A study of emotional states in candidates undergoing the diagnostic process for COVID-19.

BACKGROUND: Waiting for results is often associated with a state of anxiety and restlessness. The current study is intended to study the emotional state of people waiting for their results after undergoing COVID-19 testing.
METHODS: A descriptive study was done among 140 participants enrolled by simple random technique over a period of 1 month in May 2020. The participants who gave sample for COVID-19 were assessed for their emotional state at two stages - after giving sample and during the waiting period before telling results to them. A self-designed questionnaire focusing on the demographics and emotional state was submitted by the participants distributed to them as Google Forms. Wilcoxon signed-rank test and McNemar test were used to compare the statistical change in emotions over a period of time.
RESULTS: Around 63.6% and 68.8% of the participants had neutral emotional state after giving sample and before announcement of results, respectively. The mean score of agreement with decision to test was 9 ± 1.6 and discomfort related to testing was 4.6 ± 2.6 on Likert scale of 1-10. A statistically significant difference (P = 0.01) was observed in mean response for "something can be done to help" after giving sample (1.6 ± 0.4) and before announcement of results (1.8 ± 0.3).
CONCLUSIONS: Patients undergoing testing for COVID-19 undergo psychological turmoil and use various coping methods. Patients endorsed various suggestions including quicker generation of results, environmental changes and counselling services to help them cope better. Incorporating these suggestions may improve the diagnostic process in patients with COVID-19. Copyright:

The coronavirus pandemic is having a huge impact on every aspect of human life.[1] The psychological impact of the current pandemic can be seen at every stage of the disease starting from incurring the infection to the time after cure. Diagnosis of a condition can be associated with a whirlwind of emotions. Adding to this is the stress of the waiting period as the outcome cannot be predicted or controlled. Studies have been conducted on emotional reaction of patients during the waiting period after a diagnostic test. One study from a breast cancer screening program reported anxiety in about 50% of candidates in every stage of prediagnosis.[2] A handful of studies on awaiting results of prostrate screening and in vitro fertilization (IVF) have been conducted.[34] COVID-19 testing hesitancy has been seen among people due to many reasons such as social stigma because of disease once they become positive (fear of isolation), or due to the mental trauma being faced by them while waiting for the results.[5] The mental impact of COVID-19 can be either directly due to the results of the samples or indirectly due to the environmental factors such as the place of sampling (infrastructure of building), behavior of the staff involved in conducting tests, or the intrinsic mental peace of the person.[67]

The outbreaks are associated with stress among people and that can lead to change in eating habits, sleeping patterns, worsening of chronic health problems, existing mental health problems, and fear and worry about own health or the health of loved ones.[8] The period of unpredictability and uncertainty in situations such as waiting for the results can be made stress free by using meaning-based coping strategies.[9] Coping interventions administered to participants during the waiting period have been shown to have positive emotional outcome in one study.[4] Further, the support (information regarding testing, explaining procedure of taking sample) from the medical staff can be seen lacking during the COVID-19 pandemic owing to lesser number of healthcare providers as compared to patients coming for testing. A study has proposed support to be integrated in the continuity of care process for patients of breast cancer who came for testing.[2] The human body has an excellent mechanism of homeostasis which maintains the stable internal state, despite changes in the surroundings. The same can be seen with the emotions also. Emotional response has two salient features, i.e., intensity and duration.[10] It has been seen that the emotions at one point in time get diluted over a period of time and emotional state changes. Under the influence of emotions, humans can be extremely inaccurate in time judgments. Emotions can be seen to influence our perception to time as it alters our sense of time when we are with our friends (time flies) and when we are getting bored (time drags).[11] This can be explained by the time emotion paradox.[12]

At this time frame, waiting for COVID results would be no different. Further, COVID-19 may be associated with stigma, leading to some people avoiding testing. To our knowledge, no studies have been conducted to understand the emotional state of people after undergoing COVID-19 testing.

METHODS

The descriptive study was carried out in a tertiary care institute in North India. A total of 140 participants were enrolled in the current study. The sample size was selected through purposive sampling by enrolling patients over a period of 1 month from May 1 to 30, 2020. Web-based questionnaire was used to collect data for the study. All the participants who had undergone the COVID-19 test within a span of 1 h in our hospital were part of the study. Simple random sampling technique was employed to enroll the sample size.

