Demographical Factors Associated with Psychological Distress and Family Environment during COVID-19 Pandemic in Jordan: A Large Sample Study

Received: 22-Jul-2021, Manuscript No. ijmrhs-22-69983; Editor assigned: 25-Jul-2022, Pre QC No. ijmrhs-22-69983(PQ); Reviewed: 29-Jul-2022, QC No. ijmrhs-22-69983 (Q); Revised: 29-Jul-2022, Manuscript No. ijmrhs-22-69983(R); Published: 30-Jul-2022

INTRODUCTION

The restrictions that most governments have implemented worldwide to contain the COVID-19 pandemic (e,g.lockdown, quarantine or curfew) have significantly impacted people's daily lives. In addition to its socioeconomic impacts, it has separated people from their loved ones, restricted their movements, increased domestic violence, switched operations to remotely (studying and working), changed wedding and consolation habits, put financial strains and strict rituals for hygiene[1].

This confinement (imprisonment) has immediate and long-term consequences. It potentially leads to the psychological impact of COVID-19 on people's mental health, such as an increase in the psychological symptoms of anxiety, distress, disturbed sleep and depression and affecting family functions [2].

Since the breakdown of the COVID-19 pandemic, enormous studies have investigated the pandemic's psychological sequences in different aspects of human life. However, there was no direct research about the relationship between the demographical factors, psychological distress and family environment, so this study aimed to investigate the relationship between some demographical factors, psychological distress and family environment during COVID-19 in Jordan. The demographical factors include sex, age, marital status, level of education, family members who respond to the questionnaires (fathers, mothers or offspring), the number of family members, and commitment to the governmental regulations. The study was conducted from October to December 2020 [3].

Family environment

The family environment includes the circumstances and social climate conditions within families. Each family environment is unique as each family comprises different individuals in a different setting (the discussion of this concept is beyond the scope of this study). The relationship between family environment and family members is mutual, affecting each other, and in unexpected circumstances such as a pandemic, this relationship is affected.

Fathers and mothers needed to deal with many changes regarding their children. As their children stay home twentyfour hours away from school, they need to organize playing areas, plan physical activities, and do or help with their children's school responsibilities. Likewise, numerous guardians needed to oversee challenges and torment identified with sick or dead family members, having had limited income or sometimes lost their work.

A better family environment was shown to be associated with higher levels of self-efficacy. For example, family members can freely communicate with each other, express themselves, and have frequent high contact intimacy with other family members, which will lead, in turn, to a high level of self-efficacy. In addition, some studies suggest that a high level of self-efficacy was associated with low anxiety and depression [4-6].

Age

The COVID-19 pandemic affects all age groups, particularly older people, either because of the consequences of the regulations or if they catch the virus (WHO, 2020 a, b). However, older people, especially women, are more concerned about healthy behaviour as the consequences may be vital, whereas younger people may not suffer the consequences of unhealthy choices (Barber and Kim, 2020). However, Wang et al. (2020) found no relationship between age and stress during the COVID-19 pandemic. Relatedly and concerning age, Bergdahl and Bergdahl (2002) found that the level of stress increased between 20 years and 40 years of age, and this increment reached the lowest degree by the age of (60) [7-9].

Marital Status

Married people have higher coping skills than single people. Singles scored higher in measures of anxiety, depression and distress. Individuals with children reported an increased stress level during the COVID-19 pandemic; this stress may increase parents' depression and anxiety. Some studies found higher distress among singles than married people. Also, higher rates of psychological distress were found among younger and unmarried individuals [10,11].

Level of Education

Psychological problems appear more in disadvantaged socioeconomic groups one of the variables that specify the variability groups is the level of education that differs from one community to another (Molarius and Granstrom, 2018). Although low education is associated with mental health problems (Fryers, Melzer, and Jenkins, 2003), the association between educational level and psychological distress varies according to different variables: culture, population, gender, and may change over time [12,13].

