Adaptive measures to deal with the next pandemic caused by climate change in at-risk groups

Abstract

Background

The intensity of the perceived stress during the pandemic is a very basic variable for the risk analysis and proper disaster response. The present study was conducted with the aim of determining the relationship between perceived stress and social support during covid-19 in diabetic patients in order to design a suitable plan for a possible pandemic.

Methods

This cross-sectional study was conducted in 2021 on 212 diabetics in Hormozgan province / southern Iran. Data were collected online using Whatsapp using social support and perceived stress questionnaires specific to COVID-19. Data were analyzed by SPSS 22 software using Pearson correlation coefficient tests.

Results

The mean and standard deviation (SD) of the stress score was 18.46 ± 4.41. Mean ± SD of social support dimensions were emotional support 30.76 ± 5.96, information support 21.63 ± 4.56, instrumental support 32.48 ± 6.68, and evaluative support 23.53 ± 4.83. There was a significant correlation between emotional support (r =-0.377, P < 0.001) and instrumental support (r =-0.280, P < 0.001) with perceived stress.

Conclusion

The inverse relationship between emotional and instrumental support and perceived stress in diabetic patients during the Covid-19 pandemic suggests that health promotion interventions focus on increasing these two forms of social support in order to reduce stress during disasters. Especially when there are warnings about the release of microbial agents from melting polar ice and the possibility of the next epidemic.

Background

Living conditions are full of stressful factors that make a person suffer from mental and physical diseases [1]. Because mild stress is a necessary component of one’s health and serves as a driving force for adjusting to unfamiliar circumstances, stress is not necessarily a bad thing [2]. However, stress can negatively impact people’s health if it is not maintained or under control [3]. The COVID-19 pandemic was one of the stressors experienced by the people of the world, this experience was accompanied by negative effects on stress and mental health [4, 5]. Evidence showed that one of the factors related to COVID-19 was underlying diseases in patients [6]. According to the results of a meta-analysis, 51% of hospitalized patients were associated with an underlying disease, where diabetes was the second most common underlying disease with a 7.3% mortality rate [7]. The results of another study showed that depending on the global region, 20 − 50% of people with COVID-19 had diabetes [8]. These statistics show that diabetics are a vulnerable group to COVID-19 or other probable microbial pandemic and the stress caused by disease [6]. The issues that initially caused excessive stress and mental health problems in COVID-19 were the unknown nature of the disease, the uncertainty about the future of the disease and the lack of definitive treatment [9, 10] These challenges can also cause panic about possible future climate change pandemics. Instead, supportive living environment, especially social support, has been reported as one of the factors to deal with the severity and complications of microbial pandemics [11].

When it comes to the release of microbes due to the melting of polar ice and the possibility of a pandemic after that, there should be a proper plan to cope with these stresses, especially in the case of vulnerable groups [12].

Social support is the care, comfort and help that other people or groups provide to another [13]. It also serves as information that leads people to believe that they are lovable, respected, and part of a network of mutual obligations [13]. This support may be provided by a variety of sources such as spouse, family, relatives, friends, co-workers, or social organizations. Studies found that people with social support feel more belonging and self-esteem [13]. The positive attitude that such a situation creates can significantly neutralize stress [14]. Social support in diabetes is defined as a psychological view of social networking in line with an individual’s ability to cope with diabetes [15]. Therefore, it is necessary to study the stress and identify vulnerable people at different levels of society, especially in high-risk groups such as diabetics. It is also necessary to examine the level of social support and its relationship with stress. These evaluations can help health officials in providing psychological solutions and interventions to improve people’s mental and physical health. Accordingly, the present study aimed to determine adaptive measures to deal with the Next Pandemic caused by Climate change in at-risk Groups, by evaluating the relationship between perceived stress and social support during COVID-19 in diabetic patients of southern Iran.

Methods

Study design and participants

This was a cross-sectional study in which 212 diabetic patients under care in diabetes center of Hormozgan province participated. A center where prevention, treatment, and psychological counseling are given to diabetes patients by specialists and professional experts.

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The sample size was calculated based on the appropriate formula, in which the standard deviation was 11 and d = 2.2, and the design effect of 1.1 was applied to increase the sample size. The final sample size was estimated at 216 people. Participants completed the questionnaires after obtaining informed consent. As a matter of fact, in total, 212 patients completed the data gathering tools, demonstrating a response rate of 98.1%. Inclusion criteria included; registration in the diabetes center of Hormozgan province as a diabetic person, not having COVID-19 at the time of the study, ability to use cyberspace, ability to read and write, and age over 18 years.

Measures

The data collection tool was a questionnaire included demographic checklist, social support scale, and perceived stress scale, the last two of which were specific to COVID-19. The first part of the questionnaire included 19 demographic questions such as age, sex, marital status, level of education and history of diabetes.

