Anxiety and depression among people living in quarantine centers during COVID-19 pandemic: A mixed method study from western Nepal

Background In response to the COVID-19 pandemic, incoming travelers were quarantined at specific centers in Nepal and major checkpoints in Nepal-India border. Nepal adopted a generic public health approaches to control and quarantine returnee migrants, with little attention towards the quality of quarantine facilities and its aftermath, such as the poor mental health of the returnee migrants. The main objective of this study was to explore the status of anxiety and depression, and factors affecting them among returnee migrants living in institutional quarantine centers of western Nepal. Methods A mixed method approach in this study included a quantitative survey and in-depth interviews (IDIs) among respondents in quarantine centers of Karnali province between 21st April and 15th May 2020. Survey questionnaire utilized Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) tools, which were administered among 441 quarantined returnee migrants. IDIs were conducted among 12 participants which included a mix of six quarantined migrants and healthcare workers each from the quarantine centres. Descriptive and inferential analyses were conducted on quantitative data; and thematic analysis was utilized for qualitative data. Results Mild depression (9.1%; 40/441) and anxiety (16.1%; 71/441) was common among respondents followed by moderate depression and anxiety {depression (3.4%; 15/441), anxiety (4.1%; 18/441)} and severe depression and anxiety {depression (1.1%; 5/441), anxiety (0.7%; 3/441)}. Anxiety and depression were independent of their socio-demographic characteristics. Perceived fear of contracting COVID-19, severity and death were prominent among the respondents. Respondents experienced stigma and discrimination in addition to being at the risk of disease and possible loss of employment and financial responsibilities. In addition, poor (quality and access to) health services, and poor living condition at the quarantine centres adversely affected respondents’ mental health. Conclusion Depression and anxiety were high among quarantined population and warrants more research. Institutional quarantine centers of Karnali province of Nepal were in poor conditions which adversely impacted mental health of the respondents. Poor resource allocation for health, hygiene and living conditions can be counterproductive to the population quarantined.


Status of depression and anxiety
Moderate: 4.1%; 18/441) and Severe: 0.7%; 3/441) compared to depression (Table 2). There was 1 8 8 no significant association of depression and anxiety with socio-demographic characteristics of 1 8 9 the population (Table 3 and Table 4). Characteristics of study participants in IDIs 1 9 1 A total of 12 respondents, six each quarantined migrants and health workers from various 1 9 2 quarantine centres participated in the IDI. Age of participants ranged from 22 years to 46 years. Immigrants were quarantined in different centres both in India and Nepal, the total duration 1 9 4 ranging from 9 to 45 days. Health workers with various educational backgrounds were recruited 1 9 5 in this study. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. ; https://doi. org/10.1101org/10. /2020 Factors influencing mental health 1 9 8 Overall findings 1 9 9 Mental health of people living in quarantine centers were influenced by multiple factors (Fig 2).  reducing transmission. They also expressed their strong commitment to stay in quarantine to save 2 0 8 their family and the community from acquiring disease from them. "…This disease is highly contagious. Even my friends who travelled along with me are 2 1 0 infected however it can be prevented using masks and frequent handwashing. This is an 2 1 1 emergency condition and we [family and community] are at risk. So, we need to be safe." Almost all participants were also aware of the rising case and death tolls due to COVID-19 2 1 4 globally. The disease was perceived to be extremely contagious and the fear of dying from the 2 1 5 disease was widely prevalent. Although, all of them were asymptomatic for COVID-19, they 2 1 6 expressed their worry of contracting the disease from the fellow quarantined people they had to 2 1 7 live in close proximity with. Some of the respondents were also aware of their fellow travelers 2 1 8 testing positive for the disease and the high rate of disease transmission in Indian cities where 2 1 9 they worked before travelling to Nepal which escalated their fear of being infected although were 2 2 0 currently symptomless. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. ; https://doi.org/10.1101/2020.11.05.20224436 doi: medRxiv preprint 1 0 Respondents also expressed their dissatisfaction towards the authorities mixing them with more 2 2 5 in-coming people which they thought could increase their risk of infection. This was often the 2 2 6 reason for conflict between quarantined people and the authorities, and newcomers and people 2 2 7 residing earlier in quarantine. "….we did protest to not let 25 newcomers stay here. The local people also protested and 2 2 9 threw some stone towards them at midnight [but it didn't work]." The quarantine centers in Nepal were rapidly set up in response to a large number of migrants 2 3 2 coming from India and operated without adequate measures to prevent transmission within the 2 3 3 centers. Travelers were provided space based on the availability and people coming from 2 3 4 different places and at different times were often sheltered in the same rooms. The fear of contracting the disease, suffering and dying from the disease stirred the mental well-2 3 6 being of the participants which was often expressed in the form of restlessness and insomnia.  immigrants that may have led to high discrimination towards them. Despite that most were 2 4 5 asymptomatic, they still faced the acts of discrimination. The discrimination was based on, in 2 4 6 addition to the fear of them bringing the disease as they were returning from high transmission 2 4 7 areas in India, the political and socio-economic factors. They were often denied food and water 2 4 8 during their journey. "The people from province 5 did not even give us water [for being from another CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. ; https://doi.org/10.1101/2020.11.05.20224436 doi: medRxiv preprint