The literature results were inconsistent; some studies found that postgraduate students scored higher in coping than secondary school holders who reported more stress, and lower education is more susceptible to poor coping strategies with stress and distress [14]. Other studies found an association between low education and high prevalence of depression and another study found that people with a low and medium level of education had a lower risk of psychological distress than people with high education [15-17].

Sex

Women experienced higher distress during quarantine, and they may take care of their work responsibility and care for children, husbands, and homes. In addition, females are more vulnerable to developing mental and physical problems in response to life stressors or potentially traumatic events this may be because females are exposed to risk factors such as gender inequality, gender-based violence and gender discrimination [18].

In Jordan, Massad et al. (2020) found that approximately four out of ten participants experienced COVID-19-related anxiety. In addition, younger participants, women, and people with poor social support were more likely to experience quarantine-related anxiety [19].

Wang, Kala and Jafar (2020) reviewed 68 studies comprising (288,830) participants from 19 countries. They found that the prevalence of anxiety and depression was more in females versus males, younger ages versus older, living in rural versus urban areas, and lower versus higher socioeconomic status.

Study questions

Q1: Are there significant differences in the sample performance on the K10 scores related to sex, level of education, marital status, and the family member who answered the study questionnaires (fathers, mothers, and off sprig)?

Q2: Are there significant differences in the sample performance on the modified short-form family environment scale (MSFES) scores related to sex, level of education, marital status, and the family member who answered the study questionnaires?

Q3: Is there a significant correlation between K10 scores and the demographical factors (age, number of family numbers and level of commitment to governmental regulations)?

Q4: Is there a significant correlation between the modified short-form family environment scale (MSFES) and the demographical factors (age, number of family numbers and level of commitment to governmental regulations)?

Methods

Sample

The sample comprised 1211 adults (355 males and 856 females) aged between 18–67 years (mean age 29.55 years, SD: 10.84). See (Table 1) for sample characteristics.

Measures

• Demographics: The demographic factors included sex, age, marital status, level of education, role within the family (father, mother and offspring), family members number, and commitment to governmental regulations.

• The Kessler Psychological Distress Scale (K10): K10 is a simple measure of psychological distress that aims to measure depression and anxiety symptoms using ten questions answered according to the previous four weeks. Each question is scored from one "none of the time" to five "all of the time", and scores range from 10 (indicating low psychological distress) and 50 (indicating severe psychological distress). A cutoff score of twenty and above will be considered as reflecting the degree of psychological distress [20,21].

• K10 has been translated and validated for Arabic culture by Easton et al. (2017) and is used extensively in many countries. The reliability of the Arabic version was 0.88, and in the current study, Cronbach's alpha was 0.93.

• The Modified Short-form Family Environment scale (MSFES): This is an Arabic modified version of the original scale (Moos and Moos, 1986). The original scale consists of 90 items that have been modified and abbreviated to 36 items. The modified version consists of the following six subscales (name and number of items): Cohesion (13,19,1,7,31,25), Expression (14,2,20,8,26,32), Conflict (33,21,27,3,9,15) Intellectualcultural orientation (I-C0) (22,34,4,16,10,28) Orientation Towards Recreational Activities (OTRA) ( 29,35,11,17,23), and Organization (24,30,36,6,18,12).

The scale has been used to assess the family environment from different informants' perspectives and single-family members' perspectives (Charalompous, Kokkions, and Panayiotou, 2013).

The participants made their choice on a Likert scale from (1-5); (1) applied very weakly, (2) applied weakly, (3) applied moderately, (4) applied highly, and (5) applied very highly. For the current study, Cronbach's alpha for the subscales was 0.801-0.890.

Procedure: a cross-sectional study has been done using Google form and published using the Internet, targeting participants aged 18 and above years, Arabic-speaking mothers tong, given a consent form and completed all questionnaires. The data were collected between October-November 2020.

Results

Q1: Are there significant differences in the sample performance on the K10 scores related to sex, level of education, marital status, and the family member who answered the study questionnaires? The t-test for two independent groups was done for sex and marital status, whereas analysis of variance (ANOVA) was done for level of education and the family member who answered the study questionnaires.

