Introduction

The coronavirus disease (COVID-19), caused by a novel strain of coronavirus, was declared a pandemic by World Health Organization (WHO) on 11 March 2020 (World Health Organization, 2020). Centre for Health Protection Department of Health The Government of the Hong Kong Special Administrative Region (2021) stated that the most common incubation period of COVID-19 was around five days, and the case fatality ratio was higher among the older aged population. On 18 June 2021, there were more than 177 million cases and 3.8 million deaths globally (World Health Organization 2021). In Hong Kong, there were 11,885 confirmed cases with 210 deaths (The Government of the Hong Kong Special Administrative Region 2021).

The resultant effects of this pandemic were stressful for the general population in Hong Kong and globally. To limit the spread of COVID-19, in Hong Kong, social distancing was practiced by kee** ≥ 1 m of distance between persons. Other protective measures were implemented such as wearing surgical masks, limiting seating capacity at eateries, temporary closure of high risk premises, working from home, and suspension of school classes (Centre for Health Protection, 2021; Fong, et al., 2020a,2020).

Research evidence exploring factors associated with psychological distress, fear of COVID-19 and co** strategies amongst the general population such as community members, healthcare workers and health care service users in Hong Kong and worldwide is scarce. Since the pandemic shows no sign of ending, understanding the pandemic’s impacts on mental health and co** strategies amongst the public, and identifying their predictors, are essential to design psychological support strategies during/after the pandemic, and to prevent long-term mental health problems. Therefore, this study aimed to assess the levels of psychological distress, fear of the COVID-19 infection and main co** strategies used among a wide range of people in Hong Kong, and to identify key factors associated with these mental health conditions/variables.

Methods

Study Design and Participants

A cross-sectional survey study was conducted using an online platform. The survey link was distributed via social media, text messages, emails and word of mouth to reach the general population in Hong Kong. The study population included Hong Kong residents who were aged ≥ 18 years and able to respond to an online questionnaire in English. Participants, including the general public, healthcare workers, health care service users, and university students and staff, were recruited from various community settings and groups via the online platform and social media between December 2020 and mid-January 2021.

Sample Size Estimation

The sample size was calculated by OpenEpi. Considering 7,428,300 as the population of Hong Kong at the end of 2020 (Census and Statistics Department, The Government of the Hong Kong Special Administrative Region, 2021b), the prevalence of worsened mental health among Hong Kong residents during the COVID-19 pandemic ranging from 25.4% to 65.6% (Choi et al., 2020; Tso & Park, 2020), at 95% confidence intervals and 80% power, the estimated minimum sample size was 292. Snowball sampling of friends, university staff and students, and invitation messages in social media were used to recruit participants.

Study Instruments

A structured online survey questionnaire was adopted from an international study led by researchers in Australia (Rahman et al., 2020). Participants first completed a series of questions about socio-demographic information such as age, gender, education level, and employment, and other information related to any perceived stress due to change in employment, being a frontline worker, change in financial situation during the pandemic, and patterns of unhealthy lifestyle (smoking and drinking).

Psychological distress was assessed using the 10-item Kessler Psychological Distress Scale (K10) (Furukawa et al., 2003). The K10 is a reliable and valid scale, with Cronbach’s alpha of 0.92 (Rahman et al., 2021). The Cronbach’s alpha of K10 was 0.95 in this study. The K10 items were rated on a 5-point Likert scale (1 = none to 5 = all the time), with the possible total score range from 10 to 50. Higher scores indicated higher level of psychological distress.

The level of fear of COVID-19 was evaluated using the 7-item Fear of COVID-19 scale (FCV-19S) (Ahorsu et al., 2020). FCV-19S is a reliable and valid scale, with Cronbach’s alpha of 0.82–0.87 (Ahorsu et al., 2020; Rahman et al., 2021). The Cronbach’s alpha of FCV-19S in this study was 0.91. Responses also used a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The total score ranged from 7 to 35. Higher scores indicated higher level of fear of COVID-19.

Co** strategies were assessed using the 4-item Brief Resilient Co** Scale (BRCS) (Sinclair & Wallston, 2004). BRCS has been widely used during the COVID-19 pandemic with acceptable psychometric properties (Cronbach’s alpha ranged from 0.63 to 0.79) (López et al., 2020; Rahman et al., 2021). In this study, Cronbach’s alpha was 0.88. It was also assessed with a 5-point Likert scale ranging from 1 (nothing) to 5 (a lot). Responses were summed to create a total score (range = 4–20), with higher scores signifying a higher level of resilient co**.