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Participants were vocal about the discrimination faced by them and often expressed their 2 5 3 annoyance towards these acts that hurt their esteem. They compared their quarantine experience 2 5 4 in Nepal with their travel in India while returning home and expressed their dissatisfaction with 2 5 5 the management of quarantine centers and the behavior of authorities towards them. "Whenever we ask for something, the thing is thrown towards us rather than passing it 2 6 0 on hands. In India, we used to stay in queue and get required articles respectfully. Participants were mostly labor migrants to India, most of them with a monthly income of less 2 6 5 than $200. They had lost their job due to the pandemic and were returning home without a troublesome for them to return without an earning. Some participants further related their worsening economic condition with their family 2 7 2 responsibility and expressed their concern over earning for living and providing education to   . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. ; https://doi.org/10.1101/2020.11.05.20224436 doi: medRxiv preprint 1 2 India is a popular destination for the labour migrants, especially from hilly regions in western Nepal. Among all the labor migrants, most are seasonal travelers who work for few months in insecurities for finding an employment in Nepal. living condition at the quarantine centers were reported to be one of the stressors by many  "…packaged meals used to be delivered in quarantine centre for us, but the food used to Poor facilities for water and sanitation deprived them from the maintenance of their personal and 2 9 4 environmental hygiene. In addition to these, being a factor for their personal discomfort and 2 9 5 dissatisfaction, this was disturbing the residents living around the quarantine centres and was 2 9 6 often a reason for complains against quarantined population. "…an auntie here [community person housed next to quarantine centre] complains that 2 9 8 we are being unhygienic and dirty. But we have problem with water here, we are not 2 9 9 given enough water. We haven't been able to take bath for several days." People were often quarantined at more than one place in Nepal and India during their travel. For 3 0 2 many participants, this led to very long cumulative quarantine duration, which was reported to be  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. There were no rooms for any re-creational activities. The fellow quarantined people were just the 3 1 3 'strangers' for most of the participants. When asked if they got chance to share their problem and anyone who were strangers to them. Although quarantined people were aware of the need to 3 1 6 quarantine them; and complied with the government regulation to stay in the quarantine center 3 1 7 for at least 2 weeks after arrival in Nepal, they thought they were living a miserable life there. Although some quarantine centers had started some forms of mental health services such as 3 2 2 yoga, the participants explained that counselling services in quarantine centers were poor (worse 3 2 3 than the expected). Participants also expressed lack of confidence in the health system of the country when COVID- for optimal routine health services at the quarantine centres and were worried of encountering 3 3 2 health crisis during their stay. Many participants had chronic problems such as gastritis, diabetes and hypertension and they felt treatment. Although some health workers thought that they were providing the essential services 3 3 7 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. control. Then, we gave her medicine for rashes, but could not test for her blood sugar.

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We had to counsel her to stay in quarantine and defer her sugar testing until she The main objective of this study was to explore the status of mental health and factors affecting  This study reported prevalence of anxiety to be 20.9% and depression to be 13.6% which aligns 3 5 6 with a previous reports that highlights high prevalence of depression and anxiety in population unaffected (6.7% and 11.9%) has been reported from China [29]. Some studies have reported 3 6 0 alarmingly high occurrence of mental disorders among those being quarantined. For instance,  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. ; https://doi.org/10.1101/2020.11.05.20224436 doi: medRxiv preprint 1 5 While emerging evidence indicate increased anxiety and psychological distress due to COVID-3 6 7 19, factors other than disease itself significantly affects the mental wellbeing of the population.

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For example, in a study from Germany where over 50% of participants expressed anxiety and    . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. ; https://doi.org/10.1101/2020.11.05.20224436 doi: medRxiv preprint 1 6 Poor access to health care services is reported from the quarantine centers in Nepal [6, 10]. As 3 9 6 the health system in Nepal was already strained due to the impact of 'covidization', people 3 9 7 lacked access to essential health services [34,44]. Many of the participants already had medical 3 9 8 conditions which needed urgent care. People with self-perceived illnesses supposedly have   quarantine is pervasive, substantial and can be long lasting [13]. In parallel to instituting essential  The psychological consequences during disasters are often the neglected aspects in public health   . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Strengths and limitations 4 2 5
This is to our knowledge the first study conducted in Nepal to explore anxiety and depression 4 2 6 among people who had to stay in the quarantine centres during COVID-19 pandemic. One of the 4 2 7 main strengths of this study is that it uses a mixed method design in an adequate sample.

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Nonetheless, the study may have incurred recall and social desirability bias. In addition, anxiety   Although no statistically significant association of anxiety and depression with socio-    CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review) preprint
The copyright holder for this this version posted November 10, 2020. ; https://doi.org/10.1101/2020.11.05.20224436 doi: medRxiv preprint 1 8 • Steps towards alleviating fear and stigma through education and awareness about the 4 5 2 disease should be implemented.

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• Censoring exaggerated and unverified news and ensuring that the information being 4 5 4 disseminated through media is factual and reliable is necessary to mitigate the damage  • Strategies for promoting societal acceptance and psychosocial support are very crucial to 4 5 7 mitigate the impact of stigma and discrimination.  and recreational support.

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. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. Nepal, 5 June 2020, https://risingnepaldaily.com/miscellany/state-minister-blames- shortage-for-poor-management-of-quarantines (5 June 2020).

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[12] How is COVID-19 impacting the people of Nepal? WaterAid, 5 3 2 https://www.wateraid.org/global-covid-19-response/nepal (2020, accessed 9 October 5 3 3 2020).       Birendranagar, Surkhet, Karnali Province, Nepal, 2020.   . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. properties. J Cousneling Clin Psychol 1988; 56: 893-897.   [28] Ravi Philip Rajkumar. COVID-19 and mental health: A review of the existing literature.    at the beginning of the COVID-19 pandemic in Germany. Brain Behav 2020; 1-10.   . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020.     . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. ; https://doi.org/10.1101/2020.11.05.20224436 doi: medRxiv preprint 2 7 6 4 7  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020.  is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. The map was created with ArcMap version 10.8.1 and GPS coordinates were taken from field 6 5 6 locations.

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. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted November 10, 2020. ; https://doi.org/10. 1101/2020