Table 2 shows the t-test results for sex and marital status.

The results and discussion can be presented as follow:

Looking at the means in Table 2, females scored significantly higher on the twenty and above level. The percentage of psychological distress among the whole sample was 69.28% (twenty and above level). This suggests that the entire sample has higher psychological distress, and females experience more psychological distress than males. Males may have more resilience than females during pandemics and feeling that they carry more responsibilities in such a crisis may make them show less psychological distress. On the other hand, females' work may be impacted more during the COVID-19 pandemic, and the responsibilities of females like home caring and hormonal changes (ovarian hormones), female-typical roles, fear of contamination and fear of losing family members may make them more susceptible to psychological distress [22].

In addition to this, the brain functions associated with emotional distress regulation and cognitive control were more noticeable in males than females. These results that females have more psychological distress during the COVID-19 pandemic are consistent with e.g. Xiong et al., 2020; Tee et al., 2020; and Wang et al., 2020 [23-25].

Q2: Are there significant differences in the sample performance on the modified short-form family environment scale (MSFES) scores related to sex, level of education, marital status, and the family member who answered the study questionnaire?

The t-test for two independent groups was done for sex and marital status , whereas analysis of variance (ANOVA) was done for level of education and the family member who answered the study questionnaires.

Looking at the means (Table 2), singles (unmarried) people score significantly higher in the twenty and above level (in per cent 71% unmarried vs 66.7% married), suggesting that unmarried people have higher.

These results suggest that unmarried people suffered more psychological distress than married people during COVID-19. The higher unmarried psychological distress, compared to married people, may occur because married people have more social support than unmarried, and family members could express more of their problems, concerns, and strains as they feel that they share the strains (collective unconscious). In contrast, unmarried people do not have this sharing opportunity with an intimate partner. Therefore, during COVID-19 and its regulations, such as quarantine, lockdown, and friends staying apart, unmarried people will feel lonelier, and loneliness predicts psychological distress. In addition, unmarried people may be more concerned about the caring aspect during the pandemic (i.e., who will take care of them if they get infected and remind them of self-hygiene rituals). Besides, unmarried people are alone during the pandemic facing its consequences; for example, no other family member will compensate if they lose their jobs. Another point related to the feeling of identity, as being husband, father or mother, with doing the related roles gives people the feeling of value, especially when they support others during the tough time. Therefore, it seems that being alone makes people suffer more in crises and pandemics than if they are married (Table 3).

Analysis of Variance (ANOVA) and Post hoc Scheffe test showed significant differences in the K10 in the twenty and above level and the level of education (Table 4). The secondary and less level showed higher scores than the postgraduate level (p-value 0.012), and the bachelor level showed higher scores than the postgraduate level (p-value 0.000) (Table 3).

Also, analysis of Variance (ANOVA) and Post hoc Scheffe test showed significant differences in the K10 twenty and above level and the role in the family (Table 5). The mothers showed higher scores than fathers (p-value 0.026), and offspring showed higher scores than fathers (p-value 0.002).

First: results of the t-test.

• Males scored significantly higher on cohesion, expression, and conflict, but females scored significantly higher on orientation toward recreational activities.

Although the averages in these subscales are significant, they were close; males show more cohesion, expression and conflict; males may probably feel more responsible in the pandemic situation, showing more cohesion and expression and related to this responsibility, they show more conflict. In comparison, females tend to orient toward the recreational activities subscale, maybe because they think this is part of their responsibilities and may regard these activities as part of female-typical behaviour (Table 6).

• Married people scored significantly higher than unmarried in cohesion, expression, orientation toward recreational activities and conflict subscales.

Being married and having a partner, and maybe children, may require practising more cohesion than unmarried as married people have another member to express the bad and good experiences, and they have more atmosphere to practice recreational activities, but if they are alone, that would be limited. Concerning the conflict, married people have a partner and family members to agree and disagree with them, whereas such thing is absent from unmarried people's lives.