Data Collection

Ethics approval was obtained from the Survey and Behavioural Research Ethics Committee of The University (SBRE-20–172). After obtaining the ethics approval, an invitation with the information and instructions of the online survey, together with its hyperlink (webpage) and QR code, were shared through different social media platforms (e.g., Facebook, Instagram, LinkedIn, and Twitter), emails and text messages. The plain language information statement and consent form, which provided a thorough explanation of the study including the research aims, procedure, risks and benefits, and voluntary participation, appeared on the first screen-page of the online survey. Only those who provided consent on the first page and admitted to be an adult (aged 18 or above) on the second page, by ticking the button (Yes) at the end of the page(s), would confirm their agreement and their eligibility of participation in this study, respectively. After that, the subsequent webpages contained the full set of study questionnaires for individual participants to complete. All items on each page should be completed before participants could move to the next page. It took 15 to 20 min to complete the survey; and all of their responses were anonymous. No personal identity and information of the participants such as name, residential address and identification number were collected.

Data Analysis

Data entries and statistical analyses were performed by using IBM SPSS 25.0 (IBM Crop., Armonk, NY). Descriptive statistics, such as mean and standard deviation and frequency and percentage, were used to summarize and present the data of participants’ sociodemographic characteristics and study variables. To assess mental health conditions and to be consistent with the previous study (Rahman et al., 2020), participants’ psychological distress, fear of the COVID infection and co** strategies were grouped into different levels. Psychological distress (K10 score) was defined into low (score 10–15), moderate (score 16–21), high (score 22–29) and very high (score 30–50); fear of COVID-19 (FCV-19S score) was defined into low (score 7–21) and high (score 22–35); and co** strategies (BRCS score) were categories into low (score 4–13) and moderate to high (score 14–20).

Univariate logistic regression analyses were conducted to explore the association between variables. Those factors with p < 0.25 were selected as potential confounding variables for multivariate logistic regression to delineate factors associated with the main study variables (psychological distress, fear of COVID-19 and co** strategies). Results of the multivariate logistic regression models for each of those three variables were calculated and presented with adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Level of significance of all statistical tests used was set at 0.05 (two-sided).

Ethical Considerations

Ethics approval was obtained from the Survey and Behavioural Research Ethics Committee at The Chinese University of Hong Kong (No. SBRE-20–172). The study was conducted following the principles stated in the Declaration of Helsinki. No personal identity and information was collected or reported. Informed consent for participation in the study was obtained on the first page of the survey where study information was provided prior to participants completing the questionnaire.

Results

Characteristics of Participants

In total, 555 individuals completed the survey. Characteristics of the participants are listed in Table 1. The mean age of the participants was 47.7 years (± 12.89) and 67.2% were female. The majority of the participants were living with their family members (85.4%) and had a bachelor’s degree or above (80.7%). Over one-third of the participants (40.7%) identified themselves as frontline or essential service workers during the COVID-19 pandemic. For mental health measures, K10 scores ranged from 10–40 (M = 18.8; SD = 7.38); FCV-19S scores ranged from 7–33 (M = 17.78; SD = 6.70; and BRCS scores ranged from 4–20 (M = 13.88, SD = 3.17). Of the 555 participants, more than half (53.9%) experienced moderate to very high levels of psychological distress, one-third (31.2%) experienced a high level of fear of COVID-19, and over half (58.6%) showed moderate to high resilient co** (Supplementary Tables 1, 2 and 3, respectively).

Table 1 Characteristics of the study population
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Psychological Distress

The univariate analyses (Table 2) showed significant associations between moderate to very high level of psychological distress and other variables. After adjusting for potential confounding variables, the multivariate logistic regression test (Table 2) indicated some factors associated with psychological distress. Living with family members (p = 0.010, AOR: 3.24, 95% CIs: 1.33–7.94), current alcohol consumption (p = 0.034, AOR: 2.07, 95% CIs: 1.06–4.05), and high level of fear of COVID-19 (p < 0.001, AOR: 5.76, 95% CIs: 2.76–12.15) were associated with ‘moderate to very high’ psychological distress of the participants. Conversely, participants aged 30–59 years (p = 0.031, AOR: 0.30, 95% CIs: 0.10–0.90) and ≥ 60 years (p = 0.001, AOR: 0.13, 95% CIs: 0.04–0.45), perceived good to excellent mental health status (p < 0.001, AOR: 0.13, 95%CIs: 0.06–0.26), and ‘moderate to high’ resilient co** (p = 0.028, AOR: 0.51, 95%CIs: 0.28–0.93) were associated with low levels of psychological distress.

