factor explained only 35.734%, which is less than a threshold of 50% (Podsakoff & Organ, 1986) . Further, Smart PLS-3 was used to perform the measurement and structural models to test the study's hypotheses (Hair et al., 2017) . 

As part of the diagnostic test, multicollinearity was checked to evaluate the inter-correlation among variables. In checking for multicollinearity, the variance inflation factor (VIF) and tolerance values were considered to detect misleading results (Marsh et al., 2004) . As shown in Table 2 , the highest correlation value between the variables is 0.583, and the highest VIF value is 1.099.

These results indicate no collinearity issues exist as VIF values are below the threshold level (Table 3, Hair et al., 2017; Yu et al., 2015) .

The two steps procedures were applied to evaluate the models: the measurement model and structural model (Henseler et al., 2009 ).

The measurement model of the study was examined using average variance extracted (AVE), Cronbach's alpha (α), composite reliability (CR), and discriminant validity. For the indicators' outer loadings, DEP 8, 12, 14, and 18 and QOL1, 2, 3, 4, 5, 6, 7, and 8 recorded items loadings below 0.40 and hence, were dropped (Hair et al., 2014) .

Discriminant validity was also assessed by evaluating the loading, cross-loading, and heterotrait-monotrait (HTMT) ratio criterion. As shown in Table 4 , the prime factor items have higher loadings than other items in other variables. Moreover, as recommended by Henseler et al. (2015) , the HTMT values should be less than 0.85 to ensure discriminant validity. Based on this criterion, all the values are less than 0.85 (see Table 5 ). Table 6 shows that the standardised root means residual (SRMR)

is 0.07, which is lower than 0.08, thus indicating a good model fit (Hair et al., 2017) . Cross-validated redundancies (Q 2 ) are more significant than zero (Figure 3 ), showing the model has adequate predictive relevance (Hair et al., 2017) . The coefficient of determination (R 2 ) is 0.512, indicating that the exogenous variables have substantial effects on the endogenous variable (Hair et al., 2017) .

In the second step, as recommended by Dijkstra and Henseler (2015) , consistent bootstrapping was applied to 5000 samples for the reflective measurement model to test the study's hypotheses. Note: N = 377, *p ≤ 0.001 or t ≥ 3.29, **p ≤ 0.01 or t ≥ 2.58, ***p ≤ 0.05 or t ≥ 1.96, β, path coefficient; DEP, depression; FOC, fear of Covid-19; LL, lower limit; QOL, quality of life; UL, upper limit.

shows that fear of COVID-19 has a significant negative relationship with QOL (β = À0.088, t = 2.181, p > 0.05), which supports H1, while depression has a significant negative relationship with QOL (β = À0.679, t = 20.135, p > 0.05), which supports H2 (Figure 4 ).

This study is significant because the novel COVID-19 has psychologically and physically shaken the world; consequently, people are suffering from fear of COVID-19, situational depression, and their impact on QOL (Ahorsu et al., 2020; Ahuja et al., 2020) . The present study has been conducted to examine the relationships between fear of COVID-19, situational depression, and QOL among Pakistani citizens. Also, future studies should focus on the impact pre and post COVID-19 because the pandemic is still ongoing, as well as researchers should analyse whether social distancing and lockdowns affect people's health both physically and mentally.

The authors are grateful to the editor and anonymous referees of the journal for their extremely useful suggestions to improve the quality of the paper.

The data set is available on request. 

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Preliminary estimation of the basic reproduction number of novel coronavirus (2019-nCoV) in China, from 2019 to 2020: A data-driven analysis in his Bachelor of Hospitality Management (Hon.) and Masters by research from Universiti Utara Malaysia. His research interest includes organizational studies in hospitality management, consumers' behaviour, tourists' behaviour, green innovation and environmental impacts of the tourism industry. He has been considered as reviewer and editor in several journals and conferences. He has good command in SPSS, PLS-SEM and related quantitative techniques. How to cite this article