The second results of ANOVA Table 7 show the descriptive statistics of the results, and Table 8 shows the ANOVA results.

Analysis of Variance (ANOVA) and post hoc Scheffe test showed the following results:

• The results showed significant differences in Cohesion and the level of education. The postgraduate level showed higher scores in cohesion than the bachelor level (p-value 0.017) (Table 6).

• The results showed significant differences between the expression and the level of education. The postgraduate level showed higher scores in the expression than the bachelor's (p-value 0.017).

• The results showed significant differences in the Organization and the level of education. The diploma level showed higher scores in the organization than the secondary and less level (p-value 0.05).

• The results showed significant differences in cohesion and the role in the family. The differences were between fathers and mothers (p-value 0.026); the fathers showed higher scores in the cohesion and the fathers and offspring (p-value 0.000); the fathers showed higher scores in cohesion and the mothers and offspring (p-value 0.034); the mothers showed higher scores in the Cohesion.

• The results showed significant differences in the expression and the role in the family. The differences were between fathers and offspring (p-value 0.000); the fathers showed higher scores in the expression, and the mothers and offspring (p-value 0.000); the mothers showed higher scores in expression.

• The results showed significant differences in conflict and the role in the family. The differences were between fathers and mothers (p-value 0.003); fathers showed higher scores in the conflict; fathers and offspring (p-value 0.000); the fathers showed higher scores in conflict.

• The results showed significant differences in the intellectual-cultural orientation and the role in the family. The differences were between fathers and offspring (p-value 0.001); the offspring showed higher scores in the intellectual-cultural orientation, and the mothers and offspring (p-value 0.016); the offspring showed higher scores in the intellectual-cultural orientation.

• The results showed significant differences in the organization and the role in the family. The differences were between fathers and mothers (p-value 0.023); the mothers showed higher scores in the organization, and the fathers and offspring (p-value 0.001); the offspring showed higher scores in the organization.

Q3: Is there a significant correlation between k10 scores and the demographical factors (age, number of family numbers and level of commitment to governmental regulations). The results are presented in Table 9.

The results of the Pearson correlation coefficient showed a significant negative correlation between age and the number of family members, which means that as age increase, the family number decrease, and this fits with the notion that they tend to have fewer children as people age.

Age also showed a significant negative correlation with psychological distress (K10), suggesting that as people get old, they have less psychological distress; maybe they rationalize that there is nothing to worry about anymore. Also, age correlated positively with resilience and resilience correlated negatively with psychological distress [26]. Other studies found that psychological distress decline with age (e.g., Jorm et al., 2005). This result is inconsistent with other studies (e.g., Barber and Kim, 2020; Losada-Baltar et al., 2021).

On the other hand, the number of family members showed a significant positive correlation with psychological distress (K10). Increased family members are associated with increased demands of family space, income, conflict and other resources of the family, which in turn may increase psychological distress among the family members [27].

Q4: Is there a significant correlation between the modified short-form family environment scale (MSFES) and the demographical factors (age, number of family members, and level of commitment to governmental regulations)? The results are presented in Table 10.

The person correlation coefficient showed the following results:

First: There is a significant positive correlation between age, cohesion, expression, conflict, and organization, suggesting that these family characteristics increase with age. All these are expected to increase with age as they are positive family characteristics except for conflict. Therefore, one would expect that as people get older, they may lose temper and be involved more in family conflicts; however, one may disagree with this and explain that people try to live in peace as they age and avoid conflicts. Also, the results showed a significant negative correlation between age and intellectual-cultural orientation. Although this suggests that as people age, they become less interested in social, intellectual, social and cultural activities; one would predict the opposite correlation. Maybe the culture did not encourage participation in such activities, and perhaps people in the COVID-19 pandemic are not interested in these activities due to the pandemic impacts [28].