The second part was the researcher-made social support scale, consisted of 32 questions with four dimensions. Emotional support includes 9 questions with a range of scores (9–45), informational support with 7 questions (35 − 7), instrumental support with 9 questions (9–45), and evaluative support with 7 questions (7–35). All questions were designed based on a 5-point Likert scale (from never = 1 to always = 5) and the total scores of the scale ranged from 32 to 160. The validity of the social support questionnaire was assessed with a ten-member panel consisting of faculty members of the department of health education and promotion, and health psychology. (CVI = 0.93, CVR = 0.89). The third part was 10-item questionnaire to assess perceived stress caused by COVID-19 [16, 17]. Questions are provided with a five-point Likert scale (never, almost never, sometimes, relatively often, and often) with a range of 0 to 40. In interpretation, higher scores indicate a higher level of perceived stress in the participants, and as a cut-off point, a score greater than 25 is considered high stress.

To determine the reliability of data gathering tool, social support and perceived stress questionnaires were completed by 20 diabetic patients on two time with 10-days interval. The test-retest results showed the significant correlation of scores on two time for social support questionnaire (r = 0.967, p < 0.001), and perceived stress (r = 0.975, p < 0.001). Also, the internal consistency of the questions was confirmed by Cronbach’s alpha of 0.87 for social support questionnaire and 0.90 for perceived stress.

All ethical considerations, such as preserving the dignity of individuals, clearly explaining the purpose of the research, presenting the results to the relevant authorities for necessary actions, were carried out. Ethic approval for the research was received from the Ethics Committee of Bandar Abbas University of Medical Sciences IR.HUMS.REC.1399.370. Due to the high prevalence of COVID-19 at the time of the study and the risks of people’s presence, sampling was done online. After determining the sample size, people were randomly selected from the list of patients of Hormozgan Diabetes Center. Then, the objectives of the study were explained to the patients on the phone, and after obtaining their informed consent, the link of the questionnaire was sent to them via WhatsApp. The confidentiality of the information and answers was assured and the informed consent form was placed on the first page of the online questionnaire.

Statistical analysis

The collected data were analyzed using SPSS-22 software. The Shapiro-Wilk test was used to evaluate the normality of the distribution of numerical variables, descriptive indicators were used in the form of mean, standard deviation, minimum and maximum for numerical variables, and frequency and percentage representations were used for categorical variables. Pearson correlation was used to examine the relationship between social support and stress.

Results

In this study, 212 diabetic patients participated with a mean ± SD of age of 49.3 ± 17.17, and a minimum age of 18 years and a maximum of 74 years. The majority of people were women (57.1%) and married (79.7%). The level of education was divided into 4 groups: elementary 19.3%,, middle school 24.1%,, diploma 34.4%,, and university education 22.2%, respectively. Nearly half of the people (47.6%) had a history of underlying disease, of which heart disease (27.9%) was the most common underlying disease. Also 51.4% had a history of COVID-19 in their relatives.

The mean (SD) scores of social support dimensions in diabetics are shown in Table 1, indicating emotional support = 30.76 ± 5.96, information support = 21.63 ± 4.56, instrumental support = 32.48 ± 6.68, and evaluative support = 23.53 ± 4.83. The highest level of social support was observed in the dimension of instrumental support, then the dimension of emotional support, and the dimensions of evaluation support and information support were in the next stage, respectively. Also the mean (SD) of perceived stress was 18.46 ± 4.41.

Table 1 Mean and range scores of perceived stress and dimensions of social support

The mean score of perceived stress was classified into two groups included high and low level, according to the cut-off point (scores greater than 25), only 11 people (5%) had high stress (Fig. 1).

Fig. 1

Distribution based on the intensity of stress caused by the COVID-19 pandemic

Pearson correlation was used to examine the relationship between social support and stress. A significant positive correlation was observed between dimensions of social support including emotional support and information support (r = 0.528, P < 0.001), emotional support and instrumental support (r = 0.730, P < 0.001), emotional support and evaluative support (r = 0.554, P < 0.001), information support and instrumental support (r = 0.502, P < 0.001), information support and evaluative support (r = 0.635, P < 0.001), and between instrumental and evaluative support (r = 0.668, P < 0.001). Among the dimensions of social support, there was only significant negative correlation between emotional support and stress (r= -0.377, P < 0.001) and instrumental support and stress (r= -0.280, P < 0.001). No significant correlation was observed between information support and stress and between evaluative support and stress (Table 2).

Table 2 Pearson correlation coefficient between stress and social domains

Discussion

This study was conducted to determine adaptive measures to deal with the Next Pandemic caused by Climate change in at-risk Groups, by evaluating the relationship between perceived stress and social support during COVID-19 in diabetic patients of southern Iran. The findings of the study showed that the perceived stress was at a low level in 94.8% of diabetic patients. Different levels of stress during the COVID-19 pandemic have been reported in different parts of Iran [18,19,20,21]. The results of a study conducted in Denmark showed that 14.3% of the participants were in a state of high stress [22]. Another study showed that diabetics had moderately high level of stress during COVID-19 pandemic [23,24,25]. These results can be used as a basis for planning to deal with the next possible pandemic.