Table 2 Factors associated with psychological distress among the study population (based on the K10 score)
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Fear of COVID-19

Table 3 showed the univariate analyses to identify associations between high level of fear of COVID-19 and other variables. The multivariate logistic regression results (Table 3) showed that perceived moderate to a great deal of stress due to a change in employment conditions (p = 0.002, AOR:4.12, 95%CIs: 1.72–9.88), being a frontline or essential service worker (p = 0.017, AOR: 2.72, 95%CIs: 1.19–6.19), experiencing ‘moderate to very high’ psychological distress (p < 0.001, AOR: 6.00, 95%CIs: 2.84–12.70), and using healthcare services to overcome COVID-19 related stress in past 6 months (p = 0.002, AOR:6.38, 95%CI: 1.98–20.55), were associated with a high level of fear of the COVID-19 infection. However, a low level of fear of the COVID-19 infection was related to being a nurse (p = 0.032, AOR:0.38, 95%CIs: 0.16–0.92).

Table 3 Factors associated with levels of fear among the study population (based on FCV-19S score)
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Co** Strategies

The univariate analyses identified a number of variables were associated with moderate to high level of resilient co** (Table 4). After adjusting for potential confounding variables, as shown in Table 4, participants who perceived good to excellent mental health status during the COVID-19 pandemic (p = 0.001, AOR:2.76, 95%CIs:1.53–4.95) were more likely to have ‘moderate to high’ resilient co**. On the contrary, those who perceived a change due to an unsure financial situation (p = 0.015, AOR:0.43, 95%CIs: 0.22–0.85), being tested positive (p = 0.035, AOR:0.10, 95%CIs: 0.01–0.85) or negative on the COVID-19 screening test (p = 0.024, AOR:0.42, 95%CIs: 0.20–0.89), high levels of fear of the COVID-19 infection (p = 0.029, AOR:0.51, 95%CIs: 0.28–0.93), and using healthcare services to overcome the COVID-19 related stress in past 6 months (p = 0.050, AOR:0.36, 95%CI: 0.13–1.00) were associated with a low level of resilient co**.

Table 4 Factors associated with co** strategies among the study population (based on BRCS score)
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Discussion

Our findings showed over half (54%) of the participants experienced ‘moderate to very high’ levels of psychological distress and about one-third (31%) reported a high level of fear of the COVID-19 infection. Despite having moderate to high levels of psychological distress and fear, more than half (60%) demonstrated ‘moderate to high’ resilient co**. Our findings are somewhat consistent with the results of a similar Australian study (Rahman et al., 2020) using the same set of instruments. The Australian study showed that about two-thirds (62.9%) of Australian people experienced ‘moderate to very high’ levels of psychological distress. This finding was also similar to a recent study conducted in 194 cities in mainland China in which 53.8% of the respondents rated the psychological impact of the COVID-19 outbreak as moderate to severe (Wang et al., 2020). Both the Australian and this Hong Kong study report that about 30% of the participants had a high level of fear of the COVID-19 infection (Hong Kong: 31.2% and Australia: 31.9%). However, the Australian participants demonstrated low resilient co** (97.3%) versus a much lower percentage (about 40%) in this Hong Kong study (Rahman et al., 2020). Resilience refers to the ability to withstand setbacks, adapt positively and rebound from adversity (Luthar & Cicchetti, 2000). A tendency to effectively use cognitive appraisal skills in a flexible, committed approach to active problem solving despite stressful circumstances is described as “resilient co** behavior”. People with high levels of resilient co** tend to believe in their abilities to address adverse circumstances and usually succeed at challenges (Sinclair & Wallston, 2004). Moreover, those with higher resilience co** abilities showed less difficulty co** with the emotional challenges of the pandemic crisis (Killgore et al., 2020). Given that the Australian study (June 2020) was conducted six months before this study (December 2020 to Mid-January 2021), the participants in this study might have a better understanding of the COVID-19 infection and related information, the use of relevant preventive measures such as quarantine, social distancing and wearing masks, and successful stress management and co** strategies and experience sharing. As a result, people in Hong Kong during the later stage of the pandemic could show better co** through self-learning and resilience.

Psychological Distress

Living with family members, current alcohol consumption and a high level of fear of COVID-19 were associated with moderate to very high levels of psychological distress. Conversely, being older (30–59 years, ≥ 60 years), perceived good to excellent mental health, and moderate to high resilient co** were associated with low levels of psychological distress.