Second: Commitment to government regulations was positively correlated with family subscales; cohesion, intellectualcultural orientation, orientation towards recreational activities, organisation and correlated negatively with conflict. Commitment to government regulations seems associated with the family's positive characteristics; the more the family cohesion, involvement in intellectual-cultural activities, and recreational activities, the more they become accustomed to governmental regulations. Conversely, if people are engaged in family conflict, they seem not to comply with the government's regulations.

Third: The number of family members correlated negatively with all family environment subscales except conflict (did not reach significant) and correlated positively with the intellectual-cultural orientation subscale. This correlation suggests that increasing family numbers may interfere negatively with cohesion, expression, sharing of recreational activities, and organisation of family affairs. In addition, increased family numbers may make the family space crowded, affecting family activities [29]. For some activities such as intellectual-cultural orientation, the correlation results suggest that increasing numbers of family numbers are associated with increased sharing in intellectual-cultural orientation; probably, the increased number of family members makes sharing possible in such activities.

Fourth: Cohesion correlated positively with expression, intellectual-cultural orientation, and orientation towards recreational activities and organisation but correlated negatively with conflict. Cohesion allows sharing of all other family positive characteristics and activities; at the same time, it decreases the conflict.

Fifth: Expression correlated positively with conflict, intellectual-cultural orientation, orientation towards recreational activities and organisation.

Sixth: Conflict correlated positively with organisation and correlated negatively with intellectual-cultural orientation. If conflict (amount of openly expressed anger, aggression, and conflict in the family) increased, the organisation (degree of clear organisation and structure in planning family activities and responsibilities) during the COVID-19 pandemic increased. Maybe people put more effort into the family's organisation, like commitment to government regulation, hygienic rituals, budgeting, and schedule of the family responsibilities where conflict is expected between family members. The negative correlation between conflict and intellectual-cultural orientation (interest in political, social, intellectual, and cultural activities) can be explained as family members sparing no time for such activities during the pandemic. As conflict increases, participation in such activities also decreases; maybe conflict takes all the time [30-35].

Seventh: Intellectual-cultural orientation correlated positively with orientation towards recreational activities and organisation. To share interests in, for example, political, social, intellectual, and cultural activities, people need to have the capacity to share recreational activities, and these two need more organisation to be accomplished. During the COVID-19, families are confined at home and may have less physical activities, which may spare time for recreational activities and be oriented toward intellectual-cultural activities [36].

Eighth: Orientation towards recreational activities correlated positively with the organisation. It is a mutual relationship; to share and do recreational activities, people need organisation; if they are organised, they can do more recreational activities. People during COVID-19 may suddenly be oriented toward these activities because their usual activities diminished [37, 38].

Conclusion

This study investigated the demographical factors associated with the effects of COVID-19 concerning psychological distress and family environment. Using a relatively large sample and towards the end of the 2020s, the pandemic still negatively affects mental health and family relations. These adverse effects of COVID-19 affect parents, offspring, married and unmarried people and people with different levels of education.