Another result of the present study was the significant relationship between perceived stress and social support. The results showed that among the 4 social support dimensions, only two instrumental and emotional dimensions had a negative and significant correlation with perceived stress. In other words, with the increase of emotional and instrumental support, the amount of perceived stress decreased, such a results reported in similar study [26]. The importance of instrumental and emotional support and the effect of these two dimensions on each other as predictive factors in comfort combined with well-being have also been reported in other studies [26, 27]. When an unforeseen threat arises and there has been no prior direct experience with the scenario, using instrumental coping mechanisms to manage one’s perceived vulnerability to infection may have a good effect on adherence to protective measures [27]. If compromise strategies are not adopted in the early moments of confronting unknown epidemics, violence and personality disorders may spread throughout society, especially among those at risk [28]. Therefore, having a comprehensive plan for the next possible pandemic is one of the necessities [29]. Simulating possible epidemics caused by climate change using artificial intelligence can be a good solution to create a basis for using the results obtained from the relationship between stress and risk groups in the COVID-19 epidemic [30, 31].

In a study in Poland, approximately 40% of respondents with diabetes reported significantly improved self-management of the disease. More than 60% of patients also reported that they started eating nutritious foods at regular meals during the COVID-19 pandemic [23]. One of the reasons for such results can be low stress in patients. In the case of the present study, considering that the study was conducted more than one year after the outbreak of Covid-19, diabetics have probably obtained proper health and nutrition information through various sources and have been able to overcome the stress caused by the pandemic.

One of the factors influencing stress is social support. Social support has a significant effect on environmental adaptation and mental health [32, 33]. It helps people feel better about themselves and better able to cope with situations, and it also affects people’s self-esteem, hopeful thoughts, mental health, and quality of life [34]. In general, social support is related to the quality of life of diabetics both physically and psychologically [26]. Studies have shown the positive effects of social support on the psychological state of individuals in the face of stressful events [35]. In the present study, the relationship between perceived stress and emotional support and instrumental support had a significant negative correlation, and the results of previous studies also indicated that weakness in social network and social support are associated with more severe diabetes complications [36, 37]. Therefore, it can be concluded that by increasing social support and especially based on the results of this study, by increasing the emotional and instrumental support of people, their stress can be reduced.

Emotional support (empathy, love, trust, and care) and instrumental support (providing the tangible help one needs) [38], are two factors that should be considered in people with diabetes. Emotional support for diabetes management can reduce the stress of diabetics [39]. During the COVID-19 pandemic, intervention through emotional support of individuals can reduce their stress [40] and using emotional support can increase people’s well-being [15]. Instrumental support is the most common support that diabetics receive to manage their condition [41]. There is a significant negative correlation between instrumental support and self-blame [42], and self-blame can increase COVID-19 induced stress [43].

Stress in 2020 during the COVID-19 outbreak was significantly higher than the previous year and also significantly higher than the average stress reported annually since 2007 in the same community [43]. People’s mental health must be maintained in such situations since the release of COVID-19 may expose them to stressful stimuli in various sections of society. In order to maintain mental health with the proper psychological methods and techniques, it is crucial in the current high-risk situation to identify persons who are susceptible to psychological diseases at different levels of society.

According to the results of the present study, the management and planning of health professionals is essential in improving the health of diabetic patients. In addition to paying attention to physical health, the mental health of these people is also a priority. As mentioned, improving social support dimensions such as emotional and instrumental support can play a significant role in managing the stress of these people.

One of the limitations of this study was that the data was collected by self-report, therefore, some degree of measurement error may have occurred. It is also possible that the literacy of using smartphones and completing the online questionnaire was not appropriate in all people. However, the present study had some strengths. Its strengths include the priority and importance of the subject in view of the COVID-19 pandemic in the country, the use of the online method to complete the questionnaires, and compliance with health protocols. In diabetics, there was a substantial link between stress and social support. The majority of study participants had modest levels of felt stress.

Conclusions

Support on both an emotional and practical level was linked to less stress. It might be argued that the growing emotional and practical support can help diabetics feel less stressed. In order to strengthen social support and ensure people’s mental health, it is advised to identify those at high risk for psychological diseases and offer a suitable remedy.

With regard to climate change, there is a warning that a viral or microbial epidemic may follow the melting of the polar ice caps. Considering the inverse relationship between emotional and instrumental support and perceived stress in diabetic patients during the COVID-19 epidemic, it is suggested that health promotion interventions based on increasing these two forms of social support adapt to the possible pandemic caused by Climate changes to reduce stress, especially among vulnerable groups during disasters.