Procedure

Candidates who visit the designated testing area, of the tertiary care hospital for COVID testing, were known to have a waiting period of about 8 h until the declaration of results. The medical specialist after the routine COVID testing procedure obtained informed consent from all the participants. These participants were then contacted telephonically within an hour of the testing procedure (after giving test or first entry), sent the link for the survey, and were given instructions to fill out the online survey form. Participants were free to clear their queries at any point in time. They were once again reminded to fill out sections 1 and 3 after 5 h of the initial testing, i.e., during the waiting period before announcement of results (before results announcement or second entry).

A self-designed questionnaire was used for this study prepared using Google Forms. Initially, the questionnaire was tested for validity by sending it to five participants. Based on the response and feedback obtained, the questionnaire was revised. The final 32-item questionnaire, focusing on sociodemographic information, testing-related information, and emotional reactions, was designed which required about 5–6 min to complete.

The data were transported into the Microsoft excel 2019 and were analyzed in IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. (Armonk, NY: IBM Corp.). Descriptive analysis in terms of frequencies, means, and standard deviations were used to characterize the sample. Wilcoxon signed-rank test and McNemar test were used to compare the statistical change in emotion over a period of time.

Ethical considerations according to the guidelines by the ICMR 2017 and Declaration of Helsinki (modified 2000) were adhered in all participants enrolled in the study. Approval was sought and obtained from the ethics committee of the institute before the initiation of the study.

RESULTS

A total of 140 participants were enrolled in the study. About 123 (88%) participants belonged to the age group of 20–40 years. About 109 (78%) study participants were healthcare providers, and 61 (43.6%) were living with their families with no overcrowding. About 126 (91%) participants responded that they were comfortable going back home after negative results, and 71 (51%) responded that they were given beforehand counseling about the test. Around 52 (37%) participants got tested as their quarantine period was getting over [Table 1].

Table 1

Demographic characteristics of study participants enrolled in the study (n=140)

Characteristics	n (%)
Gender
Male	76 (54.3)
Female	64 (45.7)
Age group (years)
<20	4 (3)
20-40	124 (88)
>40	12 (9)
Education
Illiterate	3 (2.1)
Primary or less	7 (5)
Above primary but not completed high school	10 (7.2)
Completed high school	27 (19.3)
Completed secondary education	8 (5.7)
Above secondary education (B.Sc., M.Sc., MBBS, MD, etc.)	85 (60.7)
Healthcare provider
Yes	109 (77.9)
No	31 (22.1)
Role as healthcare provider
Doctors	13 (11)
Nurses	41 (34.7)
Laboratory/other technical staff	8 (6.8)
Hospital attendant	26 (22)
Sanitation attendant	14 (11.9)
Others	18 (13.6)
Kind of accommodation
With family, no overcrowding	61 (43.6)
With family, overcrowding	23 (16.4)
Living with tenants in a single room	10 (7.1)
Living alone	34 (24.3)
Living in a hostel	12 (8.6)
Reason for testing
Symptomatic and advised by doctor	20 (14.3)
Volunteered because of symptoms or contact with infected person	20 (14.3)
Routine screening because of place of duty	20 (14.3)
Quarantine period is getting over	52 (37.1)
Asymptomatic but came in contact with a positive patient	23 (16.4)
Testing due to travel purposes	5 (3.6)
Waiting place after test
Ward	33 (23.7)
Quarantine facility	80 (56.9)
Residence	27 (19.4)
Concern about passing infection to others
Yes	25 (18)
No	68 (48.5)
May be	36 (25.5)
Not applicable	11 (8)
Comfortable going back home after negative result
Yes	126 (90.6)
No	14 (9.4)
Received beforehand counseling about test
Yes	71 (51.4)
No	34 (24.6)
Maybe	12 (8.7)
Yes, but could have been better	23 (15.3)
Comfortable about testing premises
Yes	120 (85.8)
No	10 (7.1)
Could be better	10 (7.1)
Well prepared for procedure
Yes	86 (61.4)
No	22 (15.7)
I wish I had known better	32 (22.9)

The average age of the participants was 29.9 ± 7.6 years. The mean score of agreement with decision to test was 9 ± 1.6. The mean score of 4.6 ± 2.6 was found regarding comfort of test. The median time between advice and test was 8 h (range 0–240 h) as represented in Table 2.

Table 2

Perception of study participants regarding COVID-19 test

Characteristics about the test	Mean (SD)	Range
Agreement with decision to test	9.0 (1.6)	1-10
Discomfort related to testing	4.6 (2.6)	1-10
Median time (h) between advise to test and actual testing	8	0-240

SD – Standard deviation

Around 112 (80%) participants of the enrolled responded the second time, i.e., before announcement of results. Majority of the participants were in a neutral emotional state before the testing. The other commonly experienced emotions throughout the waiting period are enumerated in Table 3.