Declarations

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

1. Afifi, Mustafa. "Gender differences in mental health." Singapore medical journal, Vol. 48, No. 5, 2007, p. 385.
   Google Scholar
2. Andersen, Ingelise, et al. "Social inequality in the prevalence of depressive disorders." Journal of Epidemiology and Community Health, Vol. 63, No. 7, 2009, pp. 575-581.
   Google Scholar     Crossref
3. Andrews, Gavin, and Tim Slade. "Interpreting scores on the Kessler psychological distress scale (K10)." Australian and New Zealand journal of public health, Vol. 25, No. 6, 2001, pp. 494-497.
   Google Scholar     Crossref
4. Barber, Sarah J., and Hyunji Kim. "COVID-19 worries and behaviour changes in older and younger men and women." The Journals of Gerontology: Series B, Vol. 76, No. 2, 2021, pp. 17-23.
   Google Scholar     Crossref
5. Bergdahl, Jan, and Maud Bergdahl. "Perceived stress in adults: prevalence and association of depression, anxiety and medication in a Swedish population." Stress and Health: Journal of the International Society for the Investigation of Stress, Vol.18, No. 5, 2002, pp. 235-41.
   Google Scholar     Crossref
6. Bozdag, Faruk. "The psychological effects of staying home due to the COVID-19 pandemic." The Journal of General Psychology, Vol. 148, No. 3, 2021, pp. 226-48.
   Google Scholar     Crossref
7. Charalampous, Kyriakos, Constantinos M. Kokkinos, and Georgia Panayiotou. "The Family Environment Scale: Resolving psychometric problems through an examination of a Greek translation." International Journal of Educational and Psychological Assessment, Vol. 13, 2013, p. 2.
   Google Scholar
8. Clemente-Suarez, Vicente Javier, et al. "Social and psychophysiological consequences of the COVID-19 pandemic: An extensive literature review." Frontiers in Psychology, 2020, p. 3077.
   Google Scholar     Crossref
9. Cohen, Miri, Svetlana Baziliansky, and Alex Beny. "The association of resilience and age in individuals with colorectal cancer: an exploratory cross-sectional study." Journal of geriatric oncology, Vol. 5, No. 1, 2014, pp. 33-39.
   Google Scholar     Crossref
10. Duchaine, Caroline S., et al. "Psychosocial work factors and social inequalities in psychological distress: a population-based study." BMC Public Health, Vol. 17, No. 1, 2017, pp. 1-10.
    Google Scholar     Crossref
11. Dwairi, W. and Jaradat, A. "Family Environment: An Investigation of the Effect of Family Environment on Bullying of Irbid Governorate Students as a Model." Journal of Social Affairs, Vol. 32, No. 126. 2015, pp. 151-74.
    Crossref
12. Easton, Scott D., et al. "The Kessler psychological distress scale: translation and validation of an Arabic version." Health and quality of life outcomes, Vol. 15, No. 1, 2017, pp. 1-7.
    Google Scholar     Crossref
13. Elhessewi, Ghada S., et al. "Psychological distress and its risk factors during COVID-19 pandemic in Saudi Arabia: a cross-sectional study." Middle East Current Psychiatry, Vol. 28, No. 1, 2021, pp. 1-7.
    Google Scholar     Crossref
14. Freeman, Aislinne, et al. "The role of socio-economic status in depression: results from the COURAGE (ageing survey in Europe)." BioMed Central public health, Vol. 16, No. 1, 2016. 1-8.
    Google Scholar     Crossref
15. Fryers, Tom, David Melzer, and Rachel Jenkins. "Social inequalities and the common mental disorders." Social psychiatry and psychiatric epidemiology, Vol. 38, No. 5, 2003, pp. 229-37.
    Google Scholar     Crossref
16. Hemati, Zeinab, et al. "Relationship between parental communication patterns and self-efficacy in adolescents with parental substance abuse." Iranian Journal of Child Neurology, Vol. 14, No. 1, 2020, p. 49.
    Google Scholar
17. Jacob, Louis, et al. "COVID-19 social distancing and sexual activity in a sample of the British Public." Journal of Sexual Medicine, Vol. 17, No. 7, 2020, pp. 1229-36.
    Google Scholar     Crossref
18. Jorm, Anthony F., et al. "Age group differences in psychological distress: the role of psychosocial risk factors that vary with age." Psychological medicine, Vol. 35, No. 9, 2005, pp. 1253-63.
    Google Scholar     Crossref
