This is the first study that reports on the prevalence and demographic correlates of perceived stress during the COVID-19 pandemic within Canada. Text4Hope had 32,805 subscribers after the first week of launching the program. 6,041 respondents completed the baseline survey, giving a response rate of 18.4%. There were 5,528 respondents who completed the PSS; this sample size is well above what was needed to have a 99% confidence level in our estimate. The prevalence rate of moderate/high stress in Alberta was determined to be 84.8%. Significant associations were found between all demographic variables, except ethnicity, with moderate/high stress. All variables were added to the binomial logistic regression model for analysis. Our model, identified gender (i.e., identifying as female), age (i.e., being ≤ 25), current employment status (i.e., being unemployed), and current housing status (i.e., renting) as significant demographic predictors for moderate/high stress.
Based on the 2014 Canadian Community Health Survey data, 23% of Canadians aged 15 years or older reported feeling “quite a bit” or “extremely stressed.”41 While the surveys are not directly comparable (i.e., individuals are asked to reflect on different timeframes), the prevalence rate from this study indicates that stress levels may be elevated compared relatively recent Canadian data. Our findings align with the literature, which suggest that elevated psychological stress is typical of epidemic and disease outbreaks.42-44 They also align with other evidence emerging from the COVID-19 pandemic.10-12 Our prevalence rate is substantially higher than that reported by Wang et al. at 8.1% in the general Chinese population.10 We speculate that the discrepancy between prevalence rates is possibly attributable to differing survey times. In the Chinese study, data was collected from January 31 to February 2, 2020, a day after the WHO declared COVID-19 a public health emergency of international concern on January 30, 2020. At this point, there were 7,818 total confirmed cases worldwide.45 Our study collected data from March 23 to March 30, 2020, which was shortly after the WHO had declared COVID-19 a pandemic on March 11, 2020. At that time, there were 118,319 confirmed cases globally,46 a 15 time increase compared to January 30, 2020. Nevertheless, there are cultural and contextual differences that may also explain the difference.
In relation to correlates of perceived stress in the present sample, identifying as “other gender,” being ≤ 25 years of age, having attained less than a high school diploma, being unemployed, being single, and living with family were associated with significant stress. Several of these factors have been reported in association with higher rates of psychological stress during COVID-19 and natural disasters.10,25,26,31 Our data indicate that specific groups are at risk for greater levels of stress in response to public health emergencies and this represents an important focus for interventions during times of crisis. Overall, our findings are consistent with other studies examining the demographic correlates of stress.10-12
Our model identified gender as a predictor of moderate/high stress. Specifically, female identifying individuals were 1.5 times more likely to report moderate/high stress than male identifying individuals. This is comparable to prior results for the general population10,12 and for healthcare workers15 during the current pandemic. As proposed by others,12 the greater likelihood of reporting moderate/high stress in female identifying individuals may be attributed to a number of factors. Several studies have suggested that females generally score higher on the PSS,47,48 report higher intensity of psychological symptoms,49 and are exposed to a greater number of stressful life events compared to those identifying as male,50 which may contribute to the higher prevalence estimate with female identifying participants.
The association between age and psychological stress in the literature is mixed. Some reports indicate an absence of an association while others observe a significant positive or negative correlations between age and stress.10,11,12 In agreement with others,12,51 we found a negative correlation between age category and moderate/high stress in our model. Specifically, individuals in the ≤ 25 year category were more likely to report on moderate/high stress levels compared to all other age categories. While COVID-19 symptoms are more severe and mortality rates are higher for older individuals,52 there is evidence to suggest that older individuals may generally score lower on the PSS compared to younger individuals, suggesting that stress perception naturally declines with age.48 Additionally, older individuals have been found to have lower reactivity to stressful events, which may be related to greater resiliency or more effective emotional regulation abilities.51 Another explanation, based on research conducted during the SARS outbreak, is that younger individuals tend to have significant psychiatric morbidities, which has been shown to correlate with higher levels of stress.12,53 More research is needed to elucidate the effects of age on perceived stress for COVID-19.