Table 3

Emotional state of the participants before and after COVID-19 testing

Type of emotion	After giving sample (n=140), n (%)	Before results announcement (n=112), n (%)
Neutral	89 (63.6)	77 (68.8)
Fearful/worried	35 (25)	26 (23.2)
Happy	9 (6.4)	8 (7.1)
Sad	5 (3.5)	0
Angry/annoyed	1 (0.7)	1 (0.9)
Disgusted	1 (0.7)	0
Surprised	0	0

Patients were asked to rate their state of mind like how hopeful or energetic they felt ranging from a scale of 1–10, and most of them had a more or less positive outlook as mentioned in Table 4. Among the other factors related to their state of mind, only the question “Do you think something can be done to help you during this time?” was found to have statistically significant change (P = 0.00) over the waiting period [Table 4].

Table 4

Emotional state of study participants after giving sample and before announcement of results

State of mind	Mean (SD)		P
	After giving test	Before result
Feeling hopeful	7.9 (1.8)	8.2 (1.5)	0.22
Feeling energetic	7.6 (1.8)	7.8 (1.8)	0.49
Something needed to help	1.6 (0.4)	1.8 (0.3)	0.00
Comfort of testing area	7.8 (1.8)	7.9 (1.6)	0.32

SD – Standard deviation

DISCUSSION

Emotions are the psychological state of mind which can vary from time to time and from person to person. The same situation can have two different emotional states with change in time. The change in emotional state also depends upon the intensity of emotions. The current study found a high agreement with decision of COVID-19 test and the procedure employed for testing uncomfortable. The study found a statistically significant change in response to “something can be done to help participants during the waiting period” after giving sample and before announcement of results.

The study found that most of the participants were of young age (mean age 29.9 ± 7.6 years). Majority of the participants were the healthcare providers working in hospital and belonged to the age group of 20–40 years.

The testing was considered uncomfortable by the study participants as the procedure involves taking nasopharyngeal swabs. The oropharyngeal swab is comparatively easier than nasopharyngeal swabs as the tract for passing the swab stick is more on former than in latter which leads to less discomfort. A qualitative review found that the physical discomfort and route of administration are the reasons for medical noncompliance.[13] The agreement among the study participants for testing was very high (mean score 9.0 ± 1.6) which indicates that people are concerned about their COVID-19 status and rely upon the test though the procedure is uncomfortable.

Majority of the participants in the current study reported their emotional state as neutral. Neutral affect is defined as feeling indifferent, nothing in particular, and lack of preference one way or the other.[14] Izard pointed out that all experiences occur in emotion full world and neutral affect does not exist because people are always feeling something.[15] Adukhkha masukha is the area in affective tonality where experience appears as relatively bland and neither distinctly painful nor pleasant.[16] Since most of the participants were the healthcare workers as that too who were posted in the COVID-19 duties, it assumed that their emotional state has reached to neutral state over a period of time. They were conditioned to the situation where they could not feel angry or surprise to the situation. Further, studies need to be conducted among general population to find out the exact emotional state during waiting period.

A majority of the respondents endorsed that they could be helped to cope better with the waiting period. While waiting for results, the time seems to drag for them (time emotion paradox).[12] When asked for specific measures that would help them cope better, respondents endorsed the provision of results being delivered more quickly, provision of means of entertainment such as television in the waiting area, playing funny videos or humorous programs on the television, and provision of counselling services. Emotion-focused coping strategies are the ways to alleviate distress by minimizing the emotional component of the stressor.[17] A study found low-cost self-help coping interventions to increase positive affect during waiting period of fertility treatment.[4] Positive affect is associated with better physical health and lower risk of mortality.[18]

Implication

The study is first of its kind in India to study the emotions of participants while waiting for their test results. The mixed methods employed for results helped in extracting the views of participants and helped in understanding their psychology during waiting period. This study supports the notion of making testing procedures for COVID-19 quicker and to provide assistance during the waiting period.

Limitations

Since the questionnaire was a self-administered questionnaire, chances of social desirability bias cannot be excluded. The repeated filling of questionnaire after 5 h without knowing the emotional state of participant might have added bias to the results.

CONCLUSIONS

Patients undergoing testing for COVID-19 undergo psychological turmoil and use various coping methods. Patients endorsed various suggestions includingquicker generation of results, environmental changes and counselling services to help them cope better. Incorporating these suggestions may improve the diagnostic process in patients with COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.