19. Kessler, Ronald C., et al. "Screening for serious mental illness in the general population." Archives of general psychiatry, Vol. 60, No. 2, 2003, pp. 184-89.
    Google Scholar     Crossref
20. Kogler, Lydia, et al. "Impact of self-esteem and sex on stress reactions." Scientific reports, Vol. 7, No. 1, 2017, pp. 1-9.
    Google Scholar     Crossref
21. Kowal, Marta, et al. "Who is the most stressed during the COVID‐19 pandemic? Data from 26 countries and areas." Applied Psychology: Health and Well‐Being, Vol. 12, No. 4, 2020, pp. 946-66.
    Google Scholar     Crossref
22. Lawal, Abiodun Musbau, et al. "Differential effect of gender, marital status, religion, ethnicity, education and employment status on mental health during COVID-19 lockdown in Nigeria." Psychology, health and medicine, Vol. 27, No. 1, 2022, pp. 1-12.
    Google Scholar     Crossref
23. Losada-Baltar, Andrés, et al. "“We are staying at home.” Association of self-perceptions of ageing, personal and family resources, and loneliness with psychological distress during the lock-down period of COVID-19." The Journals of Gerontology: Series B, Vol. 76, No. 2, 2021, pp. 10-16.
    Google Scholar     Crossref
24. Massad, Islam, et al. "The impact of the COVID-19 pandemic on mental health: early quarantine-related anxiety and its correlates among Jordanians." Eastern Mediterranean health journal, Vol. 26, No. 10, 2020, pp. 1165-72.
    Google Scholar     Crossref
25. Minello, Alessandra. "The pandemic and the female academic." Nature, Vol. 17, No. 1, 2020.
    Google Scholar     Crossref
26. Molarius, Anu, and Fredrik Granström. "Educational differences in psychological distress? Results from a population-based sample of men and women in Sweden in 2012." British Medical Journal Open, Vol. 8, No .4, 2018, p. 021007.
    Google Scholar     Crossref
27. Moos, R. H. " Family Environment Scale manual." 2nd ed. Palo Alto. 1986.
28. Jun, Jin, Sharon Tucker, and Bernadette Mazurek Melnyk. "Clinician mental health and well‐being during global healthcare crises: Evidence learned from prior epidemics for COVID‐19 pandemic." Asian Journal of Psychiatry, Vol. 52, 2020, p. 102066.
    Google Scholar     Crossref
29. Lehr, Camilla A., Chee Soon Tan, and Jim Ysseldyke. "Alternative schools: A synthesis of state-level policy and research." Remedial and Special Education, Vol. 30, No. 1, 2009, pp. 19-32.
    Google Scholar     Crossref
30. Tee, Michael L., et al. "Psychological impact of COVID-19 pandemic in the Philippines." Journal of affective disorders, Vol. 277, 2020, pp. 379-91.
    Google Scholar     Crossref
31. Tian, Tengfei, et al. "Mental health burden of frontline health professionals treating imported patients with COVID-19 in China during the pandemic." Psychological Medicine, Vol. 52, No. 2, 2022, pp. 398-99.
    Google Scholar     Crossref
32. Youssef, Farid F., et al. "Knowledge and attitudes towards mental illness among college students: Insights into the wider English-speaking Caribbean population." International Journal of Social Psychiatry, Vol. 60, No. 1, 2014, pp. 47-54.
    Google Scholar     Crossref        
33. Wang, Yeli, Monica P. Kala, and Tazeen H. Jafar. "Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: A systematic review and meta-analysis." PloS one, Vol. 15, No. 12, 2020, p. 0244630.
    Google Scholar     Crossref
34. World Health Organization. "Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19).2020."2020.
    Google Scholar
35. World Health Organization. "Coronavirus disease (‎‎ COVID-19)‎‎: situation report, 206." 2020.
    Google Scholar
36. Xiong, Jiaqi, et al. "Impact of COVID-19 pandemic on mental health in the general population: A systematic review." Journal of affective disorders, Vol. 277, 2020, pp. 55-64.
    Google Scholar     Crossref
37. Yamada, Masaaki, Michikazu Sekine, and Takashi Tatsuse. "Psychological stress, family environment, and constipation in Japanese children: The Toyama birth cohort study." Journal of Epidemiology, Vol. 29, No. 6, 2018, pp. 220-26.
    Google Scholar     Crossref
38. Yan, Shiyan, et al. "Sex differences and psychological stress: responses to the COVID-19 pandemic in China." BioMed Central public health, Vol. 21, No. 1, 2021, pp. 1-8.
    Google Scholar     Crossref