Employment status contributed significantly to our model, with unemployed individuals having more than 2 times the likelihood to report moderate/high stress compared to those who were employed. Similarly, Nelson et al. reported that the loss of employment due to COVID-19 was related to increased psychological symptoms.11 Periods of economic recession have been linked with degradation of mental health, negative coping strategies (e.g., alcohol and drug use), and suicide rates.54,55 These detriments may persist for long periods during financial recession. Given the unprecedented number of Canadians applying for Federal jobless benefits and emergency income aid, our findings are aligned with the reporting of current trends in the economy. Since we found age to be negatively correlated with moderate/high stress, it is not surprising that retirees were 1.6 times less likely to report moderate/high stress compared to those who were employed. Generally, older individuals are more likely to be retired. We found no statistical association between being a student and reporting moderate/high stress. This contrasts a positive association with being a student and reporting higher stress scores found by Wang et al.10 A reason for these differences could be related to how participants were sampled. In the Chinese study, the online survey link was initially disseminated to university students who were then encouraged to share the link with others. In this study, Text4Hope was endorsed by provincial government officials and presented as a service offered to the general public. As such, the sampling method in our study may be more reflective of a general population.
Finally, our model suggests that current housing status is a predictor for moderate/high stress. Similar to unemployment status, this finding may be linked to economic instability. There is evidence supporting the association of housing foreclosures with unemployment, poverty, and suicide rates.55 In our study, renters were 1.7 times more likely to report moderate/high stress than home-owners. Although federal emergency funding and financial aids have been put in place throughout Canada, there are several stressors directly impacting renters. In a recent survey of 1,100 renters across Canada, around 70% of respondents reported that COVID-19 had impacted their financial situation and 42% stated that they did not qualify for employment insurance or federal emergency funding.56 The report also indicated that 35% of respondents did not have enough money to pay rent on May 1, 2020. In Alberta, this is the date where rent non-payment eviction can be enforced, which may have contributed to higher reporting of moderate/high stress in renters.
There are several limitations in this study. This is a report of a single cross-sectional sample, which limits the ability to track changes in perceived stress over time. Additionally, Text4Hope is an intervention to help reduce stress and anxiety due to the COVID-19 pandemic. It is possible that voluntary subscribers differ in marked ways from the general population of Alberta, which could systematically influenced the perceived stress prevalence rate. Specifically, individuals who have higher stress levels may be more likely to enrol in the Text4Hope program. Additionally, the current study was limited to a Canadian setting and was overwhelmingly represented by individuals who identified as Caucasian (82.2%), which may limit generalizability to other non-Western countries. Finally, this survey is unable to measure the direct effect of COVID-19 on persons with any confirmed mental disorder.
Despite the above limitations, our findings have clinical and policy implications. First, the results provide important information on demographic correlates of perceived stress in Alberta during the COVID-19 pandemic. This can help health authorities identify high-risk groups based on sociodemographic information for early psychological interventions. The results can also be used as a historical reference for future studies of mental health impacts of pandemics and other natural disasters. Notably, our findings may inform aspects of the development of mobile-based interventions intended to provide support and minimize negative psychological impact during pandemics and other disaster settings. In particular, we provide a framework on how mobile-based interventions can be a useful tool to provide mental health support and can be used to collect population-level data in a short timeframe. This approach may be a key strategic contribution to inform stakeholders for time sensitive policy decisions during pandemics and other disasters. The current results support the case for mobile-based interventions in planning how to allocate resources to meet the mental health needs of at risk populations in a disaster context.
The near- and longer-term psychological impacts of COVID-19 remain unknown. Longitudinal studies will be necessary for our attempts to understand any temporal effects occurring due to this pandemic. In particular, time series analysis should be conducted to determine the changes in psychological impacts in a population in this context. The Text4Hope study team intends to report on the 6- and 12-week Text4Hope data once they become available. The upcoming dataset will provide information on the effectiveness of daily supportive text messages during a pandemic. Additionally, we will be able to report on user satisfaction, changes in the severity of psychological stress, and self-reported changes in health utilization patterns against the current baseline reference data for prevalence estimation from this first-time sample.