Living with family members was associated with moderate to very high levels of psychological distress in this study while the Australian study reported no association (Rahman et al, 2020). Hong Kong is well known as a city with high-density housing and many are living in micro flats. Smaller residential size is associated with an increased risk of psychological distress among the general population (Wong et al., 2016). During this COVID-19 pandemic, the public has been advised to practice physical distancing, avoid crowded areas, and to work from home. Within a limited space in a small flat, living with family members may be equivalent to living with poorer personal space, leading to a higher level of psychological distress. For participants who have children, because children must study at home, working from home may mean heavier parental responsibilities, for example, dealing with parent–child relationships and monitoring children’s study, therefore increasing their emotional burden (Wu et al., 2020).

Our study and Rahman et al. (2020) showed that current alcohol consumption was associated with moderate to very high levels of psychological distress. Increased alcohol consumption over the last six months was also related to a higher level of psychological distress and fear of COVID-19, and lower levels of co** strategies in univariate analyses. However, this variable was not included in the multivariate logistic regression due to limited responses. During the COVID-19 pandemic, adverse changes in health behaviours, mainly alcohol intake, were also associated with higher depression, anxiety and stress symptoms (Callinan et al., 2021; Stanton et al., 2020). Social isolation, quarantine, changes in employment status or uncertainty about the future, and any pandemic-related psychological distress may serve as significant triggers for increased alcohol intake (Ramalho, 2020; Stanton et al., 2020). Increased alcohol consumption might also be explained as a strategy to cope with perceived distress (Callinan et al., 2021; Stanton et al., 2020).

Being younger may be another potential risk factor for distress related to COVID-19 (Qiu et al., 2020). A nationwide study among 52,730 respondents in China showed that the young adult group, 18–30 years, reported the highest distress level during the pandemic (Qiu et al., 2020). The potential explanation might be that young participants are more likely to obtain pandemic-related information, including negative and inaccurate news from various social media and thus trigger stress (Qiu et al., 2020). In addition, young people have the primary responsibility for social productivity and their family, and therefore bear more psychological pressure (Liu et al., 2020). However, our findings are in line with other studies which demonstrated a higher level of fear and psychological disorders among frontline healthcare workers than non-frontline workers (Cai et al., 2020).

Co** Strategies

Good to excellent perceived mental health was associated with a moderate to high level of resilient co**. Change in financial situation, testing positive/negative for COVID-19, high levels of fear of COVID-19 and using healthcare services to overcome COVID-19 related stress in the last six months were associated with low resilient co**. Interestingly, compared with the participants who had no known exposure to COVID-19, those who tested positive or negative for COVID-19 had lower levels of resilient co**. This could be explained where these participants, either being tested as positive or negative for COVID-19, having known exposure or possible contact with an infected person, and their perceived uncertainties about their own health status, might cause them to adopt maladaptive or avoidance co** responses, therefore lowering their resilience.

Our study found that the level of psychological distress was interrelated with the level of fear of COVID-19, indicating a positive mutual influence relationship. Moreover, in line with previous studies, our study found that resilience and psychological distress/fear are negatively associated (Killgore et al., 2020; Yasien et al., 2016), indicating that high resilience may help the public to adapt to the new norm during the pandemic, despite dealing with a fearful and stressful situation. Such psychological resilience-related interventions have also been applied in China during the pandemic and was shown to be to improve overall mental health among the general population (He et al.,

Implications for Research and Practice

Our study findings identified key factors associated with psychological distress, fear and co**. Local policymakers may consider necessary steps to reduce the effects of COVID-19. First, mental health services for different kinds of population, such as frontline healthcare workers, parents and young adults, can be delivered through eHealth such as video call consultations and hotlines to improve psychological well-being, and can be considered as precautionary measures for COVID-19 as well as physical distancing. Second, strategies aimed at adopting or maintaining heath behaviours should be promoted to avoid subsequent potential alcohol misuse and alcohol-related social harm and to address increase in psychological distress during the pandemic. Third, efforts by policymakers are needed to ensure proper, transparent, and timely dissemination of information related to COVID-19. The government, media and news organisations may need conjoint efforts to curb the spread of inaccurate media-fuelled infodemics that generate fear and panic. Resources for co** strategies during this pandemic are urgently needed to alleviate psychological distress. Despite more than half of the participants demonstrating moderate to high levels of resilient co**, 41.4% were demonstrated low resilient co**. Therefore, the development of series of resilience training activities is strongly recommended to reduce adverse mental health outcomes in a sudden public health epidemic.

Conclusion

The present study explored the key factors associated with psychological distress, fear of COVID-19 and co** strategies among the diverse population in Hong Kong. Mental health support strategies should be provided continuously to prevent the mental impact of the COVID-19 epidemic from turning into long-term illness.