Setting

The South Batinah Governorate (SBG) is located in the north of Oman and has a population of 465,550 [10]. It is divided into six states, namely: Barka, Rustaq, Musanaa, Nakhal, Wadi Mawel and Awabi, in order of population size. This study was conducted as a cross-section between 15 November 2020 and 22 December 2020. The inclusion criteria required patient participants to belong to SBG, to have had a verified diagnosis of COVID-19 through a Polymerase Chain Reaction (PCR) test prior to 6 November 2020, to be aged 18 years or over and to be listed in the SBG disease surveillance database. Cases which failed to satisfy these criteria were excluded from the study. A small number of patients were found to belong to SBG, but were staying outside during isolation period were also included. A complete list of all patients was provided by the Department of Disease Surveillance and Control, along with their mobile contact numbers.

Sampling

The total number of confirmed COVID-19 cases in SBG was 12,108 as of 7 November 2020. However, after excluding patients under 18 years and those who belong to other governorates within Oman, the number was reduced to 11,223 patients. These patients were listed within the database in ascending order in accordance with the date of their confirmed diagnosis. Epi Info software (version 7.2.2.6; Centers for Disease Control and Prevention (CDC), Atlanta, Georgia USA) was employed to estimate the sample size. Thus, based on the assumption that 50% of participants were aware and compliant with health isolation measures and experienced moderate levels of stress, with a 95% confidence interval and a design effect of one, the ultimate sample size was 371. However, the sample size was increased to compensate for possible losses, wrong contact numbers and patients refusing to participate. Using a systematic random sampling (k = 28) and a random start for selection of the first participant, 400 participants were selected. Whenever participants either could not be reached via their mobile numbers or they declined to participate, the next patient on the list was contacted as an alternative. In total, 379 participants completed the full questionnaire and were included in the analysis.

Instruments

A predesigned questionnaire was created using Microsoft Forms and distributed to all participants via a WhatsApp link. It was bilingual (Arabic and English), thereby allowing participants to select the language they preferred to use. In addition, the questionnaire was designed to be compatible with smart phones, laptops, desktops and tablets.

Before the questionnaire was distributed to the mobile phones of participants, they received a phone call from two trained personnel, the objective of the conversation being not only to outline the research objectives and content, but also to obtain verbal consent.

The questionnaire included four major components, the first of which was a set of sociodemographic questions designed to acquire data pertaining to nationality, gender, education, residence, work, income, medical history and social status.

The second set of questions explored the conditions of health isolation, including duration, place, conception, medical service, challenges and compliance with isolation protocols.

Thirdly, there were questions designed to elicit information about the psychological stress levels associated with health isolation, which were measured using two validated scales, to wit: K10 and IES-R, both of which were available in validated English and Arabic language versions. The K10 is an attractive and simple tool, with strong psychometric properties, wherein psychological distress can be assessed through 10 questions. These questions evaluate the frequency of different symptoms experienced in the preceding 4 weeks on a scale of 1–5, where 1 = none at all and 5 = all the time. Hence, the total results range from 10 to 50 [11, 12]. The IES-R is an appropriate instrument for evaluating the subjective distress resulting from a traumatic life event. This instrument assesses symptom frequency for 22 items on a five-point Likert scale, where 0 = Not at all and 4 = extremely. The results range from 0 to 88. The IES-R has three subscale domains (avoidance, intrusion and hyperarousal) where the calculated mean provides insights into the level of distress experienced [13, 14].

The fourth question set comprised three questions designed to obtain self-evaluations of medical services using a five-point Likert scale, wherein 1 denoted “very poor”, 2 signified “poor”, 3 represented “fair”, 4 equated to “good” and 5 comprised “excellent”.

The Ministry of Health (MOH) protocol required all individuals who had been in contact with confirmed cases to quarantine for 14 days. Any individual with a positive COVID test was obliged to self-isolate for a minimum of 10 days from the test result date onwards. Isolation ceased after 10 days, provided the individual had been symptom-free for the previous 2 days [15].

Whilst some individuals were obliged to isolate for less than 14 days, other individuals may have been in isolation for longer periods. Such cases included those who had already been in isolation for several days prior to a positive test result and individuals who exhibited long-lasting symptoms.

Participants were classified into two groups, based on the month of diagnosis, because the first few months of March through June were epidemiologically classed as cluster transmission cases in Oman, whereas cases from July to November occurred at a time when community transmission became real.

Monthly income was defined as negatively impacted when the patient or her/his spouse or any breadwinner was not paid for a number of weeks or months during the pandemic. This also included cases where individuals had lost their jobs during the pandemic or where there was a salary deduction related to the isolation period.

Statistical analysis

The data collected through the Microsoft Form was exported as a Microsoft Excel file before being organised, tabulated and statistically analysed using IBM SPSS 25.0 (IBM Corp., Armonk, New York USA). Subsequently, the resultant numerical data were presented as means and standard deviations, whilst the categorical data were presented as numbers and percentages.

The reliability test was calculated using the Cronbach’s alpha (α) for both the K10 and IES-R scales; 0.893 and 0.922 respectively. Hence, the three self-evaluation questions pertaining to medical service provision and clinical, psychological and socioeconomic aspects produced a Cronbach’s alpha (α) of 0.773.

The K10 total score was divided into four sub-categories, comprising low (10–15), moderate (16–21), high (22–29) and very high (30–35) [16]. A chi-squared test was used to identify differences between the sub-categories. The binary coding for K10 was used in the logistic model, with the combination of low and moderate levels indicating low distress (scores of 21 or less), while high distress comprised the combination of high and very high (scores of 22 or greater).

The total score of IES-R was further divided into high and low stress. Scores of 25 or higher were considered high stress [17] and the mean and standard deviation (SD) were calculated for the subcategories of the independent variables. In addition, the normality assumption was evaluated via both the Kolmogorov–Smirnov test and visual assessment, whilst the Mann–Whitney U test and the Kruskal–Wallis test were used to compare the subgroups. Odds ratios (OR) and related 95% confidence intervals (95% CI) were calculated using bivariate and multivariable analyses (unconditional binary logistic regression). Only statistically significant covariates in the bivariate analyses were included in the multivariable model. The p value adopted was p ≤ 0.05.

Ethical considerations

Prior to the administration of the questionnaire, verbal consent was obtained from all participants through telephone conversations with two trained team members. This was supplemented with the electronic consent provided by each respondent during the questionnaire process. Participants could opt to complete English or Arabic language questionnaires. All data was collected anonymously and only used for research purposes. Confidentiality was safeguarded throughout the research process. Ethical approval was sought and obtained on 21 July 2020 from the Research and Ethical Review and Approval Committee, Directorate Planning and Studies at the South Batinah Governorate (Research Code 02072020).

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